Every finding on record at Hoboken University Medical Center Tcu

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) failed to restrain employees hair and, b.) failed to sanitize and air dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following:On 12/29/25 at 11:24 AM, in the presence of the Food Service Director (FSD) the surveyor observed the following:1.Near the dishwashing area, the surveyor observed a Food Service Worker (FSW #1) with a hairnet on but the hair net was observed not covering all of the FSW #1's hair. The FSW #1 stated that he did not realize his hair net was like that. 2.In the area near the 3 compartment sink the surveyor observed a shelf with stacked sheet pans of various sizes. The surveyor observed the following; four 1/4 sized sheet pans stacked with water between them, four 1/3 sheet pans stacked with water between them, three 1/6 sized sheet pans stacked with water between them, and, two 1/2 sized sheet pans stacked with water between them. The FSD stated that these items should be air dried before stacking.At 11:50 AM, the surveyor observed a FSW #2, who was observed washing steam table pans in the 3 compartment sink. The FSW #2 stated that he been here 3 months not sure what happened with the stacked and wet steam table pans but they should be air dried first. The Uniform Dress Code policy with a revision date of 1/25/25, revealed Wear the approved hair restraint when on duty regardless of length or presence of hair. The Storage of Pots, Dishes, Flatware, and Utensils policy, with a revision date of 1/26/25, which revealed Air dry all food contact surfaces, including pots, dishes, flatware, and utensil before storage, or store in a self-draining position. Do not stack or store when wet. At 1:30 PM, the surveyor reviewed the above concerns with the Administrator and the Director of Nursing. NJAC 8:39-17.2(g)

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to a) maintain proper kitchen sanitation practices and clean equipment, and b) properly store foods in a safe manner to prevent the development of food borne illness. These deficient practices observed as evidenced by the following: On [DATE] at 10:16 AM, in the presence of the Environmental Services Director/ Food Service Director (EVD/FSD), the surveyor toured the kitchen and observed the following: 1. In the walk-in freezer, the surveyor observed several boxes of opened food items that were unlabeled with open expiration date. Those items were as follows: *Flat bread, opened, sealed, out of original box, placed on top of box, used and unlabeled with open expiration date. *Whipped topping, opened, sealed out of original box, placed on shelf and unlabeled with open expiration date. *Tater tots, opened, sealed in bag, out of original box, placed on shelf, and unlabeled with open expiration date. All listed items were opened, unlabeled with open date or expiration dates. The EVD/FSD manager was unable to say when the packages were opened. 2. In the walk-in freezer, the surveyor observed several boxes of opened food items that were exposed to the freezer air unsealed, and unlabeled with open expiration date. Those items were as follows: *Pate Pizza; small round, unsealed large quantity bag, unlabeled with open date. *Pizza crust large round; opened and unsealed large quantity bag, unlabeled with open date. *Vegetable burger sleeve; opened to the element and unsealed, unlabeled with open expiration date. *Loose premade pretzels, large quantity bag, opened to the element and unsealed, unlabeled with open expiration date. *Beef burger, loose, large quantity bag, opened to the element and unsealed, unlabeled with open expiration date. All listed items were opened, unlabeled with open date or expiration dates. The EVD/FSD manager was unable to say when the packages were opened or when they expired. 1. In the food preparation area,the surveyor observed that 3 of 3 trash cans were filled with garbage and food debris which were uncovered in locations as follows: 1) food prep table that had bread on it, 2) chef prep table that had dessert in 3 pans covered with clear plastic wrap, 3) and, one under the tray line. In the food preparation area, the can opener was observed with brown and red sediment build up and was able to be scratched off by the EVD/FSD. The holder for the can opener had visible debris. The EVD/FSD could not recall the cleaning policy for the can opener and was unable to say when it had been washed and cleaned. The Head Chef (HC) stated, I changed the blade when I first got hired, 2 months ago. The catch trays under 3 of 5 cooktop units had copious amounts of blackened, burnt on and sticky residue that was on foil and under the foil on the pan. The foil was shredded to pieces exposing the tray. The survey observed 2 of 4 double door convention ovens that the glass doors were opaque with brown hard and sticky residue. The HC and EVD/FSD could not comment on when it was cleaned last. On [DATE] at 10:15 AM, the surveyor interviewed the EVD/FSD, who stated, that labeling of food is a requirement in the kitchen and his expectation of his staff. The food should be labeled with expiration date and if opened it should be labeled with open date and the package should be resealed to keep the contents fresh. Labeling allows for first in first out concept which saves food integrity, prevents freezer burn, and waste production. It also prevents food born illness. On [DATE] at 10:15 AM, the surveyor interviewed the HC regarding the cleaning process for equipment and food storage in the freezer, who stated, I need to educate the staff of what cleaning means on the log and have it more defined. The cooks should be sealing the opened bags of food in the freezer to maintain the food integrity. On [DATE] at 11:30, the survey team presented the concerns to the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Director of Rehab (DOR) for kitchen. The LNHA and the DON had no further information to provide. The surveyor reviewed a policy titled food storage, effective date of ,d+[DATE] and revised date of ,d+[DATE], which revealed: Purpose: To prevent contamination by transmission of disease-carrying microorganisms. Policy: It is the policy of the Food Services Department to develop a mechanism to ensure the safe and accurate storage of food and nonfood products. Food storage methods are strictly defined. Procedures: 2.) Inspect food regularly for damage due to spoilage. 3.) Rotate Stock so that older items are used first. Date products to ensure the use of First in-First out procedures. The surveyor reviewed the policy titled, Food Safety HACCP, effective date of ,d+[DATE] and a revised date ,d+[DATE], which revealed: Policy: The food and nutrition services department has a comprehensive food safety and self-inspection system that includes equipment monitoring to ensure the effectiveness and quality of the food safety program for all of our food service customers. Purpose: Our Hazard Analysis Critical Control Points (HACCP) Program looks at the flow of potentially hazardous foods, the path that food travels throughout delivery of products, storage, preparation, holding or displaying, serving, cooling, and storing leftovers for the following day, and reheating foods. The surveyor reviewed a document titled, Food Safety Management System, food safety product labeling and dating guidelines, document code 1.2.19, revision date [DATE], page 1 of 3, which revealed, Purpose and Scope: Assist with labeling requirements on food products and use by dates. Note: Where a State, Provincial and or Local health regulation is more stringent than our company standard, you are required by law to follow those regulations. NJAC 8:,d+[DATE].2(g)

