Every finding on record at Woodcliff Lake Health & Rehabilitation Center

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the resident's primary physician (MD) accurately dated their physician progress notes (PPN) during their visit to ensure the resident's current medical regimen was up to date. This deficient practice was observed for 3 (three) of 18 residents (Residents #12, #18, and #40). This deficient practice was evidenced by the following: 1. On 4/30/25 at 10:30 AM, the surveyor observed Resident #12 asleep in bed. On 4/30/25 at 11:54 AM, the surveyor reviewed the electronic Medical Record (eMR)/ hybrid medical record (paper and electronic) of Resident #12, which revealed the following: A review of the admission Record (AR - an admission summary) reflected that Resident #12 was admitted with diagnoses that included but were not limited to asthma (a lung disorder characterized by airway narrowing). A review of the recent quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) with a date of 4/14/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that the resident had moderately impaired cognition. A review of the PPNs in the eMR reflected the following Effective Date, Created Date, and/or Late Entry (any documentation that is recorded in the eMR beyond 24-48 hours of the encounter is classified as a late entry) designation which indicated the PPN of MD #1 was not documented on the effective date (Date of Service): 1. PPN with an effective date of 9/26/24 and a created date of 10/26/24. 2. On 4/30/25 at 10:34 AM, the surveyor observed Resident #18 in bed sleeping. On 5/2/25 at 11:50 AM, the surveyor reviewed the eMR of Resident #18, which revealed the following: A review of the AR reflected that Resident #18 was admitted with diagnoses that included but were not limited to Parkinson's (movement disorder of the nervous system that worsens over time) disease without dyskinesia (unintended or involuntary movement) without mention of fluctuations. A review of the recent Q/MDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 5 out of 15, which indicated severely impaired cognition. A review of the PPN of MD #2 in the eMR reflected the following: 1. PPN with an effective date of 1/21/25 and a created date of 2/10/25. 2. PPN with an effective date of 3/21/25 and a created date of 4/4/25. 3. On 4/30/25 at 11:19 AM, the surveyor observed Resident #40 awake, who stated that they had not seen the doctor recently. On 5/2/25 at 12:51 PM, the surveyor reviewed the eMR of Resident #40, which revealed the following: A review of the AR reflected that Resident #40 was admitted with diagnoses that included but were not limited to chronic obstructive pulmonary disease (a disease that restricts breathing). A review of the annual MDS, dated [DATE], indicated that the facility assessed the residents' cognitive status using a BIMS score of 13 out of 15, which indicated intact cognition. A review of the PPN of MD #2 in the eMR reflected the following: 1. PPN with an effective date of 3/12/24 and a created date of 10/17/24. 2. PPN with an effective date of 3/26/24 and a created date of 10/17/24. 3. PPN with an effective date of 4/5/24 and a created date of 10/17/24. 4. PPN with an effective date of 5/24/24 and a created date of 10/17/24. 5. PPN with an effective date of 6/11/24 and a created date of 10/17/24. 6. PPN with an effective date of 7/26/24 and a created date of 10/17/24. 7. PPN with an effective date of 8/13/24 and a created date of 10/17/24. 8. PPN with an effective date of 9/10/24 and a created date of 4/4/25. 9. PPN with an effective date of 10/25/24 and a created date of 4/4/25. 10. PPN with an effective date of 11/11/24 and a created date of 4/4/25. 11. PPN with an effective date of 12/20/24 and a created date of 4/4/25. 12. PPN with an effective date of 2/7/25 and a created date of 4/4/25. 13. PPN with an effective date of 3/11/25 and a created date of 4/4/25. On 5/2/25 at 10:20 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that both MDs came regularly to the facility and would write their PPN to the eMR. On 5/5/25 at 09:20 AM, MD #2 met with the team of surveyors to discuss the above concern. The MD #2 stated that they had a complete record, but had moved them over that day. MD#2 stated that they had their own system, which is [Name redacted] electronic health record (EHR), where they had all their documentation, and that two staff members, the Director of Nursing (DON) and the Nursing supervisor could access the system due to Health Insurance Portability and Accountability Act (HIPAA - confidentiality of medical records). On 5/5/25 at 9:44 AM, the surveyor called MD #1's office to discuss the above concern, but the secretary stated that the MD was on vacation. On 5/5/25 at 12:05 PM, the surveyor met with the Licensed Nursing Home Administration (LNHA) and DON. The DON acknowledged the concern about the MD's medical record availability. A review of the facility's policy titled Physician Services with a revised date of 10/2024 under Policy Interpretation and Implementation: 6.b) The physician progress noted shall be maintained in accordance with acceptable professional standards and practices as necessitated by the medical beneficiary's and medical condition. NJAC 8:39-23.2(a)

Complaint number: NJ00169346 Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards of practice by not clarifying a Physician's Order (PO) for 1 of 5 residents reviewed (Resident #175). This deficient practice was evidenced by the following: On 5/1/25 at 9:52 AM, the surveyor reviewed the closed electronic medical record (E-mar) for Resident #175 which revealed the following: A review of the Resident #175's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included but were not limited to: pneumonia, dysphagia (difficulty swallowing), gastrostomy (the creation of an artificial external opening into the stomach for nutritional support, tube feeding (TF), or enteral feeding (EF)), and malignant neoplasm of major salivary gland. A review of the Discharge Minimum Data Set (MDS) an assessment tool used for the management of care) date 11/18/23, revealed under Section C, a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated that the resident had severe cognitive impairment. The MDS further revealed under Section K, that Resident #175 was receiving TF. A review of the November 2023 Physician orders (PO), revealed a PO dated 11/2/2023, Enteral Feed Order four times a day Bolus Feeding. Recommend 8 (237 milliliter (ml)) can of Jevity 1.2 (1422 total volume (TV)). Administer 1 can and half at 8am, 12pm, 4pm, and 8pm. On 5/1/25 at 12:12 PM, the surveyor interviewed the Registered Dietitian (RD#1), who stated the EF PO for Resident #175, should have been clarified because the PO states to give eight and six cans of Jevity 1.2 in the same order. RD#1 further stated they do not know why the error was not corrected by the nurse providing the EF. On 5/2/25 at 12:46 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Chief Operating Officer (COO) to review concerns regarding the PO for Resident #175. The DON stated the Regional Registered Dietitian (RRD#1) was looking into the concern and inform the surveyor of their findings. On 5/2/25 at 12:56 PM, the surveyor interviewed RRD #1 with the DON present. RRD #1 stated they were unable to explain the conflicting EF PO, but that Resident #175 was receiving eight cans of Jevity 1.2 per day and that had been the correct Enteral Feeding PO for the resident. Neither RRD #1 or the DON could explain PO error nor why the nurse did not correct the error. On 5/6/25 at 9:15 AM, the LNHA provided the surveyor with a facility policy titled, Administering Medication Using Electronic System (PCC) with an updated date of 11/2024. Under the policy interpretation and implementation, it states, 3. Document tube feeding administration as per order in EMAR .6. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right tie and right method (route) of administration before giving the medication. On 5/6/25 at 11:01 AM, the surveyor met with LHNA, DON, COO and Regional RN (RRN #1) for the exit conference. No further pertinent information provided. NJAC 8:39-19.4(a)(1)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's primary physician (MD) responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every 60 days for Medicaid recipient residents. This deficient practice was identified for 1 (one) of 18 residents (Resident #12) reviewed for physician visits. This deficient practice was evidenced by the following: On 4/30/25 at 10:30 AM, the surveyor observed Resident #12 asleep in bed. On 4/30/25 at 11:54 AM, the surveyor reviewed the electronic Medical Record (eMR)/ hybrid medical record (paper and electronic) of Resident #12, which revealed that the resident's MD there is no Physician Progress Notes (PPN) after 10/29/24 and 2/25/25. A review of the admission Record (AR - an admission summary) reflected that Resident #12 was admitted with diagnoses that included but were not limited to asthma (a lung disorder characterized by airway narrowing). A review of the recent quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) with a date of 4/14/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that the resident had moderately impaired cognition. On 5/2/25 at 10:20 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that the MD comes regularly to the facility and writes their PPN to the eMR. On 5/5/25 at 9:44 AM, the surveyor called MD's office to discuss the above concern, but the secretary stated that the MD was on vacation. On 5/5/25 at 12:05 PM, the surveyor met with the Licensed Nursing Home Administration (LNHA) and the Director of Nursing (DON), who did not provide further information. A review of the facility's policy titled Physician Services with a revised date of 10/2024 under Policy Interpretation and Implementation: 9. After the initial 30-day visit, all visits must then occur at 30-day intervals up until 90 days after the admission date. After the first 90 days, visits must be conducted at least every 60 days thereafter. Additional visits after the initial visit can be conducted by the physician, physician's assistant, or Nurse Practitioner. NJAC 8:39-23.2(d)

