Every finding on record at Applewood Village, Inc

Based on observations and interviews on 11/25/24, in the presence of the Director of Plant Operations (DOPO), it was determined that the facility failed to ensure that the resident call bell system properly functioned by a.) ensuring the call bell system volume was set to a level to be heard and b.) devices used to identify call bell notifications were functioning properly. This deficient practice had the potential to affect all residents and was evidenced by the following: On 11/25/24 at 1:08 PM, the surveyor observed when the call bell was tested for Resident room [ROOM NUMBER], there was no audible notification of the call. There was visual notification on the computer screen at the nurse's station and by light outside of the resident room. At the time of the observation, the surveyor interviewed the DOPO, who confirmed that there was no audible notification and stated that there should have been audible notification at the nurse's station. The DOPO stated that the aides also carried pagers that identified when a call bell had been activated. The DOPO then approached the nurse on duty and asked if they had a pager for the call bell system. The nurse stated that they did and proceeded to check their pockets. The nurse was unable to locate the pager in their pocket but was able to find it locked in the top drawer of the medication cart. The DOPO retrieved the pager to show the surveyor that the pager received notifications from the call bell system. The DOPO was unable to show that the pager received notifications from the call bell that was tested and stated that the pager was on vibrate mode. The DOPO was unsure of why the pager was not receiving notifications. On 11/25/24 at 1:24 PM, the surveyor observed when the call bell was tested for Resident room [ROOM NUMBER], there was no audible notification of the call bell system. The DOPO, while carrying the call bell pager, confirmed that they did not receive notification on the pager of the call bell activation. On 11/25/24 at 1:31 PM, the surveyor observed when the call bell was tested for Resident room [ROOM NUMBER], there was no audible notification of the call bell system. However, the aide on that unit received notification by pager of the call bell activation. On 11/25/24 at 2:00 PM, the surveyor interviewed the DOPO, who stated that they were able to figure out the problem with the audible notification at the nurse's station; that the volume had been turned down at the main computer. The DOPO stated he turned the volume up so that it could be heard. NJAC 8:39-31.2(e), 31.8(c)9

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices by; a) performing hand hygiene during medication administration and b) donning (putting on) the appropriate Personal Protective Equipment (PPE) prior to entering an Enhanced Barrier Precaution room. This deficient practice was identified for 1 of 6 residents observed during medication administration (Resident #20) and 1 of 3 residents observed for wound care (Resident #28), and was evidenced by the following: 1. On 11/24/24 at 9:45 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) conduct medication administration. After administering medications to Resident #26, LPN #1, without performing hand hygiene and still holding the cup of water which Resident #26 used to drink from, went directly over to Resident #20. LPN #1 proceeded to adjust Resident #20's blanket and brushed her hand overtop the resident's hair while informing Resident #20 that she would administer their medications. LPN #1 then proceeded back to the medication cart, located in the hallway outside the resident's door, and disposed of Resident #26's used cup of water. LPN #1, without performing hand hygiene, documented in the computer on of the medication cart; then accessed the medication cart drawer to obtain Resident #20's assistive hearing devices. LPN #1, still with no performed hand hygiene, obtained the blood pressure machine and proceeded to Resident #20's bedside where she donned disposable gloves and placed the resident's assistive hearing devices on the resident. LPN #1 then doffed (took off) her gloves and without performing hand hygiene, placed the blood pressure cuff on the resident to obtain the resident's vital signs. LPN #1 then removed the blood pressure cuff off the resident's arm and brought the machine back out to the hallway. Without performing hand hygiene, LPN #1 then donned clean gloves and disinfected the machine using disinfecting wipes. LPN #1 then disposed of the wipe, doffed and disposed the gloves and then performed hand hygiene with alcohol-based hand rub (ABHR). On 11/24/24 at 10:05 AM, the surveyor interviewed LPN #1 who confirmed that she forgot to perform hand hygiene in between residents during medication administration and that it was important for infection control purposes. On 11/26/24 at 10:02 AM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN), who stated that the general expectation was to perform hand hygiene with soap and water or use ABHR before starting a procedure and in between residents. The IP/RN further stated that hand hygiene was to be performed in between glove changes always. The IP/RN confirmed LPN #1 should have performed hand hygiene after administering Resident #26's medications before touching Resident #20; prior to accessing the medication cart; and prior to donning and after doffing gloves. On 11/27/24 at 9:41 AM, the Director of Nursing (DON), in the presence of the survey team, the [NAME] President of Clinical Operations (VPCO), the Licensed Nursing Home Administrator (LNHA), and the Director of Clinical Operations (DCO), acknowledged that proper hand hygiene was to be performed by all nurses while administering medications. 2. On 11/24/24 at 11:32 AM, the surveyor reviewed Resident #28's electronic medical record which indicated the following: A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis which included but was not limited to; infection of the skin and subcutaneous tissue (layer underneath the skin) and pressure ulcer of the sacral region (lower back). A review the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/16/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A further review in Section M Skin Conditions indicated the resident had one stage 4 (full tissue thickness) pressure ulcer. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 10/11/24, for risk for impaired skin integrity and updated 10/11/24, to include a sacral pressure ulcer dated 11/20/24. Interventions included to provide treatment to sacral pressure ulcer as ordered and monitor for effectiveness. A review of the November 2024 Treatment Administration Record (TAR) included a physician's order dated 11/21/24, to cleanse sacral wound with normal saline solution (NSS)and apply Polymed non-adhesive pad (gauze pad and dressings) every day shift for wound care. If dressing loosens, apply Tegaderm (clear adhesive bandage). On 11/26/24 at 12:24 PM, the surveyor observed LPN #2 and LPN #3 perform wound care for Resident #28. On the resident's room door was a sign which indicated Enhanced Barrier Precautions (EBP) that required everyone to wear PPE which included gloves and a gown for the following high-contact resident care activities which included wound care. The surveyor observed a PPE bin outside the resident's door which contained gloves and gowns. The surveyor observed LPN #2 and LPN #3 preparing and gathering supplies for wound care; donned gloves prior to entering the resident's room, but did not don a gown. LPN #2 and LPN #3 then performed wound treatment on Resident #28 without wearing a gown. On 11/26/24 at 1:04 PM, LPN #2 and LPN #3 completed wound care and exited the resident's room. At that time, the surveyor interviewed both LPNs, who confirmed that a gown was required as part of the PPE needed to be worn during wound care and confirmed that the EBP sign on the resident's door indicated that as well. LPN #2 and LPN #3 both acknowledged that they forgot to put on a gown as required prior to and during the wound care treatment procedure. On 11/26/24 at 1:46 PM, the surveyor interviewed the DON, who confirmed Resident #28 had a sacral wound and that wound care would be classified as close contact care and required the person providing the care to wear a gown and gloves. On 11/27/24 at 9:41 AM, the DON, in the presence of the survey team, the VPCO, the LNHA, and the DCO, acknowledged that the LPNs should have worn a gown during wound care since the resident was on EBP. A review of the facility's Infection Control General Guidelines for All Nursing Procedures policy revised September 2019, included; .4. in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: a. before and after direct contact with residents; b. before donning sterile gloves; c. before performing any non-surgical invasive procedures; d. before preparing or handling medications; e. before handling clean or soiled dressings, gauze pads, etc.; f. before moving from a contaminated body site to a clean body site during resident care; g. after contact with a resident's intact skin; h. after handling used dressings, contaminated equipment, etc.; i. after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and j. after removing gloves; 5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials; 6. In addition to these general guidelines, refer to procedures for any specific infection control precautions that may be warranted . A review of the facility's Enhanced Barrier Precautions policy revised 3/25/24, included; .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi-drug resistant organisms) to staff hands and clothing. The policy further included, for residents for whom EBP are indicted, EBP is employed when performing the following high contact resident care activities: .wound care: any skin opening requiring a dressing . NJAC 8:39 - 19.4(a); 27.1(a)