Based on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to ensure a medication was administered in accordance with the physician's order and professional standards of clinical practice. The deficient practice was identified for one (1) of four (4) residents (Resident #309), administered by one (1) of two (2) nurses, observed during the medication pass 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 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 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. On 6/14/24 at 8:16 AM, during the medication administration observation, the surveyor observed Registered Nurse (RN) prepare medications for Resident #309 on the medication cart situated at the end of the resident's bed, in the resident's room. The RN reviewed the electronic Medication Administration Record (eMAR) against the medications in a unit dose (UD) packaging (a dose of medicine prepared in an individual package) which included a physician's order for Metoprolol (Lopressor) 50 milligram (mg), give one (1) tablet every 12 hours, hold if systolic blood pressure less than 90; give with meals for hypertension (high blood pressure). Administration times were for 9:00 AM and 21:00 [9:00 PM]. At 8:17 AM, the resident informed the nurse that he/she preferred the application of the Lidoderm Patches later that day. At that time, the RN stated she had taken the resident's blood pressure (BP) about 15 minutes ago, and had the result written on paper. The surveyor observed that a data entry of the BP was required on the eMAR. At that time, the RN pulled the vitals machine towards the resident and began to take the resident's BP reading. At 8:26 AM, the RN removed the resident's UD medication from the medication cart cassette, scanned each medication bar code, then took an empty medication cup and walked over to the resident's bedside. The RN emptied each medication into the medication cup, explained to the resident the indication for each medication dispensed into the empty medication cup, one at a time, while the resident self-administered. At that time, the RN confirmed she had signed for the administered medications to Resident #309 and was ready to administer to the resident's room mate assigned to the door side of the room. At 8:29 AM, the surveyor stopped the medication pass. The surveyor and the RN reviewed the (4) four emptied UD medication packages which consisted of the following: 1. Sodium Chloride (a supplement, for hyponatremia, (low sodium levels in the blood)) 2. Eliquis 5 mg (a blood thinner, for atrial fibrillation) 3. Xanax (Alprazolam, for anxiety) 4. Pantoprazole (Protonix, for heartburn or excessive acid) At that time, the surveyor asked the RN where the emptied UD package for the metoprolol was. The RN reviewed the emptied UD medication packages, looked on the medication cart, searched her pockets, looked in the cassette, searched her pockers again and found the unit dose for the Metoprolol. At that time, the RN stated, I missed it. At that time, the RN informed the resident that she had missed the administration of the pink one and administered to the resident. At that time, the RN confirmed all administration of the medications were already signed. The surveyor reviewed the medical record for Resident #309. A review of Resident #309's Admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to atrial fibrillation with rapid ventricular response (an abnormal heart rhythm that occurs when the upper chambers of the heart contract in an uncoordinated way, causing the lower chambers to beat too facility) and hyponatremia. A review of Resident #309's Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/10/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #309's cognition was intact. A review of the Physician's Progress Note included a documentation that the Metoprolol was administered for atrial fibrillation, hypertension, and anxiety benefits. A review of the Registered Nurse's most recent medication pass observation, dated 9/19/22, conducted by the Consultant Pharmacist (CP) reflected the RN had no errors. On 6/14/24 at 11:08 AM, in the presence of surveyor #2, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Director of Rehabilitation (DoR), the surveyor discussed the concern regarding the signing of Metoprolol as administered to the resident while the administration was omitted, during the medication pass administration observation. On 6/18/23 at 10:00 AM, in the presence of the survey team, and the LNHA, the DON stated, she had reviewed the chart of the resident. The DON stated that the RN should have gone back to verify everything, prior to signing to allow for self-correction. A review of the provided facility policy titled: Medications, dated/revised on 5/24 included under Policy/Procedure E. All medications are to be recorded on patient's Medication Administration Record (MAR) immediately after administration to the patient. The policy did not reflect a procedure for reconciliation of administered medications to the residents to recapture omission of administration. NJAC 8:39-29.2 (d)