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure a urinary catheter drainage bag was covered to promote dignity for 1 (Resident #68) of 4 sampled residents reviewed for dignity. Findings included: Review of a facility policy titled, Quality of Life-Dignity, dated June 2022, specified, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation Residents shall be treated with dignity and respect at all times. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. The policy specified, Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered. Review of an Admission Record indicated the facility admitted Resident #68 with diagnoses that included benign prostatic hyperplasia with lower urinary tract symptoms, chronic heart failure, and need for assistance with personal care. The admission Minimum Data Set (MDS), dated [DATE], revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Per the MDS, Resident #68 required extensive assistance with bed mobility, toilet use, and personal hygiene and had an indwelling urinary catheter. A review of Resident #68's care plan, initiated 12/19/2022 and revised 03/14/2023, revealed the resident had an indwelling catheter. Interventions instructed staff to position the resident's urinary catheter drainage bag and tubing below the level of the resident's bladder and away from the entrance door. A review of Resident #68's Order Summary Report, for March 2023, revealed an order dated 03/12/2023 to cover the resident's urinary catheter drainage bag every shift for dignity and privacy. On 03/20/2023 at 10:44 AM, Resident #68 was observed lying in bed with their urinary catheter drainage bag hanging from their bedframe on the left side of the bed. The urinary catheter drainage bag was not covered, faced the door and was visible from the hallway. The urinary catheter drainage bag contained approximately 100 milliliters (ml) of yellow liquid. On 03/20/2023 at 11:24 AM, Resident #68 was observed lying in bed with their urinary catheter drainage bag hanging from their bedframe on the left side of the bed. The urinary catheter drainage bag was not covered, visible from the doorway, and yellow liquid could be seen inside the bag from the doorway. In an interview on 03/20/2023 at 11:26 AM, Licensed Practical Nurse (LPN) #16 stated Resident #68 had a privacy cover bag for their urinary catheter drainage bag, but it was on other side of the bed. The LPN stated the resident's urinary catheter drainage bag was uncovered and was visible from the hallway, but the bag should have been covered. LPN #16 stated any staff that observed a urinary catheter drainage bag not in a privacy cover should put it in a privacy cover. During an interview on 03/22/2023 at 8:22 AM, Certified Nursing Assistant (CNA) #17 stated Resident #68 had a urinary catheter and their urinary catheter drainage bag should be covered. CNA #17 stated she expected a urinary catheter drainage bag to be in a privacy cover to maintain a resident's dignity. CNA #17 stated all staff were responsible for ensuring a resident's urinary catheter drainage bag was maintained in a privacy cover. In an interview on 03/22/2023 at 8:34 AM, Registered Nurse (RN) #18 stated Resident #68 had a urinary catheter, and the catheter drainage bag should be placed below the bladder and in a privacy cover. RN #18 stated she expected a resident's catheter drainage bag to be in a privacy bag to maintain a resident's dignity. During an interview on 03/22/2023 at 11:14 AM, the Director of Nursing (DON) stated Resident #68's urinary catheter drainage bag should always be in a privacy cover, except if the resident went to therapy and the resident requested a leg bag. The DON stated she expected urinary catheter drainage bags to be covered to maintain a resident's dignity. She stated the urinary catheter drainage bag should not be visible from the hall or doorway. The DON stated CNAs and nurses were responsible for ensuring urinary catheter drainage bags had a privacy cover. She stated CNAs should check to see if the urinary catheter drainage bag was in a privacy cover when care was provided or placed in a privacy cover when care was not being provided. The DON stated nurses should round to check to ensure urinary catheter drainage bags had a privacy cover as well. In an interview on 03/22/2023 at 1:27 PM, the Administrator stated CNAs and nurses were responsible for placing urinary catheter drainage bags in a privacy cover. The Administrator stated every shift had a supervisor on the floor, and the supervisor should periodically check to ensure urinary catheter drainage bags were covered, and the resident's assigned nurse should check as well. The Administrator stated he expected a resident's urinary catheter drainage bag to be placed in a privacy cover to maintain a resident's dignity. New Jersey Administrative Code S 8:39-4.1(a)(12)

Based on interviews, record review, document review, and facility policy review, it was determined the facility failed to report an allegation of physical abuse to the physician and responsible party for 1 (Resident #31) of 6 residents reviewed for abuse. Findings included: Review of a facility policy titled, Abuse, Neglect, and Exploitation, dated October 2018, indicated, 9. Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: a. Respond to the needs of the resident and protect them from further incident b. Notify the Director of Nursing and Administrator c. Initiate an investigation immediately d. Notify the attending physician, resident's family/legal representative ad Medical Director. Review of an Admission Record, indicated the facility admitted Resident #31 with diagnoses that included atrial fibrillation, psychosis, and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Review of an incident report, dated 02/09/2023, revealed Resident #31 reported to Licensed Practical Nurse (LPN) #5 that they had had been hit by their roommate. Per the report, there was no notification made regarding the allegation of physical abuse. In an interview on 03/22/2023 at 12:43 PM, LPN #5 stated Resident #31 told her they had been hit by their roommate. She stated she reported the allegation of abuse to the supervisor, completed an incident report, and assessed the resident for injuries, none of which were found. LPN #5 stated she did not notify the physician or the resident's representative of the allegation, because Resident #31 denied being struck and just wanted their own room. During an interview on 03/23/2023 at 1:08 PM, the Director of Nursing (DON) stated the physician and resident's family should be notified of any allegation of abuse. The DON stated the allegation of abuse reported by Resident #31 was not reported because there was nothing to report. The DON stated Resident #31's allegation that they were hit by their roommate, should have been considered an allegation of abuse and should have been reported. In an interview on 03/23/2023 at 3:48 PM, the Administrator stated allegations of abuse should be reported immediately. The Administrator stated Resident #31 alleged to a nurse that they had been hit by their roommate, but when the nursing supervisor interviewed Resident #31, the resident denied the allegation so there was no allegation of abuse to report. New Jersey Administrative Code S 8:39-5.1(a)

Based on interviews, record review, document review, and facility policy review, it was determined the facility failed to report an allegation of physical abuse to the state agency for 1 (Resident #31) of 6 residents reviewed for abuse. Findings included: Review of a facility policy titled, Abuse, Neglect, and Exploitation, dated October 2018, indicated, 13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the [events] that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law. Review of an Admission Record, indicated the facility admitted Resident #31 with diagnoses that included atrial fibrillation, psychosis, and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Review of an incident report, dated 02/09/2023, revealed Resident #31 reported to a nurse that they had had been hit by their roommate. Per the report, there was no notification to the state agency. During an interview on 03/23/2023 at 1:08 PM, the Director of Nursing (DON) stated the state agency should be notified of any allegation of abuse. The DON stated the allegation of abuse reported by Resident #31 was not reported because there was nothing to report. The DON stated Resident #31's allegation that they were hit by their roommate, should have been considered an allegation of abuse and should have been reported to the state agency. In an interview on 03/23/2023 at 3:48 PM, the Administrator stated allegations of abuse should be reported immediately. The Administrator stated Resident #31 alleged to a nurse that they had been hit by their roommate, but when the nursing supervisor interviewed Resident #31, the resident denied the allegation so there was no allegation of abuse to report. New Jersey Administrative Code S 8:39-5.1(a)

Based on interviews, record review, and policy review, the facility failed to ensure the baseline care plan indicated 1 (Resident #95) of 5 residents reviewed for falls was at high risk for falls. Findings included: The facility's policy, titled, Baseline Care Plan, revised in June 2022, indicated, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. A review of Resident #95's Admission Record revealed the facility admitted the resident with diagnoses that included lumbar disc degeneration, spondylolisthesis (when the vertebrae slip forward), difficulty walking, and muscle weakness. A review of the Nursing Admission-Readmission Screening, dated 08/19/2022, revealed Resident #95 had a current fall risk score of 60.0 upon admission to the facility, which indicated the resident was at high risk for falls. A review of Resident #95's undated Baseline Care Plan did not specify Resident #95's fall risk level or interventions to prevent the resident from falling. During an interview on 03/23/2023 at 3:24 PM, the Minimum Data Set (MDS) Coordinator stated, upon admission, the nurse would put together a basic (baseline) care plan for skin concerns, fall risk, wounds, and other care needs of the resident. The MDS Coordinator stated if a resident was admitted with a high fall risk, it should have been included on the resident's baseline care plan. On 03/23/2023 at 3:39 PM, a telephone interview was attempted with Registered Nurse #11, who was the admitting nurse when Resident #95 admitted to the facility. A voicemail message was left, but no return call was received. In an interview on 03/23/2023 at 3:43 PM, the Director of Nursing (DON) stated a resident's fall risk should be included on the baseline care plan. The DON stated she did not know why it would have been missed Resident #95's baseline care plan. During an interview on 03/23/2023 at 3:48 PM, the Administrator stated if a resident was admitted from the hospital with a high risk for falls, fall interventions should be included on the resident's baseline care plan. New Jersey Administrative CodeS 8:39-11.2(d)

Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure staff changed gloves during wound and incontinence care to reduce the risk of infection for 1 (Resident #20) of 3 residents reviewed for pressure ulcer/injury. Findings included: A review of a facility policy titled, Dressings, Dry/Clean, reviewed February 2022, revealed, 6. Position resident and adjust clothing to provide access to affected area. 7. Wash and dry your hands thoroughly. 8. Put on clean gloves. Loosen tape and remove soiled dressing. 9. Pull glove over dressing and discard into plastic or biohazard bag. 10. Wash and dry your hands thoroughly. 11. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 12. Using clean technique, open other products. 13. Pour prescribed cleansing solution over the dry, clean gauze into clean basin section of tray. 14. Put on clean gloves. 15. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. 16. Cleanse the wound. The policy further revealed, 17. Use dry gauze to pat the wound dry. 18. Apply the ordered dressing and secure with tape. 19. Discard disposable items into the designated container. 20. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. A review of a facility policy titled, Urinary Incontinence Care, revised June 2022, indicated, 2. Management of incontinence will follow relevant clinical guidelines in how to provide the proper incontinent care to prevent Infection. The policy further indicated, Use infection control measures and standard precautions during the entire procedure. A review of an Admission Record indicated Resident #20 was admitted to the facility with diagnoses that included stage 4 pressure ulcer of sacral region and multiple sclerosis. The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Per the MDS, Resident #20 was totally dependent on staff for toilet use, always incontinent of bowel and bladder and had one stage 4 pressure ulcer. A review of Resident #20's Care Plan revised 03/23/2022, indicated the resident had chronic/recurrent urinary tract infections. Interventions directed the staff to maintain standard precautions when providing resident care. A review of Resident #20's Care Plan, revised 06/20/2022, revealed the resident had a stage 4 sacral wound. Interventions directed the staff to provide incontinence care every shift and as needed with preventative skin care and keep the resident's skin clean and dry. A review of the Order Summary Report indicated Resident #20 had a physician's order to cleanse the resident's sacral wound with normal saline, lightly pack the wound with gauze moistened with normal saline, and cover the sacral wound with a foam dressing daily and as needed. During an observation of wound care on 03/21/2023 at 12:13 PM, Licensed Practical Nurse (LPN) #1 prepared an overbed table with Resident #20's wound care supplies. The Infection Preventionist (IP) was present to assist LPN #1 with the resident's care. LPN #1 washed his hands and applied gloves. Resident #20 laid in bed with the IP standing on the resident's right side. Resident #20 was rolled over to their right side and LPN #1 cleansed the resident's wound with gauze soaked with normal saline. At this time, Resident #20 started to urinate, and LPN #1 stopped wound care. At 12:34 PM, Certified Nursing Assistant (CNA) #2 entered the resident's room and LPN #1 stepped out of the room, while the IP remained in the resident's room. CNA #2 washed her hands and applied gloves. CNA #2 removed a urine-soaked cloth from between the resident's legs and placed the cloth in the trash can. CNA #2 wore the same pair of gloves when she provided incontinence care for the resident, applied a barrier cream to the resident's buttocks, applied a clean brief, and covered the resident up. CNA #2 stated she should have changed her gloves after incontinence care was provided before she placed a clean incontinence brief on the resident. On 03/21/2023 at 12:40 PM, LPN #1 resumed Resident #20's wound care, prepared his supplies, washed his hands, and applied gloves. The IP was present in the resident's room and stood on the right side of Resident #20's bed. LPN #1 cleansed the resident's wound with gauze soaked in normal saline and patted the wound area dry. LPN #1 changed gloves and then lightly packed the resident's wound with gauze soaked with normal saline and applied an adhesive foam dressing. The dressing did not adhere to the resident's skin due to the barrier cream that had been applied during incontinence care provided by CNA #2. At this time, Resident #20 started to urinate again. LPN #1 left the dressing on the resident and called for CNA #2 to again provide incontinence care for the resident. On 03/21/2023 at 12:51 PM, CNA #2 washed her hands, applied gloves, and provided incontinence care. The IP stated the resident's draw sheet needed to be replaced due to it being soiled. While wearing the same gloves she used during incontinence care, CNA #2 grabbed a clean draw sheet from a chair in the resident's room and opened a cabinet door to get a clean incontinence brief. The clean incontinence brief was applied to the resident and the draw sheet was put on the resident's bed. CNA #2 never changed her gloves during the care. On 03/21/2023 at 1:03 PM, LPN #1 prepared supplies for Resident #20's wound care, washed his hands, and put on gloves. LPN #1 removed the previous dressing, threw the dressing away, and changed his gloves. LPN #1 cleansed the resident's wound with gauze soaked in normal saline, patted the wound area dry, and lightly packed the wound with gauze soaked in normal saline. LPN #1 did not change his gloves after cleansing the wound or before applying the normal saline soaked gauze inside of the resident's wound. During an interview on 03/21/2023 at 1:13 PM, LPN #1 stated he should have changed his gloves after cleansing the wound and before applying the wound treatment. LPN #1 stated not changing his gloves could lead to infection. During an interview on 03/21/2023 at 1:07 PM, the Director of Nursing (DON) stated staff should change their gloves after the gloves become soiled. Per the DON, staff should have changed their gloves before applying a new incontinence brief on Resident #20. The DON stated it was not appropriate to get supplies with the same gloved hands after incontinence care was provided. During an interview on 03/23/2023 at 1:07 PM, the IP stated CNA #2 should have changed her gloves during incontinence care and washed her hands when the CNA went from dirty to clean. The IP also stated LPN #1 should have changed his gloves before applying the treatment to the resident's wound. On 03/23/2023 at 1:22 PM, the Administrator stated if gloves become soiled during care, staff should change their gloves. New Jersey Administrative Code S 8:39-19.4(a)(1-6)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain infection control protocols during a Covid-19 outbreak. This was observed in 2 of 3 cohorts. The deficient practice was evidenced by the following: On 5/3/22 the survey team conducted a Focused Infection Control Survey at the Facility. The facility was in an outbreak of Covid-19 with 28 positive Covid-19 residents located in the red zone on the second floor. On 5/3/22 at 11:43 AM the surveyor arrived on the second floor. The red zone was located behind two clear plastic zippered barriers with a space in the middle for donning and doffing Personal Protective Equipment (PPE) when entering and exiting the red zone. In addition to the red zone there was also a yellow zone, for persons under investigation (PUI) for COVID-19, and a green zone, with rooms for residents who were not PUI or COVID-19 positive. Yellow zone rooms had a sign outside the room to alert staff and others that the resident was under observation for Covid-19, that they were on tranmission based precautions, and that full PPE was required to be worn prior to entering the room. 1. On 5/3/22 at 12:00 PM the surveyor oberved a Licensed Practical Nurse (LPN) who identified herself as being assigned to the red zone. The LPN was wearing goggles, an N95 mask with a surgical mask on top. The LPN said she was fit tested for the N95 mask. The bottom strap for the N95 mask was on the top of her head with the top strap. The LPN was standing at the nurse's station outside of the red zone. The LPN said she just put that mask on when she left the red zone. She said she doffed her gloves, gown, cleaned her goggles with a sanitizing wipe, doffed her N95 mask and surgical mask between the double barrier at the entance to the red zone and threw them away in the receptacle in that area. She said she stepped outside of the double barrier, outside of the red zone, and donned a new N95 and surgical mask. The surveyor asked her how she was supposed to wear her N95 mask. She felt around on her head with her hand but didn't answer. The Unit Manager/LPN (UM/LPN) came over and explained to the LPN how her N95 mask should have been worn. The LPN adjusted the straps for the N95 mask properly. 2. On 5/3/22 at 12:05 PM the surveyor was speaking with the LPN and the UM/LPN, a Certified Nursing Assistant (CNA) walked by. The surveyor asked the LPN who that CNA was, and where she was working. The LPN said the CNA was assigned to the red zone. The CNA was wearing a KN95 mask and a face shield. The surveyor asked the CNA if she wore an N95 in the red zone. The CNA became angry. The CNA stated [The corporate nurse] said I could wear this in the covid unit. I cannot wear that mask [pointed to the UM/LPN's N95 mask]. I am not supposed to be working on the Covid Unit. If you want to I can go home. I am from agency. On 5/3/22 at 12:20 PM the surveyor asked the corporate nurse if she told the CNA assigned to the red zone that she could wear a KN95 mask in the red zone. The corporate nurse said she did not tell the CNA that. She confirmed that they have to wear an N95 mask in the red zone. On 5/3/22 at 12:23 PM the surveyor observed the signage on the barrier that led to the red zone. There were signs that read as follows: How to use your N95 respirator-Wear your N95 properly so it is effective Number 3 under a picture of a person wearing an N95 respirator read Pull the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears. Do not crisscross the straps. Make sure the straps lay flat and are not twisted. Respirator on/Respirator off-When you put on a diposable respirator position your respirator correctly and check the seal to protect yourself from Covid-19. The third photo in the second row had a picture of the back of a person's head with an X on it that read Do not criss cross the straps. RED ZONE to identify the area behind the zippered barrier as an area where resident's who were confirmed positive for Covid-19 resided. STOP Droplet precautions to identify that the residents behind the barrier were on droplet precautions. STOP Contact precautions to identify that the residents behind the barrier were on contact precautions. 3. On 5/3/22 at 11:49 AM, the surveyor observed a housekeeper coming out of a room and into the hallway in full personal protective equipment (PPE), wearing a gown, N95 mask, face shield, and gloves. The room had a yellow zone sign outside. There were no residents in the room. The UM/LPN later indicated the resident was moved out of the room due to a positive COVID-19 test result. That resident had been moved to the red zone. The surveyor spoke with the housekeeper and asked questions about PPE use and cleaning the room. The housekeeper stated, No English and pointed down the hallway towards the nurses' station. On 5/3/22 at 11:55 AM, the surveyor observed the housekeeper exit the room being cleaned and go to her cart in front of the door to the room. The housekeeper, with gloved hands, moved supplies on the cart and retrieved supplies to take into the room. The housekeeper returned to the room, then brought a plastic bag with dark colored clothing items from the room and placed it on top of the white bin outside of the room, in the hallway, then returned to the room. 4. On 5/3/22 at 12:26 PM, the surveyor observed a dietary aide deliver food trays, and place them outside of the red zone. The dietary aide was wearing a surgical mask under an N95 mask. The straps of the N95 mask were at the nape of the dietary aide's neck. The surveyor asked the dietary aide about how the N95 mask, and the surgical mask were being worn. The dietary aide was unable to understand and answer the surveyor's question due to a language barrier. The surveyor informed the UM/LPN, who was nearby. The UM/LPN acknowledged the dietary aide was not wearing the PPE correctly and said she would accompany the dietary aide to the dietary supervisor to educate and correct how the mask was being worn. On 5/3/22 at 12:39 PM, the surveyor interviewed the UM/LPN about PPE use on the unit. The UM/LPN stated the facility policy was to use one gown then discard in the bin designated for gowns in the resident room. The UM/LPN added, gowns should be removed in the room and should not be worn in the hallway. On 5/3/22 at 1:30 PM the surveyor reviewed the facilities policy and procedure titled Coronavirus disease (Covid-19) prevention & control: Cohorting and Transmission-based precautions protocol. Under Red zone/area (cohort 1) number 4 read PPE required in the red zone/area includes strict use of : properly fitted N95 respirator, gown, gloves, and goggles/face shield. On 5/3/22 at 2:15 PM, the surveyor informed the Administrator of the concerns observed. The administrator acknowledged the housekeeper should not have worn PPE from the isolation room into the hallway and the staff should have worn N95 masks correctly. On 5/3/22 at 2:45 PM, the surveyor reviewed the facility's policy titled, Handwashing/Hand Hygiene dated 1/20/22, which read under Policy Interpretation and Implementation, employees must wash their hands, e. Before and after entering isolation precaution settings . r. After handling soiled or used linens, dressings, bedpans, catheters, and urinals and 8. The use of gloves does not replace handwashing/hand hygiene. The surveyor reviewed the facility's policy titled, Cleaning & Disinfecting Resident Room dated 1/22, which read under Steps in the Procedure, 8. When cleaning rooms of residents on isolation precautions, use personal protective equipment as indicated. The policy did not specify the process of removing PPE or exiting isolation rooms. NJAC 8:39-19.4 (a)