Based on observation and interview it was determined that the facility failed to properly dispose and maintain waste in 1 of 1 garbage dumpster areas as evidenced by the following: On 9/12/22 at 11:40 AM, the surveyor in the presence of the Food Service Director (FSD) inspected the garbage dumpster area which included two dumpsters on a concrete pad. The dumpster lids were closed however there was extensive debris including soiled gloves, plastic cups, plastic bags, candy wrappers, shipping envelopes, papers, and discarded cigarettes on the concrete pad behind the dumpsters and in the grass adjacent to the dumpsters. The FSD stated the Housekeeping Department was responsible for maintaining the dumpster area. On 9/13/22 at 1:20 PM, the surveyor interviewed the Housekeeping Supervisor (HS) who confirmed the Housekeeping Department was responsible for maintaining the garbage dumpster area. The HS stated that she did not see the garbage and debris around the back of the dumpster area and further stated, it was an oversight. At this time, the surveyor requested a copy of the facility's policy related to maintaining and cleaning of the garbage area. On 9/20/22 at 11:30 AM, the surveyor interviewed the License Nursing Home Administrator (LNHA) who confirmed the Housekeeping Department was responsible for maintenance of the dumpster area including cleanliness. The LNHA stated the facility had no policy regarding maintaining the garbage dumpster area. On 9/21/22 at 11:31 AM, the LNHA in the presence of the Director of Nursing and the survey team acknowledged that the garbage dumpster area should be maintained free of garbage and cigarette debris. NJAC 8:39-19.7(a)(b)

Based on observation, interview and review of facility documents, it was determined that the facility failed to serve food in a safe and sanitary manner to address the risk of development of food-borne illness. This deficient practice was evidenced by the following: During the lunch meal service in the main dining room on 12/18/19, the surveyor observed the following: At 12:17 PM, Dietary Aide (DA) #1 was behind the steamtable preparing sandwiches with gloves donned. The main meal was cheese steak on a hoagie roll and the alternate was a ham salad sandwich. DA #1 picked up residents' meal tickets in between sandwich preparation without doffing gloves, handwashing and re-donning gloves. DA #1 cut a grilled cheese sandwich with the same gloved hands. At 12:26 PM, DA #1 touched the outside bag and the twist tie of the whole wheat bread to retrieve bread for sandwiches with the same gloved hands. She then cut another grilled cheese sandwich. At 12:29 PM, DA #1 again touched the outside of the whole wheat bread bag; at 12:34 PM, she touched the bag of hoagie rolls; at 12:36 PM she touched the bag of rye bread; and at 12:36 PM, DA #1 opened the bag of hot dog buns. During this time, she continued to touch the bread and prepare items with the same gloved hands that continued to touch the residents' meal tickets. At 12:39 PM, DA #1 cut another grilled cheese sandwich using the same gloved hands. At 12:40 PM, DA #1 prepared and cut up a half of a tuna salad sandwich using the same gloved hands. During the course of lunch meal service, DA #1 prepared 20 different types of sandwiches whereby she touched the bread and intermittently touched the outside bag of assorted breads and residents' meal tickets without changing gloves or performing hand hygiene the entire time. During an interview with the surveyor on 12/19/19 at 9:15 AM, the Registered Dietitian (RD) stated that staff should wash their hands prior to donning gloves. She further stated that when preparing food, if the staff touched a non food item the gloves would become contaminated and would need to be changed before touching food again. The RD also stated that if the staff touched the residents' meal tickets with gloved hands, the staff would have to change their gloves before returning to food preparation. During an interview with the surveyor on 12/19/19 at 9:40 AM, the Assistant Food Service Director stated that staff used gloves to prepare food and if they were to touch something else such as a refrigerator handle or the residents' meal tickets, the staff should have changed gloves. They should not have gone back to preparing and touching ready to eat foods such as sandwiches. During an interview with the surveyor on 12/19/19 at 11:03 AM, the Food Service Director (FSD) stated that gloves should be worn for food handling and should be changed between tasks and anytime the gloves became contaminated. He further stated that the staff should have changed their gloves after touching the residents' meal tickets and before going back to food preparation. The FSD also stated that it posed an opportunity for contamination. During an interview with the surveyor on 12/20/19 at 9:21 AM, DA #2, in the presence of DA #1, stated that staff should have changed gloves when preparing sandwiches if they touched the residents' meal tickets to prevent cross contamination. Review of an undated, Dining Services Management, policy reflected that gloves were used for food activity and hands should be washed before and after gloves were used. It further reflected that gloves should be changed between tasks and after exposure to all non-food related activity. NJAC 8:39-17.2 (g)

Based on observation, interview and record review it was determined that the facility failed to ensure transmission-based precautions were maintained for a) a urinary Foley catheter (tubing inserted into the bladder to facilitate urination) that was lying on the floor and b) personal items stored on the top of the treatment cart. The deficient practice was identified for Resident #1, 1 of 2 residents reviewed for indwelling catheters and 1 of 2 treatment carts observed and was evidenced by the following: 1. On 10/6/17 at 9:15 a.m., the surveyor reviewed the medical record for Resident #1. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 had an indwelling Foley catheter present on admission. On 10/11/17 at 9:05 a.m., the surveyor observed Resident #1 asleep in bed with the Foley catheter collection bag lying directly on the floor and the catheter tubing curled and lying directly on the floor. On 10/11/17 at 9:06 a.m., the Licensed Practical Nurse (LPN) stated the Foley catheter collection bag and tubing should not be on the floor. On 10/11/17 at 9:10 a.m., the surveyor reviewed the physician's orders [REDACTED]. On 10/11/17 at 9:14 a.m., the LPN approached the surveyor and stated that she should have cleaned the tubing of the Foley catheter since it was on the floor. On 10/11/17 at 11:11 a.m., the surveyor reviewed the Indwelling Catheter Care policy and procedure provided by the Director of Nursing (DON) and dated 10/6/17 that revealed Procedure: 7. Check to ensure that the tubing is free of kinks and the drainage bag is properly hung. 2. On 10/10/17 at 9:00 a.m., the surveyor observed the top of the treatment cart in A hall which had a blue water bottle with liquid in it. On 10/10/17 at 9:00 a.m., the Registered Nurse stated the blue bottle is a personal water bottle and should not be on the top of the treatment cart. On 10/10/17 at 9:12 a.m., the DON stated the staff should not have personal water bottles on the medication or treatment carts. On 10/11/17 at 8:11 a.m., the surveyor reviewed the Security of Medication Cart policy dated 9/13/17 that revealed 5. No personal items can be kept on the top of the medication carts or stored in the medication cart drawers. NJAC 8:39-19.4(a)