Based on observations, interviews, and facility policy review, it was determined that the facility failed to ensure resident food items were labeled and dated and failed to discard all food items that had passed their expiration date. These failures had the potential to affect all 4 residents who resided in the facility. Findings included: Review of the facility's undated policy titled, Food Safety Management System Guidelines, specified, Food labeling is essential to identify food accurately, and ensure it is stored correctly. It is a [company name] requirement to discard all foods that have passed their use by or best before date. Food items that are decanted from their original packaging must be labeled. The policy further specified, For pre-prepared/manufactured products, the label must reflect the products name, the opening date, and the use by date. Review of the facility's policy titled, Food Storage, revised ,d+[DATE], specified, Purpose: To prevent all contamination by and transmission of disease-carrying microorganisms. The policy further specified, Procedure - Follow the guidelines below to further ensure safe and accurate storage procedures: 3. Rotate stock so that older items are used first. Date products to ensure the use of First-In, First-Out procedures. 1. On [DATE] at 11:39 AM, an observation of the dry storage area revealed 10 8-ounce Glucerna Nutrition Shakes with an expiration date of [DATE]. During an interview on [DATE] at 12:02 PM, the Clinical Nutritional Manager stated expired foods should be discarded by their use-by date and she expected foods to be discarded by their use-by date. During an interview on [DATE] at 12:03 PM, the Project Manager (PM) stated expired foods should be discarded by their use-by date. According to the PM, she expected expired foods to be discarded by their expiration date. During an interview on [DATE] at 3:01 PM, with the Interim Director of Nursing (DON) and the Administrator, both stated that expired foods should be discarded by their expiration date. Per the Interim DON and Administrator, they expected expired foods to be discarded by their expiration date. The Administrator stated she completed occasional spot checks in the kitchen, but the last check was in September of 2022. According to the Administrator, the Director of Food Services was given the Centers for Medicare and Medicaid (CMS) Critical Element Pathway to follow. During an interview on [DATE] at 4:20 PM, the Director of Food Services (DFS) stated all food managers should make rounds to check for expired food. Per the DFS, she expected daily rounding by the food managers to monitor use-by dates on food. The DFS indicated staff were aware that food items must be discarded by their use-by dates. 2. On [DATE] at 11:43 AM, an observation of the walk-in cooler revealed a bag of green beans out of the original container with no label or date, a 41-ounce opened bag of flour tortillas with no opened date, an opened 2 pound bag of mild cheddar cheese with no opened date, and an opened 32-ounce bag of crumbled goat cheese with no date. On [DATE] at 11:52 AM, observations of the walk-in freezer revealed six bags of hash browns out of the original containers, with no date or label, and a round cake out of the original packaging, with no label or date. During an interview on [DATE] at 12:02 PM, the Clinical Nutritional Manager stated food items out of their original packaging or food items that have been opened should be dated and labeled. She stated she expected food items to be dated and labeled when out of the original packaging or after the food item had been opened. During an interview on [DATE] at 12:03 PM, the Project Manager (PM) stated food items out of their original packaging or opened should be dated and labeled. According to the PM, she expected food items to be dated and labeled when out of the original packaging or after the food item had been opened. Per the PM, many of the kitchen staff were new, and the facility was projected to implement a new labeling system in the future. During an interview on [DATE] at 3:01 PM, with the Interim Director of Nursing (DON) and Administrator, both stated food items out of their original packaging or after they were opened should be dated and labeled. Per the Interim DON and Administrator, they expected food items to be dated and labeled after being opened or out of their original container. The Administrator stated she completed occasional spot checks in the kitchen, but the last check was in September of 2022. According to the Administrator, the Director of Food Services was given the Centers for Medicare and Medicaid (CMS) Critical Element Pathway to follow. During an interview on [DATE] at 4:20 PM, the Director of Food Services (DFS) stated it was a team effort to monitor for proper labeling and dating of food items. The DFS stated all food managers should make rounds to check for proper labeling and dating of food items. Per the DFS, she expected daily rounding by the food managers to observe for proper dating and labeling. The DFS indicated staff were aware that food items must be labeled when out of the original packaging or after opened. NJAC 8:,d+[DATE].2(g)

Based on observations, interviews, and review of the facility's guidelines, it was determined that the facility failed to ensure respiratory equipment was properly dated and properly stored when not in use and there was a storage containment bag to place the nasal cannula and oxygen tubing when not in use for 2 (Resident #7 and Resident #8) of 2 residents reviewed for respiratory care. Findings included: A review of the facility's undated guidelines titled, TCU Unit Guidelines Resident Room Checklist Each Shift, indicated, Oxygen tubing label and date within last 72 hours and placed in a plastic bag when not in use. 1. A review of the resident demographic sheet revealed the facility admitted Resident #8 with diagnoses of urinary tract infection and congestive heart failure. A review of Resident #8's TCU Baseline Plan of Care, initiated 12/29/2022, revealed Resident #8 was to receive services and treatment for respiratory care and oxygen therapy. A review of Resident #8's Current Orders revealed an order, dated 12/29/2022, for oxygen by way of nasal cannula at two liters as needed. On 01/03/2023 at 11:13 AM, Resident #8 was observed sitting in a chair in the resident's room with oxygen tubing lying on the bed and an oxygen cannula hanging off the right side of the bed. The oxygen tubing was not dated and had no storage containment bag present in the room. Resident #8 stated they did not place the nasal cannula on the side of bed and indicated staff had taken it off and placed it on the side of the bed. On 01/03/2023 at 11:15 AM, Registered Nurse (RN) #1 was called to Resident #8's room by the surveyor, where she acknowledged that Resident #8's nasal cannula was stored off the side of the bed, the oxygen tubing was not dated, and the oxygen tubing and cannula did not have a storage bag present in the room for its storage when not in use. RN #1 stated the oxygen tubing and nasal cannula should be dated and have a containment bag to place them in when not in use. Per RN #1, the nurses were responsible for dating the tubing when new tubing was changed out and for placing a new storage bag in the room. RN #1 indicated the nasal cannula should not be stored hanging off the side of the resident's bed. According to RN #1, she did not know why the cannula was stored on the side of the bed. During a follow up interview on 01/03/2023 at 3:39 PM, RN #1 stated she changed out Resident #8's oxygen tubing that was not dated with new tubing with the current date and placed a containment bag for the storage of the nasal cannula and tubing. RN #1 indicated the oxygen tubing should be changed every 72 hours and dated after it was changed. On 01/04/2023 at 7:33 AM, Resident #8 was observed in bed in their room with a nasal cannula on their face. Resident #8's oxygen tubing was dated and there was a storage containment bag present. On 01/04/2023 at 7:34 AM, RN #2 stated oxygen tubing and the nasal cannula should be changed and dated every seven days on Mondays or when dirty. RN #2 stated the oxygen cannula should not be stored hanging off the resident's bed and should be stored in a bag when not in use. Per RN #2, the potential negative outcome of not storing the nasal cannula properly was respiratory infections. On 01/04/2023 at 7:42 AM, the Interim Director of Nursing (DON) stated oxygen tubing should be dated when changed every 72 hours or as needed. He stated the oxygen tubing and cannula should be stored in a bag when not in use. Per the Interim DON, the oxygen cannula should not be stored off the side of a resident's bed. According to the Interim DON, the potential negative outcome of not storing the oxygen tubing and nasal cannula properly were potential respiratory infections. The Interim DON stated the facility did not have a specific policy on dating the oxygen tubing, or on the proper storage and containment of the oxygen tubing and nasal cannula when not in use. On 01/04/2023 at 7:47 AM, the Administrator stated oxygen tubing and nasal cannulas should be dated and changed every 72 hours. Per the Administrator, the oxygen cannula should be contained in a storage bag when not in use and not hanging off the resident's bed. According to the Administrator, a potential negative outcome of not properly storing the nasal cannula, dating the oxygen tubing, and having a storage bag to place the oxygen tubing when not in use was an infection control issue. The Administrator stated she expected the respiratory supplies to be stored properly when not in use, dated when changed, and to have a storage bag for when the supplies were not in use. 45555 2. A review of the resident demographic sheet indicated the facility admitted Resident #7 with diagnoses that included chronic obstructive pulmonary disease. A review of Resident #7's TCU Baseline Plan of Care, initiated 12/27/2022, revealed the resident received oxygen therapy. A review of Resident #7's Current Orders, revealed an order, dated 12/27/2022, for oxygen by way of nasal cannula at three liters. During an observation on 01/03/2023 at 9:37 AM, Resident #7 was not present in their room; however, the resident's oxygen concentrator was in their room with the tubing connected, and the nasal cannula was lying on top of an incontinent pad on the resident's bed. The surveyor observed that the oxygen tubing was not dated. On 01/04/2023 at 9:02 AM, Resident #7 was observed sitting in their room in a wheelchair with a nasal cannula on their face. Resident #7's oxygen tubing was dated 01/03/2023; however, there was no storage bag in the resident's room to place the oxygen tubing when not in use. During an interview on 01/04/2023 at 12:45 AM, the Interim Director of Nursing (DON) stated oxygen tubing should be changed every 72 hours and stored in a plastic bag when not in use. According to the Interim DON, the respiratory therapist and nursing staff were responsible for changing the oxygen tubing. NJAC 8:39-19.4(a)1-6