Based on observation, interview, and record review, it was determined that the facility failed to practice appropriate hand hygiene for 2 of 12 staff. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/2020 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene, which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. On 1/4/2021 at 10:48 AM, the surveyor observed the Licensed Practical Nurse/ Unit Manager (LPN/UM) on the 3rd floor LTC green unit perform hand hygiene. The LPN/UM washed her hands for 36 seconds under the stream of running water. The LPN/UM did not wet her hands before she applied the soap and did not lather or apply friction to her hands at any time outside of the running water. The surveyor asked the LPN/UM if she should have lathered outside of the stream of water. The LPN/UM replied, I always wash my hand hands under running water. At 10:55 AM, the surveyor observed the LPN on the 3rd floor perform hand hygiene. The LPN applied soap to her hands and washed them for 30 seconds without any water, and there was no lather. The surveyor asked the LPN why she didn't get any lather after rubbing her hands together for 30 seconds. The LPN did not respond. The surveyor asked if she received in-services, which instructed her to first wet hands and then apply soap and lather. The LPN replied that she was in-serviced to first wet her hands. The surveyor asked why she didn't do that; The LPN did not respond. At 1:30 PM, the surveyors discussed the above concerns with the Administrator, DON, and Corporate Nurse. No further information was provided by the facility. A review of the facility's Handwashing/ Hand Hygiene policy revised in November 2020 indicated: Wet hands, apply soap, then vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer). Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of the sink. Dry hands thoroughly with paper towels, then turn off faucets with a clean, dry paper towel. NJAC 8:39-19.4 (a) (N)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) properly contain the dirty laundry of a PUI resident for 1 of 1 staff; b) practice appropriate hand hygiene for 1 of 3 staff; c) ensure that workers are knowledgeable regarding the cleaning chemical used in the workplace for 1 of 3 staff; and, d) sanitize the table used for staff testing in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: A review of the U.S. CDC's Guidelines for Environmental Infection Control in Health-Care Facilities (2003) included, OSHA defines contaminated laundry as 'laundry which has been soiled with blood or other potentially infectious materials or may contain sharps.' The purpose of the laundry portion of the standard is to protect the worker from exposure to potentially infectious materials during collection, handling, and sorting of contaminated textiles through the use of personal protective equipment (PPE), proper work practices, containment, labeling, hazard communication, and ergonomics. It further included, Laundry workers should wear appropriate personal protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles. According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/20 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene, which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. According to the U.S. CDC's Interim Infection Prevention and Control Recommendations for HCP During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 11/4/20 included guidelines to Collection of Diagnostic Respiratory Specimens It specified that, Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. 1. On 11/19/20 at 9:15 AM, the surveyors, met with the Licensed Nursing Home Administrator (LNHA), who informed the surveyors that there was one positive COVID-19 resident on the 3rd floor that was transferred to the 2nd floor. The LNHA stated that the positive resident's roommate remained on the 3rd floor, tested negative for COVID, and was on observation for 14 days due to exposure. At that same time, the LNHA stated that all staff on the 3rd floor were mandated to wear an N95 mask and a face shield or goggles when on the units and full personal protective equipment (PPE), which included an N95 mask, gown, gloves, and eye protector or a face shield when inside resident rooms. On 11/19/20 at 10:29 AM, the surveyor observed the Certified Nursing Aide (CNA) exited a Person Under Investigation (PUI) room on the 3rd floor, walked past five rooms to the end of the hallway, and put the dirty laundry of the PUI resident into the three-compartment bins. The PUI room had no bin inside the room to put the soiled laundry of the PUI resident. At that same time, the CNA informed the surveyor that there wasn't a bin inside the PUI resident's room to collect the soiled linen, which was why she had to bring the soiled linen out of the room. The CNA stated that the three-compartment bins at the end of the hallway were used for all 3rd-floor long hall residents even though they were not PUI. She further noted that no instruction was given to her not to use the three-compartment bins for PUI residents. At 10:53 AM, the Registered Nurse/Unit Manager (RN/UM) stated that the CNA should not have taken the dirty laundry out of the PUI resident's room due to infection control. The RN/UM further noted that the PUI resident should have had a laundry bin inside their room for soiled laundry. At 11:37 AM, the Regional Infection Preventionist/RN (RP/RN) informed the surveyor that the PUI resident on the 3rd floor should be on a 14-day quarantine, monitored for symptoms, and should stay in their room. The RP/RN stated that staff must wear full PPE when inside the resident's room, there should be a bin inside the PUI room for soiled laundry. At 2:15 PM, the surveyors met with the Regional Nurse and RP/RN in the presence of the LNHA. The Regional Nurse and the RP/RN both acknowledged that the PUI room should have had a bin inside the room for soiled linens and that the PUI resident's laundry should not have been put in the same receptacle as the other non-PUI residents. The Regional Nurse and the RP/RN both stated that the CNA on the 3rd floor should have left the soiled laundry inside the PUI resident's room. 2. On 11/19/20 at 10:44 AM, the surveyor observed the Housekeeper (HK) on the 3rd-floor unit perform hand hygiene. The HK scrubbed his hands for 38 seconds under the stream of running water. The HK did not respond when asked by the surveyor if he should be applying friction and lathering outside the running water. At that time, the LNHA was made aware of the concern. The LNHA stated that the scrubbing of hands should not be done under running water. 3. On 11/19/20 at 10:40 AM, during an interview, the HK informed the surveyor that he had worked for the facility for over nine years. The surveyor asked the HK which disinfectant he used for frequently touched surfaces. The HK replied, I'm not sure. I don't pay attention to the name of the disinfectant. I don't check the names. The surveyor asked the HK if he needed to mix the cleaning agents. The HK replied, the disinfectant has to be mixed with water; you just need to put a little to make sure it's not too strong. The surveyor then asked the HK what the contact time (time that the disinfectant needs to stay wet on a surface to ensure efficacy). The HK replied, quickly, just a few seconds. The surveyor asked the HK how many seconds, and he responded, when you touch it, and it's dry, then it's dry. At 11:00 AM, the surveyors discussed the above concerns with the Director of Housekeeping (DH). The DH informed the surveyor that the facility used Sienna for disinfecting frequently touched surfaces with 5 minutes contact time. The DH stated that the HK should know better and was provided an in-service about the disinfectant. At 12:11 PM, the surveyors discussed the above concerns with the LNHA and Director of Nursing (DON). 4. On 11/19/20 at 9:15 AM, the surveyor interviewed the LNHA, who stated that the facility had a current Covid-19 outbreak for both residents and staff who had tested positive for Covid-19. On that same date and time, the LNHA stated that staff was being tested 2x/week every Monday and Thursday. Residents were tested weekly on Friday, and that it was the Infection Preventionist Nurses (IPN) responsibility to collect the specimens. On 11/19/20 at 1:06 PM, during Covid-19 nasopharyngeal (back of the nose and throat) swab collection, the surveyor observed that after completing a swab collection for the CNA, the IPN did not sanitize the table that was used for specimen collection. The surveyor asked the IPN why she did not sanitize the table. The IPN replied, I should have. At 3:09 PM, the surveyors met with the LNHA and DON and discussed the above concerns. The DON and LNHA both acknowledged that the IPN should have sanitized the table. The LNHA stated that the facility had no guidelines for a step by step Covid-19 specimen collection procedure. The facility provided no further information. A review of the facility's Handwashing/Hand Hygiene Policy with a revised date of August 2015 that was provided by the DON included, Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds under a moderate stream of running water, at a comfortable temperature. NJAC 8:39-19.4 (a) NJAC 8:39-27.1