Based on observation, interview and record review it was determined that the facility failed to accurately document and complete Drug Enforcement Administration (DEA) 222 forms for 7 of 7 forms reviewed. This deficient practices was evidenced as follows: On 10/6/17 at 12:50 p.m., the surveyor requested all DEA 222 forms (a form for ordering schedule II control substances) for the last 6 months from the Director of Nursing (DON). The DON provided the surveyor with a binder which contained seven DEA 222 forms and back up information. The surveyor reviewed the facility's DEA 222 forms and found that the seven forms were not complete and accurately documented as follows: 1. The first DEA 222 form, was written on 5/2/17, contained an order for [REDACTED]. 2. The second DEA 222 form, was written on 5/19/17, contained an order for [REDACTED]. 3. The third DEA 222 form, was written on 6/20/17, contained an order for [REDACTED]. 4. The fourth DEA 222 form, was written on 6/26/17, contained an order for [REDACTED]. 5. The fifth DEA 222 form, was written on 7/11/17, contained an order for [REDACTED]. 6. The sixth DEA 222 form, was written on 7/24/17, contained an order for [REDACTED]. 7. The seventh DEA 222 form, was written on 9/12/17, contained a order for 1 bottle of 30 ml of Morphine 20 mg/ml solution and 20 tablets of Oxycodone/Acetaminophen 5/325 mg. The DEA 222 form was missing the received date, number of packages received and the receiver signature. On 10/6/17 at 1:15 p.m., the surveyor interviewed the DON and she agreed that the DEA 222 forms were not properly documented. The printed instructions on the back of the purchaser's copy of the DEA 222 form indicated that, When items are received the date receipt and the number of items received must be recorded in the spaces provided on the triplicate copy. NJAC 8:39-29.7 (c)

Based on observation, interview and record review it was determined the facility failed to follow clinical standards of practice for obtaining, clarifying and monitoring physician's orders for Resident's #2, #5, #6, #9, #12 and #15, 6 of 20 residents reviewed. The deficient practice is evident as follows: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities with in the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. Review of Resident #2's medical record on 10/25/16 at 10:30 a.m., revealed on 6/15/16, a interdisciplinary progress note was written that the physician was in to see rash on resident's back and a new Physician's Order was written by the physician at that time for 2.5% [MEDICATION NAME] Cream apply to rash area BID (twice a day) until clear. Four months later the physician discontinued the treatment order on 10/2/16. The July and August 2016 Treatment Administration Sheets (TAR), had on upper back right side hand written under the printed order for the treatment. On the September and October TAR's there was no site of origin for the rash. Also at this time the physician had not signed the monthly Physician's Order Sheet (POS) for July and August of 2016. Review of the Consultant Pharmacist Evaluation sheet at this time, revealed the Pharmacist Consultant did not address the incomplete treatment order for the indicated site of the rash or the unsigned POS for the visits on 7/1/16, 8/4/16, 9/1/16 & 10/3/16. 2. The surveyor reviewed Resident #6's medical record on 10/25/16 at 10 a.m. The medical record revealed the resident's medical diagnosis' included a history of pleural effusion, dementia, [MEDICAL CONDITION] and collapse and an implanted device of a permanent pacemaker (PPM) which was evident after review of a chest X-ray consult dated 4/19/16. Patient information verification and identification cards identified an implant date of the PPM on 7/23/15. Review of the POS [REDACTED]. During interview with the Director of Nursing (DON) on 10/27/16 at 10:30 a.m., the DON told the surveyor that this resident has a bedside monitor that once a month at 12:35 a.m. relays the device information to the manufacture who monitors the device and then sends the results to the cardiologist and, that the facility has now obtained all results and resident has been seen by the cardiologist in August and September of this year. On 10/26/16 at 12:50 p.m., the surveyor reviewed Resident #6's Medication Administration Sheet (MAR) and the POS which revealed an order written [REDACTED]. There was no documentation that the nursing staff were measuring the levels and recording them on the TAR and/or, in the resident's medical record. There was no observations of the resident being administered oxygen. At 1:10 p.m., the Licenced Practical Nurse (LPN) told the surveyor during interview that, the resident has not required oxygen that he/she is aware of and, he/she doesn't always check the oxygen levels when he/she does vital signs. On 10/27/16 at 10:55 a.m., the DON told the surveyor that they had identified issues with the recap (review) of the POS and chart checks at their quarterly meeting in October. 3. On 10/26/16 at 12:50 p.m., the surveyor reviewed Resident #12's Medication Administration Sheet (MAR) and the POS which revealed an order written [REDACTED]. There was no documentation that the nursing staff were measuring the levels and recording them on the TAR and/or, in the resident's medical record. There was no observations of the resident being administered oxygen. On 10/27/16 at 10:55 a.m., the DON told the surveyor that they had identified issues with the recap (review) of the POS and chart checks at their quarterly meeting in October. 4. Resident #5 was observed on 10/24/16 at 11:20 a.m., in his/her room sitting in a wheelchair and dozing off. On 10/26/16 at 9:55 a.m., the surveyor reviewed the medical record for Resident #5 which included medical [DIAGNOSES REDACTED]. Review of his medical record on 10/26/16 at 9:55 a.m., revealed that the resident required the use of a permanent pacemaker which was implanted on 8/12/14 for [DIAGNOSES REDACTED]. According to documentation in the medical record, Resident #5 had transtelephonic pacemaker checks on 6/30/15, 7/29/15, 10/30/15, 1/29/16 and 7/29/16. There was no physician's order noted for pacemaker checks until 10/25/16, after the surveyor requested to see the order for the pacemaker checks. The physician's order written on 10/25/16 requested: Pacemaker checks q3 mos (every 3 months) by DHS. 5. Resident #9 required the use of a permanent pacemaker which was implanted on 9/15/15 for [DIAGNOSES REDACTED]. The cardiologist's report of November, 2015 contained recommendations for Manual transmission 12/8/15, 1/26/16, 4/26/16 and 7/26/16. Next appointment was ordered for 9/20/16. The last order for a pacemaker check appeared on the July, 2016 physician's order sheet (POS). The current POS which was signed by the physician on 10/19/16 had no order for a pacemaker check. In response to surveyor inquiry as to the status of the order for pacemaker checks for this resident, the Director of Nurses (DON) initially told the surveyor that pacemaker checks would be done every 90 days in accordance with Medicare requirements. The DON provided the surveyor with information from the Pacemaker company which confirmed this information. This would have made the next pacemaker check 10/26/16 for which there was no current order. On 10/26/16 at 11:40 a.m., the DON told the survey team that on the previous day, the resident's physician told the DON that the family had refused to send the resident to his/her scheduled september cardiology appointment, and that no further pacemaker checks would be done. The Administrator showed the survey team the unit calendar book with the 24 hour report confirming the family's refusal for the resident to go for the cardiology appointment. The surveyor reviewed the progress notes which contained no entry for 9/20/16 identifying the family's refusal for the resident to go for the scheduled cardiology appointment. A review of the medical record failed to identify the resident's family's refusal for any further cardiology care after the 7/26/16 pacemaker check. The DON told the survey team that the resident's family member, who was the resident's Power of Attorney (POA), told the resident's physician that they did not want any further cardiology care for the resident but this information had not been relayed to the DON or nursing staff. It was not until the surveyor requested clarification of the status of the current pacemaker orders on the POS, that documentation from the physician was then entered into the medical record on 10/26/16 at 5 p.m. identifying that the resident was not to have any further visits to the cardiologist or pacemaker checks. The physician's note identified that, .no longer doing any testing .Continue with standard comfort measures, no aggressive interventions. 6. Resident #15 had a physician's order for [MEDICATION NAME] 15 mg (milligram) at bedtime as needed for [MEDICAL CONDITION] which was written on the Physician's Order Sheet (POS) on 10/22/16. The order was not transcribed onto the Medication Administration Record [REDACTED]. Refer to tag F 386 and F 428 N.J.A.C. 8:39 - 11.2(b), 27.1(a) and 29.2(d)