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNA's) received mandatory in-service training as required, which included Dementia training. This was identified for 6 of 6 CNA files reviewed for in-service training. This deficient practice was evidenced by the following: On 4/26/19 at 10:00 a.m., the surveyor reviewed the in-service education hours for six selected CNA files which were provided by the facility. The surveyor determined that there was no Dementia training listed on any of the six CNA's completed education hours. On the same day at 11:00 a.m., the surveyor asked the Director of Nursing (DON) if the CNA's received any dementia training. At 11:30 a.m., the DON confirmed that the CNA's did not receive any Dementia training. N.J.A.C. 8:39-43.17 (b)

Based on observation, interview and record review, it was determined that the facility failed to maintain infection control practices to decrease the possibility of the spread of infection. This was identified for 1 of 2 residents (Resident #60) reviewed on Transmission Based Precautions (TBP). This deficient practice was evidenced by the following: On 4/25/19 at 12:08 p.m., the surveyor observed Resident #60 in bed with the head of their bed elevated. Outside the room was a sign that read: Contact Precautions. There was a storage bin hanging from the door which contained Personal Protective Equipment (PPE-Gowns, Gloves and Masks). The surveyor then observed a facility staff member, holding a stethoscope and a piece of paper in their hands, entered the room without conducting hand hygiene or putting on PPE. A Registered Nurse (RN) was in the hallway and went to to door of Resident #60 and held up a gown for the facility staff member. The facility staff member was at the head of Resident #60's bed and asked the resident multiple questions. The RN then put on a gown and gloves and entered the residents room. The surveyor then observed the facility staff member touch the resident on their chest with bare hands. At 12:10 p.m., the surveyor observed the facility staff member exit Resident #60's room without conducting hand hygiene. At that time the surveyor approached the facility staff member who stated that they were a Physician. When the surveyor asked the Physician if he was aware that Resident #60 was on transmission based Contact Precautions, he stated that he was not aware, looked back toward the room at the Contact Precautions sign posted and stated that, Next time I will use it. The Physician then walked down the hallway, through the double doors and off the unit. The surveyor did not observe the physician conduct hand hygiene. At that same time, the surveyor observed the Minimal Data Set (MDS) Coordinator had followed the physician off the unit. At 12:13 p.m., the surveyor interviewed the MDS Coordinator upon his return to the unit. He stated that he had educated the Physician on the use of PPE and Hand Hygiene and had observed the Physician use the alcohol based hand gel that was mounted on the wall outside the unit. At 12:16 p.m., the surveyor interviewed the RN assigned to Resident #60, who confirmed that the Physician should have conducted hand hygiene before and after contact with the resident and that PPE should have been worn. The RN also confirmed that the Physician had touched Resident #60 with his bare hands. At 12:20 p.m., the surveyor interviewed the Director of Nursing (DON) who confirmed that Resident #60 was on Contact Precautions for the infection [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in their blood and that all staff, including physicians, should follow standard and transmission based precautions. The surveyor then reviewed the Center for Disease Control (CDC) website which read: To [MEDICAL CONDITION] infections, doctors, nurses, and other healthcare providers: Clean their hands with soap and water or an alcohol-based hand rub before and after caring for every patient. Use Contact Precautions when caring for patients [MEDICAL CONDITION]. On 4/26/19 at 8:40 a.m., the surveyor reviewed the Physicians Orders which identified an order dated 4/19/19 at 13:44 (1:44 p.m.) which read: Isolation Type Q12 (every 12 hours) and under, Intervention Text read: Isolation Contact. At 9:30 a.m., the surveyor reviewed the facility policy titled; Transmission Based Precautions, Isolation Guidelines dated (MONTH) (YEAR) and reviewed January, 2019, under Contact Precautions read: Contact Precautions shall be used in addition to standard precautions for Residents with infections that can be easily transmitted by direct and indirect contact. Under I. Gloves and Hand Hygiene read: A. Hand hygiene should be completed prior to donning (put on) gloves. B. Gloves should be worn while providing care for the resident or when having direct contact with the resident environment and; Under II. Gowns F. A gown should be donned prior to entering the room or resident's cubicle when clothing will come in contact with the resident or resident's environment and; Under V. Contact Precautions Are To Be Used For (Examples): M. Multi-drug resistant organisms (e.g.;[MEDICAL CONDITION], VRE, ESBL's, KPC) On the same day at 11:45 a.m., the surveyor reviewed a facility document titled, Health Information Management Progress Note for Resident #60 dated 4/24/19 at 10:00 a.m., which read under Assessment and Plan: 4. Blood bacterial culture positive. 5. Bacteremia (presence of bacteria in the blood) due to [MEDICAL CONDITION]. N.J.A.C. 8:39 - 19.4 (a)