Based on observation, interview and record review, it was determined that the facility failed to revise a care plan to address an open wound on the sacrum for 1 of 21 residents (Resident #8), reviewed for comprehensive person-centered care plan for a period of four months from 12/29/18 through 4/5/19. This deficient practice was evidenced by the following: On 7/1/19 at 9:08 AM, the surveyor observed Resident #8 laying in bed on a specialized mattress. On 7/2/19 at 11:40 AM, the surveyor observed Resident #8 in his/her room seated in a wheelchair with a cushion and padded leg rest in use. A review of the Face sheet (Resident information) reflected that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Comprehensive Minimum Data Set (MDS), an assessment tool, with Assessment Reference Date (ARD) of 3/27/19, indicated a brief interview for mental status (BIMs) score of 6 which reflected that the resident's cognition was severely impaired. The Comprehensive MDS also reflected that the resident had a healing stage 4 facility acquired wound. Review of the wound timeline provided by the Director of Nursing (DON) indicated that the resident was admitted to the facility on [DATE], with redness to the sacrum and a care plan implemented for skin and wound prevention. In addition, the wound timeline indicated the resident had a history of [REDACTED]. The wound timeline indicated that the sacrum healed on 4/5/18 and remained healed until 12/29/18, when a stage two sacral wound was identified by the nurse. The above wound timeline indicated that Resident #8's wound was unavoidable due to risk factors which included incontinence, limited mobility, history of skin breakdown, non-compliance with care and severe cognitive impairment. In addition, the resident was treated for [REDACTED]. This may have also contributed to the progression of the wound to deteriorate to an unstageable wound that required the wound doctor to perform wound debridement in order to accelerate wound healing. On 7/5/19 at 8:50 AM, the DON stated that after debridement, the sacral wound became a stage four and had further deteriorated when the resident came back from re-hospitalization on [DATE]. The Progress Note dated 4/9/19 and signed by the Nurse Practitioner, revealed that Resident #8 was readmitted to the facility status [REDACTED]. A review of the person-centered care plan revised on 4/12/18 reflected that the resident at risk for pressure ulcer due to incontinence, history of healed pressure ulcers, limited mobility and cognitive impairment. The revised care plan on 4/12/18, indicated a healed pressure ulcer to the sacrum and that skin was intact with a plan to continue to monitor interventions of the specialized mattress, cushion in the wheelchair, turn and reposition every two hours, apply Vitamin A and D or skin barrier during incontinent care and as needed. The same care plan interventions were re-evaluated on 1/9/19, with documentation to continue the plan of care. Further review of the person-centered care plan revealed that the care plan was not revised or updated to address the sacral wound that was identified on 12/29/18. It did not address the progression to the unstageable wound, and did not include that the resident was non-compliant with turning and repositioning and non-compliant with use of wedges and roll blankets. On that same day and time, the DON acknowledged that the care plan was not updated and/or, revised to reflect the identified stage two sacral wound on 12/29/18 and, that the 1/9/19 care plan was not revised when the facility had reviewed it at that time. The DON stated that the care plan was revised and updated in (MONTH) 2019. In addition, the DON stated that the care plan should be revised whenever there was a change in condition for example, when a resident developed a new wound. She also stated that care plans should be updated quarterly. A review of facility policy on Care Plans provided by the DON with an approved date of 7/16/06 indicated that, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. No further documentation was provided by the facility. NJAC 8:39-11.2(e)(1)

Based on observation, interview and record review, it was determined that the facility failed to clarify a physician's order for 1 of 21 residents (Resident #40); and, failed to follow a physician's order for administration of a medication with orders for monitoring the blood pressure for 1 of 21 residents (Resident #65) according to standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 7/1/19 at 8:56 AM, the surveyor observed Resident #40 lying in bed. A review of the resident's Face Sheet (an admission summary), reflected that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the 5/1/19 Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, indicated a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which reflected that the resident's cognition was severely impaired. A review of the Physician's Orders (PO) dated 6/18/19, revealed an order for [REDACTED]. The corresponding physician orders were transcribed into the (MONTH) and (MONTH) 2019 electronic Medication Administration Record [REDACTED]. The PO dated 6/25/19 for Vitamin C was plotted for 9 AM and 5 PM. Both orders were signed by nurses as administered. A review of the Consultant Pharmacist Evaluation revealed that the Consultant Pharmacist (CP) reviewed the medication regimen for Resident #40 on 6/18/19, which, was prior to the duplicate Vitamin C order on 6/25/19. On 7/5/19 at 12:51 PM, the survey team met with the Administrator, Director of Nursing (DON) and the Clinical Service Consultant (CSC) and discussed the above observations and concerns. The DON informed the surveyor that upon investigation, the nurses indicated that they were only administering one tablet of Vitamin C at 9 AM. The DON stated that the duplicate order for Vitamin C should have been clarified by the nurse, and should have been picked up by the 11-7 nurse during the 24-hour chart check. The DON further stated, that Resident #40 did not experience any negative outcome. On 7/8/19 at 8:43 AM, the surveyor interviewed the Registered Nurse (RN) who had signed the (MONTH) and (MONTH) 2019 eMAR at 9 a.m. The RN could not answer as to why the duplicate order for the Vitamin C was not clarified with the physician. On that same day at 8:53 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) informed the surveyor that the duplicate order for Vitamin C should have been clarified with the physician. She had no answer as to why she signed the eMAR on 7/1/19 at 9 AM for two separate Vitamin C orders. 2. On 7/1/19 at 8:59 AM, the surveyor observed Resident #65 assisted by the Speech Therapist during breakfast. A review of the resident's Face sheet reflected that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the 5/30/19 Comprehensive MDS, indicated a Brief Interview for Mental Status (BIMS) score of 99, which reflected that the resident's cognition was severely impaired. A review of the (MONTH) and (MONTH) 2019 Order Summary Report revealed an order dated 6/23/19 for [MEDICATION NAME] 5 milligram (mg) one tablet via gastrostomy tube (gt) three times a day (3x/day) for orthostatic [MEDICAL CONDITION] (low blood pressure), and to hold for systolic blood pressure (SBP) greater than 130. A review of the (MONTH) and (MONTH) 2019 electronic Medication Administration Record [REDACTED]. On 7/8/19 at 8:43 AM, the Registered Nurse (RN) informed the surveyor that [MEDICATION NAME] was a medication that had a blood pressure parameter. At that time, the RN could not speak to why she administered the [MEDICATION NAME] to Resident #65 when the SBP was greater than 130 in the month of (MONTH) and (MONTH) 2019. She further stated that she should have followed the physician's order and followed the parameters for [MEDICATION NAME]. On 7/8/19 15 8:53 AM, the LPN/UM informed the surveyor that the parameter for [MEDICATION NAME] should have been followed. On that same day at 9:08 AM, the RN informed the surveyor that the resident's blood pressure at that time was 114/64 and further stated that there was no negative effect on the resident. On 7/8/19 at 11:39 AM, the survey team met with the the Administrator, DON, and the CSC and discussed the above observations and concerns. The DON stated that the facility had no specific policy that addressed medication administration with blood pressure parameters. There was no additional information provided by the facility. A review of the Medication Administration Policy and Procedure with an effective date of 1/4/2007, did not address duplicate medication orders. NJ 8:39-11.2 (b)