Based on interview and record review, it was determined that the facility failed to consistently provide: 1) adequate monitoring for the use of psychoactive medications; and, 2) a rationale for the prolonged duration of therapy for proton pump inhibitors and H2 blockers for 4 of 20 residents (Residents #5, #10, #12 and #19 ) whose medication regimens were reviewed as evidenced by the following: 1. Resident #10 had [DIAGNOSES REDACTED].#10 had physician's orders [REDACTED]. On 10/25/16, the Director of Nurses (DON) told the surveyor that the old policy for psychoactive monitoring needed updating to correspond with the new behavior monitoring system that the facility recently put in place. On 10/26/16, the DON provided the surveyor with both the old and new facility policies for psychoactive monitoring. The DON provided the surveyor with the inservice sign in sheet on the new behavior monitoring system which was provided to nursing staff on 8/23/16. The new Psychoactive Medications Documentation procedure required: 7. Nurses are to enter behaviors, and interventions tried, on daily monitoring sheet as they occur. Resident #10 was admitted to the facility on [DATE]. From the date of admission on 10/2/16 through 10/24/16, ten episodes of behavioral symptoms were documented as exhibited by Resident #10 in the nurses progress notes in the medical record. The resident's care plan for the use of psychoactive medications and the treatment of [REDACTED]. The surveyor reviewed the Episodic Behavior and Psychoactive Summary form for October, 2016 which contained no written evidence of any behavioral symptoms in violation of facility policy and the resident's plan of care. Also, the form contained the orders for [MEDICATION NAME] but there was no monitoring identified for the use of [MEDICATION NAME]. On 10/15/16, a nursing progress note identified that Resident #10 had fallen. This event was also not documented on the Episodic Behavior and Psychoactive Summary form as a possible side effect of [MEDICATION NAME] therapy. 2. On 5/1/16, Resident #5 received a physician's orders [REDACTED]. The resident continued to receive [MEDICATION NAME] at this dose at the time of survey. This dose of [MEDICATION NAME] is recommended for up to 12 weeks therapy, until 8/1/16, for the treatment of [REDACTED].#5. 3. Resident #12 had a physician's orders [REDACTED]. The resident continued to receive [MEDICATION NAME] at this dose at the time of survey. [MEDICATION NAME] therapy for the treatment of [REDACTED]. No rationale was provided to rule out excessive dose or duration for the continued use of [MEDICATION NAME] therapy for Resident #12. 4. Resident #19 had a physician's orders [REDACTED]. [MEDICATION NAME] therapy for the treatment of [REDACTED]. The consultant pharmacist questioned the continued use of [MEDICATION NAME] on 11/4/14. Though the resident continued to receive [MEDICATION NAME] 40 mg at the time of survey, no rationale was provided for the continued use of [MEDICATION NAME] at the current dose in order to rule out excessive dose and/or duration of therapy since 2014. N.J.A.C. 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to ensure the consultant pharmacist consistently reported irregularities in the medication regimen in order for the facility to take action to correct these irregularities for 5 of 20 residents, Residents #2, #5, #6, #12 and #19, as evidenced by the following: 1. Resident #5 received a physician's orders [REDACTED]. The resident continued to receive this medication at this dose at the time of survey. Famotidine is recommended at this dose for up to 12 weeks therapy for the treatment of [REDACTED]. The consultant pharmacist failed to identify this irregularity in order to justify the continued use of famotidine at this dose. 2. Resident #12 received a physician's orders [REDACTED]. Omeprazole is recommended for 4 to 8 weeks of therapy for the treatment of [REDACTED]. On 10/26/16 at 12:30 p.m., the surveyor reviewed Resident #12's Medication Administration Record (MAR) and physician's orders [REDACTED]. There was no documentation that the nursing staff were measuring the levels and recording them on the TAR or in the resident's medical record, as well as, there was no indication in the POS as to the frequency that the oxygen level should be checked. There was no documentation by the consultant pharmacist on the monthly visits since order date of 7/19/16. 3. Resident #19 had a physician's orders [REDACTED]. Omeprazole therapy for the treatment of [REDACTED]. The resident continued to receive omeprazole 40 mg at the time of survey. The consultant pharmacist questioned the continued use of omeprazole 40 mg daily for the treatment of [REDACTED]. There had not been any further request by the consultant pharmacist since 2014 to justify the continued use of omeprazole in order to rule out excessive dose and/or duration of therapy. Refer to F329 4. Review of Resident #2's medical record on 10/25/16 at 10:30 a.m. by the surveyor, revealed on 6/15/16 a interdisciplinary progress note that identified the physician was in to see rash on resident's back and, a new physician's orders [REDACTED]. Four months later the physician discontinued the treatment order on 10/2/16. The July and August 2016 Treatment Administration Sheets (TAR's) have on upper back right side hand written under the printed order for the treatment. On the September and October TAR's there no site of origin for the rash. Also at this time the physician had not signed the monthly POS for July and August of 2016. Review of the Consultant Pharmacist Evaluation sheet at this time, revealed the Pharmacist Consult did not address the incomplete treatment order for the indicated site of the rash and/or, the unsigned POS for the visits on 7/1/16, 8/4/16, 9/1/16 & 10/3/16. 5. On 10/26/16 at 12:50 p.m., the surveyor reviewed Resident #6's MAR and POS, which revealed an order written [REDACTED]. There was no documentation that the nursing staff were measuring the levels and recording them on the TAR or in the resident's medical record, as well as, no indication in the POS as to the frequency that the oxygen level should be checked. There was no documentation by the consultant pharmacist on the monthly visits from March to October 2016. Refer to tag F 281 and 386 N.J.A.C. 8:39 - 29.3(a)1