Based on interview and record review, it was determined that the facility failed to assure that the Medical Director, or designee, attended the quarterly Quality Assurance (QA) meetings. This was found for 3 of 4 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: On 4/25/19 at 12:00 p.m., the surveyor interviewed the Director of Nursing (DON) and asked for the sign in sheets for the last four QA meetings. When the surveyor reviewed the sign in sheets for the meetings, it was noted that the Medical Director had not been in attendance for three of the four meetings. The third quarter of (YEAR) sign in sheet was dated (MONTH) (YEAR), the fourth quarter sign in sheet was dated 10/23/18, and the first quarter of 2019 was dated 2/12/19. There was no signature on any of the three sign in sheets to indicate that the Medical Director attended any of those meetings. According to the sign in sheets, the last time the Medical Director attended a QA meeting was the second quarter of (YEAR), which was (MONTH) 17, (YEAR). At that same time, the DON confirmed that the response column on the sign in sheet was to indicate who responded to an email invitation to the QA meeting. In the column next to the Medical Director's name the word none was entered. The DON confirmed that the Medical Director had not responded to the email invitation and had not attended the last three QA meetings. On 4/26/19 at 11:00 a.m., the surveyor reviewed the facility's s policy and procedure titled; Quality Improvement dated 9/12, with a revision date of 10/17 and 1/19. Under Quality Assessment and Improvement Responsibility it read: The Quality Improvement Committee will be responsible for improvement in the quality of care and the correction of identified patient care problems. The Quality Improvement Committee will consist of: Administrator, Medical Director, Director of Nursing, Social Worker, Activities Therapist, Pharmacist/Consultant Pharmacist, Rehabilitation Staff, Medical Center Infection Control Coordinator, and Registered Dietitian. N.J.A.C. 8:39-33.1 (b)

Based on observation, interview and record review, it was determined that the facility failed to secure medication on 1 of 2 medication carts. This deficient practice was evidenced by the following: On 6/25/18 at 6:10 PM, the surveyor arrived on the Transitional Care Unit (TCU). There were two medication carts in the hallway. There was no staff or resident's in the hallway. On the top of the medication cart in the hallway near room [ROOM NUMBER] was an unopened syringe of [MEDICATION NAME] (a medication used to treat and prevent a deep vein blood clot) 40mg/0.4ml. The surveyor remained near the medication cart. On the same day at 6:17 PM, the surveyor observed the Charge Nurse (CN) pick up the syringe of [MEDICATION NAME], place it in the medication cart, and lock the cart. There were no residents near the medication cart during that time. On 6/27/18 at 11:50 AM, the surveyor interviewed a Registered Nurse (RN) who confirmed that medications should not be left on the cart or out of the view of the nurse. On the same date at 12:00 PM, the surveyor informed the Administrator, Director of Nursing assisting the TCU and Chief Operating Officer. They provided no information regarding the unsecured medication. On 6/28/18 at 10:00 AM, the surveyor reviewed the facility policy titled, Storage of Drugs and Biologicals dated 09/12 and revised 10/17 under Policy/Procedure read: In accordance with state and federal laws and regulations, the Medical Center must store all drugs and biologicals in locked compartment under proper temperature controls and permit only authorized personnel to have access to keys or passwords. The surveyor then reviewed the facility policy titled, Medications dated 09/12 and revised 10/17 under G, Information Regarding Pharmacy Provisions number 1. The Transitional Care Unit is provided with: d. A locked medication cart. N.J.A.C. 8:39 - 29.4(h)