Based on observation, interview and record review, it was determined that the facility failed to properly label and dispose of medications for 1 of 3 medication (med) carts inspected. This deficient practice was evidenced by the following: On [DATE] at 10:35 AM, the surveyor inspected the 3rd floor Short Hall med cart in the presence of a Licensed Practical Nurse/Unit Manager (LPN/UM). The surveyor observed Resident #288's [MEDICATION NAME] (used to relieve pressure cause by excess gas) 125 milligram (mg) bottle inside the med cart. The LPN/UM informed the surveyor that Resident #288 had expired and that the medication should have been disposed of. At that same time, the surveyor observed a bottle of Folic Acid (vitamin/supplement) 800 microgram (mcg) that had expired on ,[DATE]. The LPN/UM stated that there should be no expired medication in the med cart. The surveyor observed one [MEDICATION NAME] pen and one Basaglar insulin pen inside a clear plastic bag with no resident's name and no open date on the plastic bag or the pens. The LPN/UM stated that the [MEDICATION NAME] was for Resident #31, and the Basaglar insulin was for Resident #37. She further stated, that the standard of practice was that insulin pens should have the resident's name and an open date. On that same day and time, the surveyor observed two Artificial Tears eye drop containers with no resident's name. The LPN/UM stated that the Artificial Tears eye drops were a facility house stock/over the counter (OTC), and should have the resident's name. She further stated, that the two house stock Artificial Tears eye drops were for Resident #41 and #6. Furthermore, there was a third Artificial Tears eye drop bottle with no name and with an opened date of [DATE] and expiration date of [DATE], written on the eye drop bottle. The Artificial Tears bottle was inside the eye drop box. The box had the resident's name and an opened date of [DATE]. The LPN/UM informed the surveyor that there was a discrepancy on what was written on the eye drop bottle and the box. She indicated that there should have been a resident's name on the eye drop. On that same day and time, the surveyor observed a Breo Ellipta ,[DATE] inhaler (used to treat airflow obstruction) medication with no name and open date. The LPN/UM informed the surveyor that the inhaler was for Resident #73. She further stated that the inhaler should have the resident's name and open date. The surveyor interviewed the LPN/UM who stated that she would get in touch with the pharmacy to replace the above medications, and that she would get new OTC eye drops. She further stated, that the medications above would be disposed of and replaced with a new one. On [DATE] at 1:25 PM, the surveyor informed the Administrator, Clinical Service Consultant, and the Director of Nursing (DON) of the above concerns. The DON stated that there should have a name on the medication container of insulin and eye drops. A review of the undated facility's Policy titled Medication Labels provided by the DON indicated that, Labels are permanently affixed to the outside of the prescription container, if a label does not fit directly onto the product, e.g. eye drops, the label may be affixed to an outside carton, but the resident's name must be maintained directly on the actual product container, and Improperly or inaccurately labeled medications are rejected and returned to the pharmacy. NJAC 8:,[DATE].4 (a) (g)

Based on observation, interview and record review, it was determined that the facility failed to communicate a physician's order for speech consultation in accordance with professional standards of nursing practice for 1 of 21 sample residents (Resident #35). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, 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. The evidence was as follows: On 6/4/18 at 12:30 p.m., the surveyor observed resident #35 in the main dining room on the main floor. The resident was in a wheelchair appearing well groomed and awaiting lunch. On 6/4/18 the surveyor reviewed the medical record for resident #35. According to the resident's face sheet (an admission summary), the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The surveyor reviewed the dietary progress note dated 5/16/18 revealing a family member request for a speech consultation to evaluate appropriate food consistency. The surveyor reviewed the dietician's written communication dated 5/16/18 recommending a speech consultation. The surveyor reviewed a physician's telephone order dated 5/16/18 for a speech consultation. The surveyor reviewed the interdisciplinary progress note indicating the nurse had obtained a telephone order dated 5/16/18 for a speech consultation for the physician, and the order was carried out. On 6/4/18 at 12:35 p.m., the surveyor and the Assistant Director of Nursing (ADON) reviewed the interdisciplinary progress notes together with the telephone order for speech consultation noting the order was carried out. The ADON stated order carried out means that speech therapy had been contacted for a consultation. On 6/4/18 at 12:10 p.m., the surveyor spoke with the facility speech therapist (ST) who stated she was not aware of a physician's order dated 5/16/18 for speech consultation for resident #35 and had not treated resident #35 in the last month. The ST further stated she had been on vacation during the time the physician's order for speech consultation was written. The ST stated the therapy department is notified of a physician's order for evaluation either by a phone call from the nurse or a copy of the order is left in the Director of Rehabilitation's (DOR) mailbox. On 6/4/18 at 12:25 p.m., the surveyor interviewed the DOR, a speech therapist. The DOR stated the residents were reassigned to her while the ST was on vacation. The DOR stated she had not evaluated Resident #35. The DOR further stated she was not aware of a physician's order for speech evaluation dated 5/16/18. The DOR reviewed her files and was unable to locate a copy of the request for speech evaluation of resident #35. On 6/4/18 at 12:35 p.m., the surveyor spoke with the ADON who stated she was unaware of a speech consult ordered 5/16/18. The ADON stated once an order for [REDACTED]. On 6/4/18 at 12:45 p.m., the surveyor spoke with the daytime nurse for resident #35 working on 5/17/18, the day after the physician's order for speech evaluation was written. The Licensed practical nurse (LPN) stated he was not aware of a physician's order for a speech evaluation dated 5/16/17. The LPN further stated he should have checked the resident's chart for daily nursing notes and should have followed up that a speech evaluation had been ordered. The LPN stated he was not aware of a facility referral form to request rehabilitation evaluation. On 6/5/18 at 12:35 p.m., the surveyor in the presence of the survey team met with the Director of Nursing (DON) and the facility Administrator. The DON acknowledged a speech therapy evaluation had not been performed as ordered by the resident's physician on 5/17/18. The DON stated there was a communication form the nurse should have filled out to inform the speech therapy department there is a physician's order for evaluation/consultation. The DON further stated she spoke with the nurse who obtained the physician's order for speech consultation, who stated it slipped his mind and he did not fill out the treatment communication form. On 6/7/18 at 9:18 a.m. and 10:30 a.m., the surveyor attempted to interview the LPN who obtained the physician's order for speech evaluation on 5/16/18 via telephone, but was unsuccessful. According to Woodcliff Lake Health and Rehabilitation Center's Scheduling Therapy Services Policy and Procedure dated effective 6/22/15, 1. Nursing shall initiate the Nursing to Therapy Communication Form when there is a change in condition. 2. The original will be sent to the Therapy Department and copies will be placed in the resident's record and given to the DON/ADON/designee. NJAC 8:39-11.2(b)