Based on observation, interview and record review it was determined the facility failed to follow it's policy and procedure for appropriate measures for infection control by the handwashing technique of the dietary staff. This deficient practice is evident by the following: On 10/24/16 at 12:30 p.m., the surveyor observed 2 food service workers (FSW) wash their hands at the sink in the kitchenette. Both of the FSW put soap in their hands and washed their hands under running water for less than 20 seconds, and then, with wet hands FSW #1 touched the paper towel dispenser to obtain paper towels to dry his/her hands. FSW #2 used wet hands to turn off the water and touched the paper towel dispenser to obtain paper towels to dry his/her hands. As soon as FSW #2 was finished, the Dietary Supervisor turned on the water, placed soap in his/her hands and washed them under running water. The Dietary Supervisor then with wet hands, turned off the water and touched the paper towel dispenser to obtain paper towels to dry his/her hands. At 10:40 p.m., during interview, the Dietary Supervisor told the surveyor that he/she always washes his/her hands under running water. On 10/26/16 at 9 a.m., the Director of Nursing (DON) provided the surveyor with a copy of the Nursing Dept. Policy and Procedure for Hand Washing with a revised date of 8/12/16. Listed under Procedure, step number 4. Rub hands together vigorously, creating as much friction as possible and continue the scrubbing action for 20 seconds and then step number 5. Rinse hands thoroughly by holding them under running water. During interview at 2:30 p.m., the DON told the surveyor the staff are not to wash their hands under running water. N.J.A.C. 8:39 - 19.4(n)

Based on observation and interview, it was determined the facility failed to ensure that the resident's environment was maintained clean, and in a homelike condition for Resident #7, 1 of 16 sampled residents. This deficient practice was evidenced by the following: On 10/21/16 at 10:45 a.m., during the initial tour, the surveyor observed Resident #7's room had a fan across the room from his/her bed. The fan was on at this time while the resident was not in the room. The fan blades and the vented covers to the back and front of the fan were heavily coated with dust. On 10/24/16 and 10/25/16, the surveyor again noted that the resident's fan blades and the vented covers to the back and front of the fan, were heavily coated with dust. At 11:45 a.m., the Registered Nurse (RN) was shown the resident's fan in the resident's room, and during interview about the cleaning schedule of the fan, the RN told the surveyor he/she doesn't know but will call housekeeping now. At 1 p.m., the Housekeeping Director told the surveyor that everything in the resident room is to be checked daily that housekeeping should of cleaned it (fan) and, housekeeping does annual deep cleaning twice a year. N.J.A.C. 8:39 - 31.4(a)

Based on record review, it was determined the the facility failed to ensure the physician provided an accurate treatment order and sign all Physician's Order Sheets (POS) within the required time frame. This deficient practice occurred for Resident #2, 1 of 20 residents sampled for review as evidenced by the following: Review of Resident #2's medical record on 10/25/16 at 10:30 a.m. by the surveyor, revealed on 6/15/16 a interdisciplinary progress note was written. The progress note indicated the physician was in to see rash on resident's back and a new Physician's Order was written by the physician, at that time, for 2.5% [MEDICATION NAME] Cream apply to rash area BID (twice a day) until clear. Four months later the physician discontinued the treatment order on 10/2/16. The July and August 2016 Treatment Administration Records (TAR's) have on upper back right side hand written under the printed order for the treatment. On the September and October TAR's there is no site of origin for the rash. Also at this time, the physician had not signed the monthly POS for July and August of 2016. Refer to tag F 281 N.J.A.C. 8:39 - 23.2 (a), (b)

Based on observation and review of facility policy and pertinent documentation, it was determined that the facility failed to consistently maintain accountability of controlled medication inventory for 3 of 20 residents reviewed on the survey sample, Residents #9, #16 and #17, as evidenced by the following: 1. Resident #9 had a physician's orders [REDACTED].=0.25 mg) every morning for anxiety which was ordered on [DATE]. The Ativan was documented as administered on 8/26/16 on the Medication Administration Record [REDACTED]. On 9/17/16 and 9/25/16, lorazepam was documented as administered on the MAR but no doses were documented as removed from inventory on the DIS on those dates. 2. Resident #16 had a physician's orders [REDACTED]. Upon reconciliation of the DIS with the MAR, the surveyor identified that 4 doses of zolpidem were documented as removed from inventory but were not documented as administered to Resident #16 on the MAR for 10/15, 10/20, 10/21 and 10/25/2016. 3. Resident #17 had a physician's orders [REDACTED]. One dose of alprazolam was documented as removed from inventory on 10/7/16 but was not documented as administered to Resident #17 on the MAR indicated [REDACTED] 4. Resident #18 had a physician's orders [REDACTED]. One dose was documented as removed from inventory on the DIS on 10/25/16 but was not documented as administered to Resident #18 on the MAR for that date. The DIS identified the source of the controlled medication inventory and the MAR indicated [REDACTED]. N.J.A.C. 8:39-29.(k)

Based on observation, interview and record review it was determined the facility staff made 3 errors during a medication pass observation conducted on 12/28/15. As 25 opportunities for error were observed, this calculated to a 12 % error rate. This deficient practice was identified for 2 of 2 nurses observed, and for 2 of 2 residents observed (Resident #9 and #10), and was evidenced by the following: 1) At 9:20 a.m., the surveyor observed the medication nurse #1 administer [MEDICATION NAME] 850 milligrams (mg) to Resident #9. This medication was plotted on the Medication Administration Record [REDACTED] A review of the physician's orders [REDACTED].#9, revealed a daily order for [MEDICATION NAME] to be administered twice daily at 8 a.m. and 5 p.m. According to the cautionary statement from the provider pharmacy, as well as the manufacturer of this medication, [MEDICATION NAME] was specified to be given before the meal. The same nurse administered the medication [MEDICATION NAME] 3.125 mg to Resident #9. At this time, the surveyor observed that the medication nurse did not offer or provide any food/snack to the resident. According to the cautionary statement from the provider pharmacy, as well as the manufacturer of this medication, [MEDICATION NAME] was specified to be given with food. A review of the food service department tray delivery schedule revealed that the breakfast tray for Resident #9 had been delivered to the unit at 7:30 a.m. When interviewed by the surveyor, medication nurse #1 stated that she should have given both medications at 8 a.m., with and/or before the resident's breakfast meal. When further interviewed, the medication nurse said that it was the facility's policy for nurses to administer resident's medications one hour before or after the scheduled time. 2) At 9:30 a.m., the surveyor observed the medication nurse #2 administer the medication [MEDICATION NAME] to Resident #10. The surveyor observed that that the medication nurse did not offer or provide food/snack to the resident. A Review of the POS [REDACTED] According to the cautionary statement from the provider pharmacy, as well as the manufacturer of this medication, [MEDICATION NAME] was specified to be given with food/snack. On 12/28/15 at 10:05 a.m., the surveyor interviewed the medication nurse #2, who said that she gave Resident #10's medication late. Medication nurse #2 added, that it was the facility's policy for the medications to be given one hour before or after the scheduled time. On 12/30/15, the surveyor interviewed the Director of Nursing (DON). The DON stated that it was the facility's policy to administer medications one hour before or after the scheduled dose. In addition, the DON stated that the breakfast meals were delivered to the unit at 7:30 a.m. According to the facility's policy Medication Administration Guidelines, nurses should adhere to the cautionary information listed on the MAR (do not crush, take with food, ect.) The nurse would also follow the 6 rights of medication pass: Right patient, Right drug, Right dose, Right time, Right route and Right documentation. N.J.A.C. 8:39 - 29.2 (d)