Based on observation, interview, and record review it was determined that the facility failed to implement infection control protocols. This was found with 1 of 3 residents who were on transmission based precautions, Resident #108, and with 2 of 6 residents who were observed during medication pass, Resident #1 and Resident #9. This deficient practice was evidenced by the following: 1) On 6/25/18 at 6:30 PM, the surveyor observed Resident #108 sitting in a recliner in their room. The resident said they had a knee replacement which had become infected with [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA). The resident's left leg was wrapped in an ace bandage. There was a sign outside of the room that read: Contact Precautions. The resident was aware that he/she was on contact precautions and the reason why. The resident was aware of the necessary precautions and said he/she was a nurse. On 6/27/18 at 11:15 AM, the surveyor observed a Physician's Assistant (PA) changing the dressing of the left knee of Resident #108. When the surveyor entered the residents room the PA was standing near the resident. The PA was wearing an isolation gown and had donned sterile gloves. The wound was uncovered. The PA placed [MEDICATION NAME] (an antispetic used for skin disinfection before and after surgery) soaked gauze on top of the wound, then placed two ABD pads (thick sterile gauze pads) on top. The PA then turned around and picked up the wrappers from used isolation gowns and used gloves from the floor and deposited the debris in the garbage can. The garbage can was over filled with used isolation gowns and gloves. The PA pressed the items down in the garbage can with his gloved hands. He then wrapped the foot and leg with three ace bandages using the same gloved hands. On the same day at about 11:25 AM, the surveyor observed the Physician come into the room as the PA was wrapping Resident #108's leg. The Physician listened to the resident's heart and lungs with a stethoscope while leaning against the recliner the resident was sitting on and touching the resident. The Physician was not wearing any Personal Protective Equipment (PPE). The Physician then placed the stethoscope around his neck and walked out of the room and went to the nurse's station. The Physician did not use hand sanitizer or wash his hands. The resident called him back, he returned to the room and stood by the resident talking. When the Physician was done he walked out of the room and off the unit without sanitizing his hands or his stethoscope or washing his hands. On 6/27/18 at 11:45 AM, the surveyor reviewed the resident's medical record which revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 6/28/18 at 10:00 AM, the surveyor reviewed the facility's policy and procedure titled, Transmission Based Precautions Isolation Guidelines sub-title was Contact Precautions which read: I. Gloves and Hand Hygiene: Gloves should be worn while providing care for the resident or when having direct contact with the resident's environment. II. Gowns: A gown should be donned prior to entering the room or resident's cubicle when clothing will come in contact with the resident or resident's environment. On 06/28/18 at 09:51 AM, the surveyor spoke with the facility's Staff Educator about Contact Precaution procedures. The Staff Educator stated, Hand hygiene, a minimum of gown and gloves have to be worn, any staff member that enters the room, signs are expected to be in the hallway by nurses, Physicians are expected to comply as well as Physician's Assistants, and housekeeping. 2) On 6/26/18 at 9:15 AM, the surveyor was observing medication pass. When preparing to administer a subcutaneous injection to Resident #1, the nurse dropped the unopened needle on the floor. The nurse picked the needle up from the floor with her gloved hand. The nurse asked a nurse outside of the room to get her another one as she disposed of the dropped needle in the sharps container. The nurse outside of the room brought her a new needle. The nurse gave the injection while wearing the same gloves she picked the dropped needle up from the floor with. 3) On 6/27/18 at 8:47 AM, the surveyor was observing medication pass. When preparing to administer medication to Resident #9, the nurse brought the resident pudding and a spoon in a plastic wrapper. The nurse dropped the spoon on the floor, picked it up and gave it to the resident to eat the pudding. The resident said they would eat it later. On the same day at 9:15 AM, the surveyor asked the nurse why she gave the resident the spoon that was dropped on the floor. The nurse stated, It was covered. I thought it was ok. The nurse then took the spoon back and gave the resident a new one. N.J.A.C.-8:39 19.4 (a)

Based on observation, interview and record review, it was determined that the facility failed to maintain a medication error rate below 5%. The surveyors observed two nurses administer 25 medications to three resident's and there were two medication errors. This resulted in a medication error rate of 8%. This deficient practice was evidenced by the following: 1) On 5/17/17 beginning at 8:34 a.m., the surveyor observed Registered Nurse (RN) #1 prepare the intravenously administered medication [MEDICATION NAME], an antibiotic used to treat infections. The [MEDICATION NAME] was 60 milligrams (mg) diluted in 50 milliliters (ml) of normal saline and was order to infuse at a rate of 50 ml per hour. According to the Medication Administration Record [REDACTED]. The rate of administration programmed into the Alaris Intravenous pump by RN #1 had the [MEDICATION NAME] dose infusing at 100 ml per hour for a duration of 30 minutes. When interviewed by the surveyor on the same date at 9:10 a.m., RN #1 stated the the pump is pre-programmed for the medication. At 9:11 a.m., RN #1 returned to the medication cart and reviewed the [MEDICATION NAME] order as prescribed on the MAR. RN #1 then returned to the pump that had been infusing the [MEDICATION NAME] Antibiotic at 100 ml per hour and reprogrammed the remaining medication to infuse at 50 ml per hour. On 5/18/17 at 9:30 a.m., the surveyor reviewed the facility policy titles, Pharmacy: Administration of Drugs and Pharmaceuticals under 5) The individual administering medications will perform the following 5 rights of verification prior to administration of a medication: * Right patient * Right Drug * Right dose * Right route * Right time When interviewed by the surveyor on 5/18/17 at 10:47 a.m., the Director of Nursing (DON) stated that the intravenous pumps are connected to the pharmacy and that RN #1 programmed the volume to be administered in error. 2) On 5/16/17 beginning at 10:05 a.m., the surveyor observed RN #2 administer medication to Resident #9. The RN prepared all of the medication and placed them in a plastic medicine cup. When the nurse went to the resident, Resident #9 stated that he/she was unable to swallow big pills. The RN then went through each pill and asked the resident which ones were too big for them to swallow. Resident #9 stated that the [MEDICATION NAME] and the [MEDICATION NAME] (both used to treat Diabetes Mellitus) were too big. The RN then went to the medication room and crushed both pills in two separate cups. The resident took the [MEDICATION NAME] but refused the [MEDICATION NAME]. The cautionary on the Medication Administration Record [REDACTED]. When interviewed by the surveyor on 5/18/17 at 10:00 a.m. regarding the [MEDICATION NAME], the hospital pharmacist stated, The manufacturer recommends to swallow that whole. I believe it is on the do not crush list. It effects the time to peak and the pharmokenetics of the medication. N.J.A.C. 8:39 - 27.1 (a)