Based on interview and record review, it was determined that the facility failed to obtain an order for [REDACTED]. On [DATE] at 9:54 a.m., during the review of the closed medical record revealed that Resident #97 was admitted to the facility on [DATE], readmitted on [DATE] and expired on [DATE] with [DIAGNOSES REDACTED]. A review of [DATE] Social History and Assessment (SHA) showed that the Advance Directive section was left blank. The [DATE] SHA also revealed that Resident #97 was cognitively impaired. A review of Interdisciplinary Care Conference Summary dated [DATE] showed that the Advance Directive and the Do Not Resuscitate (DNR) were both checked for yes. On that same day and time, the surveyor reviewed the medical record. There was no DNR order in the medical record. On [DATE] at 12:13 p.m., the survey team met with the Administrator and the Director of Nursing (DON). The surveyor informed the Administrator and the DON of the concern and asked what was the code status of Resident #97. The surveyor asked the DON to provide a copy of an Advance Directive of the resident. On that same day and time, the Administrator and the DON informed the survey team that if there was no code status order in the medical record, it will be automatic that the resident was a full code. The DON stated that she will get back to the surveyor and will confirm the code status of the resident. On [DATE] at 8:49 a.m., the Administrator provided a copy of Resident #97's Health Care Proxy and Living Will signed by the resident on [DATE] and revealed that the resident consented for a DNR. On [DATE] at 8:51 a.m., the survey team interviewed the Director of Social Services (DSS). The DSS informed the survey team that on [DATE] when the resident was admitted , the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) was not yet in use in the facility. On that same day and time, the DSS informed the survey team that the Resident's daughter, the Registered Nurse/Unit Manager (RN/UM) and the Director of Rehab attended that [DATE] Interdisciplinary Care Conference. The DSS stated that the Resident's daughter informed the Interdisciplinary Team that Resident #97 had an Advance Directive and a DNR. The DSS also stated that she was not sure if the Resident's daughter presented a copy of an Advance Directive and a DNR at that time. The DSS informed the survey team that as a standard of practice, it was nursing responsibility to obtain an order for [REDACTED]. On [DATE] at 9:04 a.m., the survey team interviewed the RN/UM. The RN/UM informed the survey team that she attended the [DATE] Interdisciplinary Care Conference meeting. The RN/UM stated that she was not sure of the code status of the resident that was discussed on [DATE]. The RN/UM also stated that she was not sure as to why there was no DNR order in the chart. On [DATE] at 9:50 a.m., the survey team called and interviewed the daughter who was the Power of Attorney (POA) of Resident #97. The POA informed the survey team that the resident was initially admitted to the facility around the end of (MONTH) (YEAR). The POA stated that the facility SW was informed that the resident had an Advance Directive and a DNR within two days of admission. The POA also stated that it was straightforward that she informed the SW that the resident was a DNR. The POA informed the survey team that a copy of an Advance Directive and a DNR were provided to the SW within two days. On [DATE] at 10:28 a.m., the survey team informed the Administrator and the DON of the concern. A review of the facility's policy dated ,[DATE] provided by the Administrator titled, Do Not Resuscitate (DNR) Order, included that a physician's written order indicating the predetermined request by the resident or the resident's health care representative or surrogate to withhold cardiopulmonary resuscitation (CPR) and other end-of-life resuscitative treatments in the event of cardiac and/or respiratory arrest. In addition, included that the criteria for DNR Orders were that when a resident with no decision-making capacity has a Living Will requesting a DNR status or a Health Care Representative or Surrogate decision-maker requests a DNR status in behalf of the resident who lacks capacity in making health care decisions. NJAC 8:,[DATE].1 (a)3

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate hand washing practices to prevent the spread of infection during a wound treatment observation. This deficient practice was identified for 1 of 1 resident reviewed for wound care, Resident #19. The deficient practice was evidenced by the following: During the initial tour on 5/30/18 at 09:05 a.m., the surveyor observed Resident #19 in the Day Room seated in a wheelchair with eyeglasses on. On that same day and time, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM). The RN/UM informed the surveyor that the resident had an in-house acquired wound (IHA). The RN/UM was unable to state the site and stage of the IHA. A review of the resident's face sheet revealed that Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 6/1/18 at 10:42 a.m., during wound observation, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound treatment to the resident's sacrum with assistance from RN/UM. The surveyor observed the LPN perform hand washing prior to sanitizing the table, before and after placing the supplies to the barrier on top of the table and after removing the soiled dressing. The surveyor observed the LPN applied gloves, cleanse the sacral area with normal saline (NS) and remove gloves. At that time, the LPN failed to perform hand washing prior to applying a new pair of gloves. The surveyor heard the LPN stated that by the way, I don't need to do hand washing. At the same time, the surveyor observed the LPN apply [MEDICATION NAME] cream 1%, a treatment medication to the sacrum, removed gloves and re-apply a new pair of gloves. The LPN did not perform hand washing in between glove removal. At that same time, the LPN stated that he does not need to perform hand washing. After the application of the [MEDICATION NAME] cream, the LPN removed his gloves, donned a new pair and applied a covered dressing. There was no hand hygiene performed in between glove removal. On 6/1/18 at 11:20 a.m., the LPN stated that the sacral wound was a Stage 2 pressure ulcer and healing was in progress. The LPN stated that as a standard of practice and as per facility protocol, staff must perform hand washing before donning gloves with some exemptions. Both the LPN and the RN/UM stated that the LPN did not perform hand washing in between gloves removal during wound treatment and was appropriate according to the hand washing treatment protocol. At that same day and time, the surveyor asked the RN/UM to provide a copy of facility policy and protocol for hand washing and wound care treatment. According to the Centers for Disease Control and Prevention's (CDC), Hand Hygiene Guideline for Healthcare Providers with an updated date on 3/24/17 revealed that Hand Hygiene means cleaning your hands by using either hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. In addition, CDC's Hand Hygiene Guideline revealed that Hand Hygiene must be performed after glove removal. On 6/4/18 at 1:06 p.m., the surveyor team met with the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The DON informed the surveyor that the LPN and the RN/UM stated that the LPN did not perform hand washing in between gloves removal during wound treatment of [REDACTED]. On that same day and time, the DON provided a copy of CDC Guideline for Isolation Precautions dated 2007. The DON informed the survey team that facility's Hand Hygiene policy and the protocol was based on CDC Guideline dated 2007. A review of CDC Guideline for Isolation Precautions dated 2007 provided by the DON revealed that on page 51: Hand hygiene following glove removal further ensures that the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or that could contaminate the hands during glove removal. On 6/4/18 at 1:10 p.m., the DON provided a copy of undated Policy and Procedure on Handwashing/Hand Hygiene which indicated, Employees must wash their hands for at least 20 seconds using antimicrobial soap and water under the following conditions: Before and after direct resident contact, after removing gloves or aprons and after completing a duty. NJAC 8:39-19.4 (a) (1, 2)

Based on observation, interview and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication passes on 12/29/15 and 12/30/15, the surveyor observed 4 nurses administer medications to 5 residents. There were 25 opportunities and 6 errors were observed which calculated to a medication administration error rate of 24%. This deficient practice was identified for 3 of 4 nurses observed for 4 of 5 residents, (Residents #17, #20, #21 and #23). The evidence was as follows: 1. On 12/29/15 at 9:04 a.m. during the medication pass the surveyor observed Nurse #1 review the current Medication Administration Record (MAR) for Resident #20 with an order for [REDACTED]. At this time, the surveyor accompanied by the medication nurse observed the resident in the bedroom. No breakfast trays were observed. The nurse administered a Calcium [MEDICATION NAME] 600 mg tablet and prepared the resident for a nebulizer treatment. At this time, the surveyor asked the nurse what time the resident had eaten breakfast and the nurse said breakfast was usually between 7:30 a.m. and 8:00 a.m On 12/29/15 at 10:55 a.m. the surveyor reviewed Resident #20's records which revealed [DIAGNOSES REDACTED]. In addition, the physician's orders [REDACTED]. On 12/29/15 at 11:23 a.m. the surveyor interviewed the nurse in reference to cautionary warnings. The nurse said that the cautionary warnings are usually written on the MAR and should be followed. In addition, the nurse said that the Calcium [MEDICATION NAME] was ordered by the physician with meals and the time on the MAR indicated 8:00 a.m. but had not been administered with breakfast this morning. On 12/30/15 at 10:30 a.m. the surveyor reviewed the facility policy and procedure for Medication & Treatment Administration Time which revealed When an order for [REDACTED].D. 2. On 12/29/15 at 9:04 a.m. during the medication pass the surveyor observed Nurse #1 review the current MAR for Resident #20. The MAR had an order for [REDACTED]. The nurse administered [MEDICATION NAME] 1 gram tablet. At this time, the surveyor asked the nurse what time the resident had eaten breakfast and the nurse said breakfast is usually between 7:30 a.m. and 8:00 a.m On 12/29/15 at 10:55 a.m. the surveyor reviewed Resident #20's records which revealed [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. On 12/29/15 at 11:23 a.m. the surveyor interviewed the nurse in reference to cautionary warnings for medications. The nurse said that the cautionary warnings are usually written on the MAR and should be followed. The nurse reviewed the current MAR with the surveyor and no cautionary warning was indicated for [MEDICATION NAME]. At this time, the surveyor and the nurse reviewed the label on the [MEDICATION NAME] 1 gram tablets for the resident which indicated Take on an empty stomach. The nurse said the time of administration must be changed in order for the resident to receive the [MEDICATION NAME] 1 gram on an empty stomach because during this mornings' medication pass the resident did not have an empty stomach. On 12/30/15 at 10:30 a.m. the surveyor reviewed the facility policy and procedure for Medication & Treatment Administration Time which revealed Empty stomach: one(1) hour before or two(2) after meals. On 12/30/15 at 11:00 a.m. the nurse provided the surveyor with the Electronic Pharmacist Information Consultation dated 12/11/15 which revealed [MEDICATION NAME] is best administered on an empty stomach, one hour before meals or 2 hours after meals. 3. On 12/29/15 at 9:35 a.m. during the medication pass the surveyor observed Nurse #1 review the current MAR for Resident #17 with an order for [REDACTED]. At this time, the nurse said the labeled box for the resident with the [MEDICATION NAME] was empty and there was no [MEDICATION NAME] in the back up supply. The nurse told the surveyor the other morning medications would be administered and the physician would have to be called. On 12/29/15 at 10:33 a.m. the surveyor reviewed the records of Resident #17 which revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. On 12/29/15 at 10:39 a.m. the surveyor interviewed the nurse who said a call was put out to the physician and the Pharmacy Provider and the [MEDICATION NAME] was not administered because it was not received from the Pharmacy yet. The nurse provided the surveyor with a reorder form dated 12/27/15 which was indicated that the [MEDICATION NAME] ([MEDICATION NAME]) 800 mg tablets for the resident was reordered from the Pharmacy Provider. The nurse did not know why the medication was not delivered. 4. On 12/29/15 at 9:35 a.m. during the medication pass the surveyor observed Nurse #1 review the current MAR for Resident #17 with an order for [REDACTED]. At this time, the surveyor observed the nurse administer one (1) KCL SR 10 meq tablet to the resident and sign the current MAR for administration. The nurse said the resident's morning medications were completed. At this time, the surveyor asked the nurse to again review the KCL SR order on the MAR. The nurse then said that only one (1) KCL SR 10 meq tablet was administered and she should have administered two (2) 10 meq tablets according to the order. In addition, the nurse said the cautionary warning on the MAR had to Give with meals and no food was offered and the resident ate at 8:00 a.m. On 12/29/15 at 10:33 a.m. the surveyor reviewed the records of Resident #17 which revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. 5. On 12/29/15 at 9:35 a.m. during the medication pass the surveyor observed Nurse #2 review the current MAR for Resident #21 with orders for [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 25/100 PO four times a day(QID) and [MEDICATION NAME] Slow Release 45 mg PO daily (QD). At this time, the surveyor observed the nurse administer both medications to the resident and signed the MAR for medication administration. At this time, the surveyor asked the nurse to review the [MEDICATION NAME] label from the Pharmacy provider which revealed a cautionary warning Avoid Iron by 2 hours. The nurse then said that the [MEDICATION NAME] Slow Release is an Iron product and should have been separated from the [MEDICATION NAME] by 2 hours. The nurse also said that cautionary warnings should be followed and are usually written on the MAR, but there was no written cautionary on the current MAR. In addition, the nurse said that administering the [MEDICATION NAME] and Iron products together could decrease the effectiveness of the [MEDICATION NAME] being used for [MEDICAL CONDITION]. On 12/29/15 at 10:37 a.m. the surveyor reviewed the records of the resident which revealed [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. On 12/30/15 at 10:30 a.m. the surveyor reviewed the facility policy and procedure for Medication & Treatment Administration Time which revealed The following medications should be SEPARATED from each other by TWO (2) hours: Iron - [MEDICATION NAME]. 6. On 12/30/15 at 8:27 a.m. the surveyor observed Nurse #3 remove one (1) Multivitamin tablet from a house stock bottle with a red label and administer to Resident #23. At this time, the nurse said the resident had just finished eating and the multivitamin was a plain multivitamin. On 12/30/15 at 9:07 a.m. the surveyor reviewed the records of the resident which revealed [DIAGNOSES REDACTED]. The December physician's orders [REDACTED]. On 12/30/15 at 9:08 a.m. the surveyor interviewed the nurse with regard to the types of multivitamin tablets available. The nurse showed the surveyor in the medication cart that three (3) different house stock Multivitamins are available and said the plain Multivitamin has a red label on the bottle, the second bottle has Multivitamin with minerals on the label and the last one has Multivitamin with [MEDICATION NAME] on the label. At this time, the surveyor and the nurse again reviewed the One Daily/tab Minerals ([MEDICATION NAME]) order on the MAR for the resident and the nurse said that the Multivitamin with Minerals should have been administered and not the plain Multivitamin. NJAC 8-11.2(b), 29.2(d)