Based on observation, interview and record review it was determined that the facility failed to provide a prescribed nutritional supplement for a resident assessed for inadequate intake with a goal to gain weight. This deficient practice was identified for 1 of 2 residents, Resident #8, reviewed for weight as evidenced by the following: The surveyor interviewed Resident #8 during the initial tour on 12/28/15 at 10 a.m. Resident #8 was alert and awake and answered questions appropriately. Resident #8 stated the food was good and that s/he ate in their room. The surveyor reviewed Resident #8's Admission Minimum Data Set (MDS), an assessment tool, on 12/29/15 at 1:20 p.m. Resident #8 was assessed to be cognitively appropriate. The surveyor reviewed Resident #8's December 2015 physician's orders [REDACTED]. The surveyor observed Resident #8 eating lunch in their room on 12/28/15 at 12:30 p.m. The surveyor did not observe Boost Glucose Control on the meal tray. Resident #8 stated s/he had never received it but would like to. The surveyor interviewed the covering charge nurse and a medication nurse on 12/28/15 at 12:50 p.m. Both nurses verified that Resident #8 did not have Boost Glucose Control listed on the Medication Administration Record. The covering charge nurse stated that dietary not nursing, should send the supplement with the meal tray and that the supplement should be listed on the meal ticket. The surveyor observed Resident #8's meal ticket on 12/28/15 at 12:55 p.m. Boost Glucose Control was not listed. On 12/29/15 at 9:40 a.m., the surveyor reviewed Resident #8's Nutrition assessment dated [DATE]. The Registered Dietician (RD) documented that Resident #8 had Diabetes Mellitus and Dementia. Resident #8 weighed 145 pounds but should weigh about 166-186 pounds. The RD initiated a Care Plan for inadequate intake with a goal to gradually gain weight. One of the interventions was to provide Boost Glucose Control. The surveyor reviewed Resident #8's weight record on 12/30/15 at 10 a.m. Resident #8's weight was recorded as 143 pounds on 12/10/15 and 12/24/15. The surveyor observed Resident #8's lunch tray on 12/29/15 at 12:25 p.m. There was no Boost Glucose Control observed and Resident #8 stated that s/he did not receive it the day before. The surveyor interviewed the RD on 12/29/15 at 12:26 p.m. The RD was not aware that Resident #8 did not receive the nutritional supplement. The RD stated Resident #8 was slightly underweight. The RD believed that dietary should be providing the supplement. The surveyor interviewed the Dietary Supervisor (DS) on 12/29/15 at 12:40 p.m. The DS stated that nursing was responsible for providing the supplement. The surveyor interviewed the RD and the Registered Nurse/Unit Manager (RN/UM) on 12/29/15 at 12:42 p.m. The RN/UM stated nursing was to provide the supplement. The surveyor discussed the above concern with the Director of Nurses (DON) on 12/29/15 at 2 p.m. The DON verified that there was a miscommunication between nursing and dietary as to who was to provide the supplement. N.J.A.C. 8:39-17.4(a)(1)

Based on observation, interview and record review it was determined that the facility failed to provide a [DIAGNOSES REDACTED]. This deficient practice was identified for 1 out of 4 residents, Resident #8, reviewed for [MEDICAL CONDITION] medication use as evidenced by the following: The surveyor interviewed Resident #8 during the initial tour on 12/28/15 at 10 a.m. Resident #8 had some minor complaints. Resident #8 was alert and oriented and answered questions appropriately. No negative behaviors and/or, mood disturbances were observed. The surveyor reviewed Resident #8's medical record on 12/28/15 at 12:05 p.m. Resident #8 was admitted on [DATE], for short-term rehabilitation after a hospital stay. The medical record documented that Resident #8 had the following Diagnoses: [REDACTED]. Per the Physician's admission orders [REDACTED]. No [DIAGNOSES REDACTED]. The surveyor asked the Director of Nurses (DON) on 12/29/15 at 2 p.m., what the [DIAGNOSES REDACTED].#8. The DON provided the surveyor with additional information on 12/30/15 at 9:30 a.m. According to the provided information, Resident #8 was taking [MEDICATION NAME] Acid for a history of [MEDICAL CONDITION] Disorder with Behavioral Disturbance. The surveyor interviewed Resident #8's day nurse on 12/30/15 at 10:15 a.m. Per the nurse, Resident #8 could be loud, short-tempered and refused to get out of bed at times. The nurse denied Resident #8 was verbally or physically aggressive. The surveyor reviewed the Physician's History and Physical Form, and subsequent Progress Notes on 12/30/15 at 10:25 p.m. No documentation was found that stated Resident #8 was [MEDICAL CONDITION]. An Interdisciplinary Progress Note dated 12/2015 at 5 p.m., documented that Resident #8 had been on [MEDICATION NAME] Acid for about 3 years for [MEDICAL CONDITION] Disorder. The surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) on 12/30/15 at 10:35 a.m. The RN/UM stated that all [MEDICAL CONDITION] drugs or drugs used to treat behaviors should be monitored on the Episodic Behavior and Psychoactive Summary Sheet located on the Medication Administration Record [REDACTED]. The only medication noted was [MEDICATION NAME], used to treat depression. The RN/UM stated s/he would add the prescribed [MEDICATION NAME] Acid. The surveyor discussed the above concern with the DON on 12/30/15 at 11:45 a.m. The DON stated the resident should have been monitored. The DON stated Resident #8 did not currently have any behaviors. N.J.A.C. 8:39-29.2(d)

Based on observation, interview and record review it was determined that the facility failed to: 1) identify to staff and/or visitors required contact isolation precautions; and, 2) to consistently implement appropriate infection control precautions to prevent the spread of infection. This deficient practice was identified for 1 of 4 residents, Resident #10, reviewed for infections as evidenced by the following: 1) During the medication pass observation conducted on 12/28/15 at 9:30 a.m., the surveyor observed the Licensed Practical Nurse (LPN) enter Resident #10's room. There was no signage posted at the resident's door that alerted staff and/or visitors to see the nurse before entering the room. There was no Personal Protective Equipment (PPE) available at Resident #10's room for staff and visitors entering this room. At this time, the surveyor and the LPN entered Resident #10's room without wearing any PPE. The LPN administered the medications to Resident #10. When interviewed by the surveyor at this time, Resident #10 stated that s/he was not feeling well because s/he could not get rid of this Clostridium Difficile (C-diff) infection, an infection of the colon that causes diarrhea. The surveyor then interviewed the LPN and the LPN stated that she did not know if Resident #10 had a[DIAGNOSES REDACTED] infection or not. The LPN stated that if the resident was positive for[DIAGNOSES REDACTED] they required contact precautions. The LPN stated that the facility's policy was for those entering the room to wear a gown and gloves. The LPN stated that gowns and gloves should be at the door. A review of a Laboratory Report dated 12/21/15 at 12:58 p.m., revealed that Resident #10 had tested positive of[DIAGNOSES REDACTED]. When interviewed on 12/28/15 at noon, the Director of Nursing (DON) stated that Resident #10 did have[DIAGNOSES REDACTED] . The DON said that there should have been signs posted at Resident #10's door to alert staff and visitors before they entered the room. In addition, there should have been PPE available at the door for staff and visitors. The DON stated that this information should have been communicated to the nurse during morning report. A review of the facility's Universal Standard Precautions Policy dated 11/30/15, revealed that proper signage should be applied to the doorway or entry of the infected resident's room. Signage must be visible to all residents, staff, families and visitors. N.J.A.C. 8:39-19.4(a)