Based on observation and interview, it was determined that the facility failed to always secure medications during the medication pass observation. This deficient practice occurred with 2 of 2 nurses observed during the medication pass on 5/16/17 and 5/17/17 and was evidenced by the following: 1) On 5/16/17 at 10:05 a.m., the surveyor observed RN #1 administer medication to Resident #9. The resident refused the Risperdal Concentrate 1 milligram (mg) (a medication used to treat Schizophrenia and symptoms of Bipolar Disorder) and asked to have the Metformin 1000 mg (a medications used for the treatment of [REDACTED]. The surveyor then observed RN #1 place the Risperdal Concentrate syringe and a small medicine cup with the Metformin and Januvia in it on top of the medication cart outside of Resident #9's room. RN #1 went back into the residents room to wash her hands, leaving the pills and syringe of medication unattended for approximately 1 minute. No residents were in the vicinity of the medication cart. RN #1 then took the syringe of Risperdal and cup with the Metformin and Januvia to the medication room. The nurse disposed of the Risperdal Concentrate in the container of drug buster that was attached to the wall. RN #1 crushed the Metformin and the Januvia in 2 separate cups. When the nurse went back to the residents room to administer the medication the resident refused the Januvia. RN #1 placed the cup with the crushed Januvia mixed with applesauce on the residents over-bed table. After the resident took the Metformin, RN #1 left the room, leaving behind the cup with the Januvia mixed with applesauce on the over-bed table. While RN #1 was at the medication cart signing the MAR indicated [REDACTED]. I have to throw it away. She went into the residents room to get it and it was gone. She asked the other nurse on the unit if she threw it away and she said she did not. The nurse then said, (The MDS Coordinator) probably threw it away. RN #1 then drew up 10 Units of Humulin R insulin to administer to Resident #9. When preparing the insulin, RN #1 removed two syringes from the medication cart but only used one. RN #1 then went back into Resident #9's room to administer the insulin and left the second syringe on top of the medication cart outside of the residents room. There were no residents in the area of the medication cart. 2) On 5/17/17 at 8:39 a.m., the surveyor observed RN #2 had removed the following medications from the medication cart, placed the wrapped tablets in a plastic medication cup, and a sealed bottle of Kayexalate into a small plastic drinking cup in preparation for administration to Resident #6: 1) Cardizem (a medication used to treat high blood pressure and chest pain) 30 milligram (mg) tablet. 2) Januvia (a medication used to treat diabetes mellitus) 50 mg tablet. 3) Kayexalate (a medication used to treat a high potassium level in your blood) 15 grams liquid. 4) Mucinex-DM (a medication used to treat cold and cough symptoms) 600-30 mg tablet. 5) Protonix EC (a medication used to treat certain stomach and esophagus problems) 40 mg tablet. RN #2 entered Resident #6's room and proceeded to prepare the antibiotic ordered via intravenous (IV) infusion after she placed the cup with 4 medications and the bottle of Kayexalate on the over bed table next to resident. At 8:45 a.m., RN #2 left the room after Resident #6 was complaining of shortness of breath and went to the nurses station and asked the Unit Clerk for a Respiratory Therapist. RN #2 then grabbed a key from the desk and went into the soiled utility room to discard the used IV bag from a previous dose of medication that had been infused. The cup and bottle with the above identified medications remained at Resident #6's bedside out of sight of RN #2 for 30 seconds. There were no other resident's in the vicinity of the medication and upon her return proceeded to administer the medications to Resident #6. When interviewed by the surveyor on 5/17/17 at 1:25 p.m., RN #2 confirmed that the medications should not have been left at the residents bedside out of her sight. When interviewed by the surveyor on 5/18/17 at 10:47 a.m., the Director of Nursing (DON) confirmed that the RN's should not have left the medications at the Residents bedside or on the medication cart out of their view. The DON also confirmed that MDS Coordinator had discarded the crushed Januvia. N.J.A.C. 8:39 - 29.4 (h)

Based on interview and record review, it was determined that residents were not consistently offered bed time snacks. This deficient practice occurred for 2 of 3 residents attending the group meeting. Evidenced as follows: The surveyor conducted the Group Meeting on 4/4/16 at 11:00 a.m., 2 of 3 residents stated that they were not offered a bed time snack. Residents further stated no one come around to offer snacks. The surveyor interviewed the Director of Nursing (DON) on 4/5/16 at 1:30 p.m., who stated that the hospital kitchen sends prescribed snacks for Diabetic residents on the unit, which were distributed by the Certified Nursing Assistant (CNA) every evening. The DON added the pantry usually was filled with items like cheese, crackers, juices, milk, sandwiches such as peanut butter/jelly, ham and turkey, ice cream, and soda which residents can get themselves. The DON explained that the facility does not have a system in place to verify whether staff offered a bed time snacks to each and every resident. The DON further stated that facility had system in place since last night to assure that CNA's will now offer bed time snack on a regular basis. NJAC 8:39 - 17.2 (f)1ii

Based on observation, interview, and record review it was determined that the facility failed to assure adequate privacy as it relates to clinical and personal information. this deficient practice was note for 1 (Resident #3) of 7 residents reviewed for privacy and was evidenced by the following: On 4/4/16 at 8:55 a.m. the surveyor approached the medication cart in the hallway in front of the room of Resident # 3. The medication nurse was in the resident's room. The computer that was attached to the medication cart was logged onto the resident's open chart. The information on the screen included the residents height, weight, date of birth, age, allergies [REDACTED]. At 9:18 a.m. the surveyor observed the nurse administer an injectable medication to the resident. The entire time that the nurse was in the residents room the medication cart with the attached computer was outside of the residents room and the screen was logged onto the residents open chart. The nurse exited the room at 9:25 a.m. and returned to the medication cart. On 4/5/16 at 1 p.m. the surveyor spoke with the Director of Nursing (DON) and the Administrator who agreed that the nurse should not have left the computer screen open to the residents personal information in the hallway unattended. The DON further explained that the staff were told to click on the lock icon to collapse the screen when walking away from the medication cart. NJAC 8:39-4.1 (a) 18

Based on observation, interview, and record review it was determined that the facility failed to ensure that the nurses obtained vital signs prior to administering medication to residents with monitoring guidelines. This deficient practice was noted for 2 of 2 residents, Residents #7 and #9, observed during medication pass. Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: On 4/5/16 at 9 a.m. the surveyor observed the nurse administer medication to Resident # 9. The resident received [MEDICATION NAME] 12.5 mg. The order included the cautionary warning to monitor blood pressure and heart rate. The nurse obtained the resident's blood pressure and heart rate from a clip board which was on the medication cart and logged this information into the computer. On 4/5/16 at 10:24 a.m. the surveyor observed the nurse administer medication to Resident # 7. The resident received [MEDICATION NAME] 12.5 mg. The order contained the cautionary warning to monitor heart rate and blood pressure. The nurse obtained the residents blood pressure and heart rate from a clip board which was on the medication cart and logged this information into the computer. At 10:40 a.m. the surveyor asked the nurse when the vital signs were taken. The nurse said the Certified Nursing Assistant took the vital signs at 7:30 that morning. The surveyor reviewed the facility's policy and procedure for Medication Administration. #5 under procedure read All parameters will be observed and results recorded on the (Medication Administration Record) before medication is given. Medication may be held if parameters are not met. The policy and procedure did not specify who was to take the vital signs. NJAC 8:39-27.1 (a)