Based on observation and interview it was determined that the facility failed to: a) store and date potentially hazardous foods and b) serve food appropriately to prevent cross contamination as evidenced by the following: On 12/28/15 at 9:10 a.m., in the presence of the Food Service Director, the surveyor observed shelled eggs stored in the reach in refrigerator. The eggs had been taken out of the original box and were stored on the bottom shelf. There was no date to indicate when the eggs were delivered or how long they could remain on the shelf. The surveyor observed the FSD to take temperatures of the food on the trayline. The puree pineapple was 68 degrees Fahrenheit (F). The surveyor took the temperature of another puree pineapple and it was 67 degrees F. The FSD stated that had just pureed the pineapple from the can before trayline. At 11:45 a.m., the surveyor observed the trayline checker to be wearing several disposable gloves over a cotton glove. As she was checking the trays she was pouring soup and placing lids on the soup. The lids were stuck together and she had to touch the entire surface of the lid to get them apart. She was also placing the hot bases on the tray, the entree plate and the dome lids. Then she asked the cook for a bowl of mashed potato with gravy. She handled the bowl by placing the palm of her gloved hand over the surface of the food. The hot food cook served the hot sandwich with gloved hands and placed it on the plate. With the same gloved hand, he opened the oven door to take out chicken pieces and placed them on the plate. He then picked up the fryer basket and placed them on the plate. He then went back to the trayline and continued to serve food using utensils along with picking up the hot sandwiches without changing his gloves. The cold food cook was placing garnishes on the plates with gloved hands. When the hot food cook needed plates, the cold food cook put on oven mitts and placed the hot plates on the serving line. He then took off the mitts and continued to place garnishes on the plates without changing his gloves. On 12/29/15 at 2:30 p.m., the surveyor observed a dietary worker preparing desserts on the table next to the sink designated as the handwashing sink. The surveyor asked the FSD what happened when someone wanted to wash their hands and the food was next to the sink. She stated that they would have to move the desserts. On 12/30/15 at 10:30 a.m., the surveyor received the policy on Receiving, Handling and Storage of Refrigerated Foods. It indicated that, All open items should be dated on the day they are opened. The surveyor also received the policy on the handwashing procedure. It indicated to wet hands then use soap for 20 seconds and scrub. Then the next step was to rinse. NJAC 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to use aseptic techniques in handwashing, serving of food and wound care. This deficient practice was noted for 1 employee in the kitchen, 1 of 2 residents observed for wound care, Resident #1, and 1 kitchen staff member in the main dining room, as evidenced by the following: 1. During tour of the 2nd floor unit on 12/28/15 at 9:44 a.m. the Registered Nurse (RN) informed the surveyor that Resident #1 was alert and oriented times 2, had a stage 4 sacral wound from the hospital, had [DIAGNOSES REDACTED], a suprapubic urinary catheter secondary to wound care, was able to feed self, and was transported by staff in the wheelchair. On 12/29/15 at 10:30 a.m. the surveyor observed the Licensed Practical Nurse (LPN) perform wound care to the community acquired stage 4 pressure ulcer of the sacrum. The LPN did not initially prepare the supplies to be used during the wound care. At 10:46 a.m. the LPN washed his hands, gloved, and then opened the package for the 4X4 gauze and cleaned the wound with normal saline. At 10:48 a.m. the LPN washed his hands again and donned gloves, then opened the package with the Q -Tip and placed the Q-Tip in the medicated ointment, and then applied the ointment to the base of the wound. The LPN then opened another package containing the Q-Tip and applied more medicated ointment to the wound. The LPN then opened another package containing a Q-Tip and evenly distributed the medicated ointment in the wound. The LPN then opened a package containing 4X4 gauze and packed the wound with the gauze. At 10:55 a.m. the LPN washed his hands, gloved, and opened another package of 4X4 gauze and placed the gauze over the wound, and then applied a border gauze covering. 2. During observation of the main dining room on the 1st floor on 12/29/15 at 12:20 p.m. after residents were given and applied clothing protectors and the residents were served juice and water, the staff decided to offer the residents wipes to clean their hands. The residents, however were not offered or supplied with a waste receptacle for the wipe so many placed them directly on their tables. There were approximately 19 residents in the dining room at the time, and one of the residents loudly stated, What is this? We never did this before. 3. On 12/29/15 at 12:30 p.m. in the main dining room on the 1st floor during lunch service, the surveyor observed a dietary staff member pick papers off the floor and then proceeded to serve food with no handwashing observed. 4. On 12/30/15 at 12:15 p.m. the surveyor observed the dietary staff as they passed out soup to the residents. There were approximately 20 residents in the dining room for the lunch service. The surveyor observed the dining room staff place their ungloved thumb in the bowl as the soup was being plated. This observation was seen during the entire plating of soup to the residents at different tables. 5. At 11:30 a.m. on 12/28/15, the surveyor returned to the kitchen to observe the lunch trayline. The Assistant Food Service Director (ASFSD) was washing her hands in the sink. She placed soap on her hands and then under the stream of water. She began to lather her hands for five seconds, placed them under the stream of water, and continued to lather her hands. The surveyor asked the ASFSD what was the facility's hand washing procedure. She stated that the procedure was to wash hands for 20 seconds. There was no waste receptacle next to the sink to dispose of the dirty towel. The surveyor also received the policy on the handwashing procedure. It indicated to wet hands then use soap for 20 seconds and scrub. Then the next step was to rinse. NJAC 8:39-19.4(a)1