Based on observation, interview and record review, it was determined that the facility failed to administer medications without errors. During the medication pass, the surveyor observed 2 nurses pour 29 medications for 3 Residents. One of the errors included 12 medications that were poured and about to be administered to the wrong resident (Resident #11). The Medication Pass resulted in 13 errors, and a 44.8% error rate. This deficient practice resulted in an Immediate Jeopardy situation. The immediate jeopardy was identified on 1/14/15 at 11:30 a.m. and corrected on 1/15/15 based on an acceptable plan of correction which has been implemented by the facility. The deficient pracitce was evidenced by the following: On 1/14/15 at 7:56 a.m., the surveyor approached a Licensed Practical Nurse (LPN) on A-Hall. The LPN stated that she was going to give medications to the resident in room [ROOM NUMBER] A (Resident #12). The LPN positioned the medication cart outside of room [ROOM NUMBER] (Resident #11). The LPN then opened the Medication Administration Record [REDACTED]. The LPN entered the room of Resident #11 on 1/14/15 at 7:58 a.m. and assisted Resident #11 with the breakfast tray. The LPN called Resident #11 by Resident #12's first name. On the same day at 8:10 a.m., the LPN checked the identification band of Resident #11 that was placed on his/her right wrist and proceeded to take a blood pressure and pulse oximetry reading on Resident #11's left arm and hand. The LPN again called Resident #11 by Resident #12's first name. On 1/14/15 beginning at 8:18 a.m., the surveyor observed the LPN pour 13 medications which included Eliquis, [MEDICATION NAME], [MEDICATION NAME] DM, [MEDICATION NAME], Potassium Chloride, and [MEDICATION NAME] from Resident #12's MAR. At 8:29 a.m. the LPN rechecked the MAR indicated [REDACTED]. At 8:30 a.m. the LPN knocked on the door to room [ROOM NUMBER] while holding a medication cup with the above mentioned 12 pills, and a second medication cup with 10 ml of [MEDICATION NAME], and began to enter the room of Resident #11. The surveyor stopped the LPN, when she entered the room. The surveyor asked the LPN to identify who the medications were for, and she responded with the name of Resident #12. The LPN was also asked to identify the name on the band she had viewed and she responded with the name of Resident #11. The LPN then realized the error and discarded the pills and cough medicine in the garbage bin attached to the medication cart and stated, "I need a minute" and then stood quietly by the medication cart. On 1/14/15 at 11:10 a.m. the surveyor reviewed the History and Physical dated 1/5/15 of Resident #12 who was a [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Sheet ((MDS) dated [DATE] identified Resident #12 as having a BIMS score of 15 out of 15. The facility was notified of the Immediately Jeopardy (IJ) on 1/14/15 at 11:30 a.m., and informed that a Plan of Correction (POC) was required. On 1/14/15 at 12:30 p.m., the surveyor reviewed the History and Physical of Resident #11, dated 12/2/14, which indicated that the resident was a [AGE] year old with [DIAGNOSES REDACTED]. The resident was also assessed to be hard of hearing (HOH), and had poor vision. Resident #11 had a BIMS of 11 on an MDS dated [DATE] and BIMS of 13 on MDS dated [DATE]. An interview with the Director of Nurses' (DON) on 1/14/15 at 1:00 p.m., revealed that the LPN was a per diem nurse employed by the facility, and had last administered medications on the unit on 1/3/15. The DON produced documents that indicated that the LPN had medication administration in-services annually and had no prior incidents. The POC was submitted to the survey team and after review, the survey team accepted the plan on 1/14/15 at 2:20 p.m. The survey team verified that the jeopardy situation was immediately addressed and lifted at that time. The survey team continued to verify the elements of the POC for the remainder of the survey. The nurse was removed from the medication pass and sent home after education on the day of the incident. The elements of the POC included the following: 1. The Nurse was immediately removed from medication pass until she passed medication administration pass education and verification of knowledge. This will be required quarterly.2. The MD and Medical Director were notified of the incident.3. The Nurse was educated on the 5 rights by the pharmacy consultant and avoidance of distraction. The nurse was then sent home. 4. All MARS were reviewed for appropriate and timely administration5. Education was provided to staff regarding med pass protocols, avoidance of distraction from residents and other staff during pass, and the importance of the 5 rights, including a medication test.6. Proper disposal of drugs was in-serviced with all staff. Random audits will be conducted by the DON or designee and/or pharmacy consultant monthly and results reported to the Executive Director and to the QIS committee quarterly. N.J.A.C. 8:39 - 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to employ standard infection control precautions to minimize the transmission of contaminants by cleaning resident rooms while the residents were eating in their rooms. This deficient practice was evidenced by the following: 1. On 1/13/15 at 12:25 p.m., the surveyor observed a housekeeper cleaning the room of Resident #12. The resident's roommate was seated in a wheelchair, eating lunch from an overbed table while the housekeeper was mopping the floor and wiping the furniture with cleaning fluids. 2. On 1/13/15 at 12:30 p.m., the surveyor observed the same housekeeper was cleaning the room of Resident #4. The resident was seated in a wheelchair in front of an overbed table with the lunch tray on it, while the housekeeper was mopping the floor. 3. On 1/14/15 at 12:25 p.m., the surveyor observed a different housekeeper cleaning room [ROOM NUMBER], while the resident was in bed with a lunch tray in front of him/her. The housekeeper was mopping the floor and wiping furniture with cleaning products at that time. 4. On 1/14/15 at 1:30 p.m. the Assistant Administrator provided policies and schedules for the Environmental Services Department. The policy and procedure for "Healthcare Resident Room Cleaning" specified that housekeepers "Do not clean room when resident is eating meals." The Healthcare Housekeeping Schedule indicated that between "9:15 am- 1pm - All resident rooms are to be cleaned as accessible." 5. On 1/15/15 at 10:00 a.m., the Housekeeping Director told the surveyor that she was "surprised" about the observations made during lunch time on 1/13/15 and 1/14/15. She stated that the housekeepers "should know better than to clean rooms while the residents were eating." She also stated that the housekeepers had not received any in-service training on infection control, but that it "would not be a bad idea" to provide such a program. 8:39-19.4 (a)

Based on observation, interview and record review, it was determined that the facility failed to maintain food service equipment in a sanitary manner. This deficient practice was evidenced by the following: On 1/13/15 at 9:55 a.m., in the presence of the Food Service Director, the surveyor made the following observations in the Health Care pantry/serving area: 1. The interior of the reach-in refrigerator was soiled and sticky to the touch with an accumulation of dried food spills. The refrigerator contained applesauce, juices, milk, cartons of thickened liquids, yogurt and a box of creamers. 2. The reach-in freezer also had a build-up of dried food spills on the floor of the unit. Several boxes of ice cream cups were stored in the freezer at the time of the observation. 3. The four steam table covers were soiled and sticky to the touch. There was no food in the steam table at the time of the observation. 4. Both sides of the stainless steel plate warmer/lowerator were visibly soiled with a brownish substance. 5. On 1/13/15 at 12:45 p.m., the surveyor reviewed the cleaning schedule, which indicated that the P.M. Health Care Unit Waitstaff were responsible for cleaning the interiors of the refrigerator and freezer on a weekly basis. The schedule did not include cleaning the steam table covers or the plate lowerator. 6. On 1/13/15 at 12:45 p.m., the Food Service Supervisor told the surveyor that she "checks the pantry after meal service to ensure that everything is labeled, dated and wiped down." 8:39- 31.4 (a)