Based on observation, and interview, it was determined that the facility failed to maintain a medication error rate below 5%. The surveyor observed 2 nurses administer 32 doses of medication to 4 residents and there were 2 errors. This resulted in a medication error rate of 6.25%. The deficient practice was evidenced by the following: 1. On 4/5/16 at 9:46 a.m. the surveyor observed the nurse administer [MEDICATION NAME] 12.5 mg to Resident # 9. The cautionary on the Medication Administration Record [REDACTED]. The surveyor reviewed the manufacturer specifications which indicated that the medication should be taken with food. The nurse did not offer the resident any food or milk. 2. On 4/5/16 at 10:30 a.m. the surveyor observed the nurse administer [MEDICATION NAME] 12.5 mg to Resident # 7. The cautionary on the MAR indicated [REDACTED]. The surveyor reviewed the manufacturer specifications which indicated that the medication should be taken with or immediately following a meal. The nurse did not offer the resident a meal. According to the nurse it had been 2 hours since breakfast. NJAC 8:39-27.1 (a)

Based on observation, and interview, it was determined that the facility failed to secure medication during the medication pass. This was observed for 1 of 2 nurses, Nurse # 2. The deficient practice was evidenced by the following: On 4/5/16 at 9 a.m. the surveyor observed Nurse #2 prepare 9 medications to administer. After pouring the medication the nurse left the medication on top of the medication cart in the hall by the residents room and went to wash his hands at the nurses station. At 9:40 a.m. Nurse #2 left 10 medications on the medication cart, including 1 controlled substance, when he went down the hall to ask a staff member to translate. Another nurse came over and picked up that controlled substance. When he returned a few minutes later she returned it to him. At 10:05 a.m. Nurse # 2 left the medication cart unlocked while he went into the medication room and closed the door. The nurse returned at 10:09 a.m. The surveyor said to the nurse You left the cart open. The nurse replied oh my bad and locked the cart. He then put a syringe, 2 needles, and a vial of Heparin on the cart and went to wash his hands. He came back after 2 minutes. At 10:30 a.m. Nurse # 2 went into a residents room to administer 7 crushed medications. He left 1 crushed pill in a medication cup on the medication cart in the hallway outside of the room while he administered the other 7 medications to the resident. The nurse then went back to the medication cart outside the room for the 1 crushed pill. The surveyor did not observe any resident in the area at the times of these observations. On 4/5/16 at 1 p.m. the surveyor discussed the concerns with the Director of Nursing. She agreed that Nurse # 2 should not have left the medication on the cart unattended. She further stated I cannot provide a rebuttal to that. He doesn't usually pass medication but we had a call out. NJAC 8:39-29.4 (h)

Based on observation, interview, and record review it was determined that the facility failed to ensure that all Certified Nurses Aids (CNA) maintained their certifications. This was found with 1 of 9 CNAs whose certification dates were reviewed. The deficient practice was evidenced by the following: On [DATE] at 10 a.m. the surveyor reviewed the list of Certified Nursing Assistants and their certifications expiration dates. There was one CNA whose certification expired on [DATE]. The surveyor questioned the Director of Nursing (DON) about it. The DON said she would look into it. On [DATE] at 12 p.m. the Administrator said that the CNA renewed her expired certification today and brought in proof. The surveyor reviewed the staffing schedule which showed that since the CNAs certification expired the CNA worked 20 shifts. The Administrator and DON did not provide an explanation as to why the CNA was working with an expired certification. The Administrator said we kept reminding her. NJAC 8:,[DATE].6 (a)

Based on observation, interview and record review it was determined that the facility failed to administer medications without a medication error rate less than 5% during the medication pass on the mornings of 3/3 and 3/4/15. Four Nurses administered 25 medications to 7 residents with 2 errors which resulted in an 8% medication error rate. This deficient practice was identified for 2 of 7 residents, Resident #'s 5 and 9. The evidence was as follows: 1. The surveyor observed Nurse #1 administer medications to Resident #5 on 3/4/15 at 9:28 a.m. Resident #5 had a current physician's orders [REDACTED]. On 3/4/15 at 10 a.m. during surveyor interview with both Resident #5 and Nurse #1 they stated that breakfast was delivered between 8:00 and 8:30 a.m. 2. The surveyor observed Nurse #2 administer medications to Resident #9 on 3/4/15 at 9:35 a.m. Resident #9 had a current physician's orders [REDACTED]. The Nurse #2 told the surveyor that breakfast was between 8:00 to 8:30 a.m. On 3/4/15 the surveyor reviewed the manufacturer's recommendations and the cautionary warnings listed in the Electronic Medication Administration Record [REDACTED]." The surveyor observed that for both Resident #'s 5 and 9 that the medication was not given with any food. (See examples 1 and 2 above). The surveyor interviewed the Director of Nursing at 11:35 a.m. who acknowledged that the residents had not received food with the medication but should have. N.J.A.C. 8:39-11.2(b)

Based on observation and interview it was determined that the facility failed to insure that medical supplies were removed from active stock when expired. This deficient practice was observed in 1 of 1 area of medication storage. The evidence was as follows: On [DATE] at 12:45 p.m. in the presence of a facility Nurse, the surveyor observed medications stored in the refrigerator in the medication room. There was one injection vial of Lorazepam (Ativan) 2 milligrams/milliliter which had expired in ,[DATE]. On [DATE] at 11:55 a.m. the surveyor interviewed the Direct of Nursing who stated that the above medication should have been removed from active stock before it expired. N.J.A.C. 8:39- 29.4(g)