Based on observation, interview and record review, it was determined that the facility failed to provide a safe environment free from potential hazards and accidents and failed to ensure that residents were transferred according to their assessments and care plans. Resident #1 was identified as requiring a 2 person assist with transfers without the use of a mechanical lift. One Certified Nursing Assistant (CNA) transferred Resident #1 on her own using a mechanical lift, resulting in a fracture. Resident #7 was identified as requiring the assist of 2 staff members and the use of a Vera Lift and was transferred from the bed to chair by one CNA resulting in a fall and a fracture. This deficient practice was identified for Resident #1 and Resident #7, 2 of 6 residents reviewed for falls and/or fractures, and was evidenced by the following: 1. During the initial tour on 5/22/12 at 10:15 a.m., the surveyor observed Resident #1 lying in bed with a sling on the upper left arm. The Minimum Data Set (MDS) Coordinator told the surveyor that the resident was alert and oriented and could make her needs known to staff. The MDS Coordinator stated that the resident had sustained a fracture in February while being transferred by a CNA from the bed to her wheelchair. The MDS Coordinator stated that the transfer resulted in a fracture of the left humerus. The surveyor reviewed Resident #1's care plan on 5/22/12 which indicated that prior to the fracture of the left humerus on 2/09/12, the resident had a care plan which described the procedure for transferring Resident #1. The care plan indicated that the resident was a 2 person assist with transfers. The surveyor reviewed the notes from Physical Therapy which revealed that the resident was not screened for the use of a mechanical lift. According to the annual MDS completed on 2/12/12, the resident had scored a 15 for the Brief Interview of Mental Status (BIMS), which indicated that the resident was alert and oriented. The MDS also indicated that the resident required an "extensive" assistance of 2 persons for transfers. The surveyor reviewed an X-ray report dated 2/13/12 which revealed that the resident had a fractured left humerus with slight medial displacement of the distal fracture fragment. When interviewed by the surveyor on 5/23/12 at 9:30 a.m., Resident #1 stated that she had fractured her left shoulder a few months ago when the CNA transferred her from the bed and into a chair with a mechanical lift. The resident stated that she had told the CNA that she did not use a mechanical lift for transfers, but the CNA told her that she did. The resident then told the surveyor that the CNA lifted her arms and placed her hands onto the hand grasp of the Vera-Lift, a sit to stand lift, and placed a belt around her waist. The resident said the CNA began lifting her from the side of the bed, and as this was being done, she lost her footing and she began to fall towards the floor. The resident added that the CNA had to grab her arms to prevent her from falling, and as the CNA was doing this, she heard a "popping" sound. The resident stated at this point she "knew something was wrong." On 5/23/12 at 1:45 p.m., the surveyor interviewed the Charge Nurse who stated that when using a mechanical lift, it was the facility policy to have 2 staff members for all transfers. The Unit Manager added that Resident #1 was a 2 person transfer and did not use a mechanical lift. When interviewed by the surveyor on the same date at 2 p.m., the CNA who regularly provided care to this resident stated that the resident care cards were kept on the inside of the resident's closet and that these cards contained information about the resident care needs. In addition, the CNA told the surveyor that this information was also kept in a note book at the nursing station. The CNA added that Resident #1 was a 2 person assist for transfers. At this time, the surveyor reviewed the care card that was inside the resident's closet and another form titled "Healthcare Unit Report Sheet" dated 1/17/12. Both identified the resident as a 2 person assist for transfers. On 5/23/12 at 2:30 p.m., the Director of Nursing (DON) stated that the CNA who was caring for the resident that day was from an agency. The DON stated that it was the facility policy to orient all agency staff about the resident's care needs and the facility policies. The DON told the surveyor that the CNA should have listened to the resident or asked another staff member who was more familiar with the resident's care needs. In addition, the DON stated that she was told by a staff member from the Physical Therapy Department that Resident #1 was not screened for the Veralift. The DON said that the mechanical lift should not have been used for Resident #1 and the CNA should not have attempted to operate the machine on her own. The DON added that the agency CNA was no longer allowed to work at the facility. 2. Resident # 7 had [DIAGNOSES REDACTED]. During the initial tour of the unit on 5/22/12 at approximately 10:45 a.m., the unit nurse stated that the resident needed total care by the staff, the sit to stand (Vera Lift) to transfer, and that the resident had a fall with a fracture about one month ago. The surveyor reviewed the Quarterly MDS assessment of the resident dated 1/11/12 which noted that the resident was alert; oriented to person only with a BIMS score of 13 out of a possible 15; required extensive to total assist for activities of daily living; and was transferred using the Vera Lift (mechanical sit to stand lift). The surveyor reviewed the resident's careplan, updated 1/12/12, which stated that the Vera Lift was used for all transfers. The Physical Therapy screening dated 1/12/12 had been requested by nursing due to the resident not participating in standing with the Restorative Program. The resident had complained of hip pain and had an x-ray done that revealed arthritis. In addition, the screening noted that the right foot was in inversion with a reported club foot since birth and the resident needed an assist of 2 to stand. The surveyor reviewed the Interdisciplinary Progress (IDP) note dated 2/6/12 and timed at 10 a.m. which stated that the resident's physician had been called "concerning c/o (complaint) discomfort rt shoulder from incident this am. X-ray of rt shoulder ordered." A 3 p.m. nursing note stated that the CNA had the resident seated at the bedside to get ready for the lift and the resident slipped off the bed. The CNA helped the resident to the floor. The resident then bumped her right shoulder and received an abrasion to the right knee. The next IDP note dated 2/6/12 at 9:20 p.m. stated the radiology report of the right shoulder noted an acute distal end right clavicle fracture. The surveyor reviewed the Fall Investigation Form dated 2/6/12 which noted the fall time as 8:30 a.m. and stated that the resident was assisted from a lying position to a sitting position on the side of the bed and the resident slid off the bed. The CNA statement dated 2/6/12 stated when she got the resident up to get her on the Vera Lift, she slipped out of bed, was lowered to the floor but she still hit her right shoulder. The care plan for fall prevention, initiated 3/11/07, was updated on 2/6/12, stating: "resident not to be left at edge of bed alone." During an interview on 5/22/12 at 1 p.m., the Director of Nursing stated that the CNA should have had another staff member to assist with the use of the Vera lift and that the CNA was inserviced. In an interview on 5/23/12 at 3 p.m., the CNA involved in this incident stated that she was trying to get the resident ready before calling another CNA to help her to transfer the resident with the Vera lift. She stated that as she moved the resident from a lying position to a sitting position the resident began sliding from the bed. The CNA stated that she held the resident and lowered her to the floor and the resident landed on the floor on her right shoulder. The surveyor reviewed the facility policy titled "VANDERLIFT, VANDERLIFT SCALE AND VERALIFT USE." The policy stated that the Vander-Lift and Vera-Lift could be used to physically transfer residents and that it was mandatory that 2 trained employees were available during their use. The policy stated that staff were to make certain the resident had been assessed by the professional staff and approved to be lifted by the Vander-Lift or Veralift. NJAC-8:39-27.1(a)