Every finding on record at Bartley Nursing & Rehab

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide an environment that is safe, functional, sanitary, and comfortable. This deficient practice was identified for two of three dining rooms (Main and Dogwood).This deficient practice was evidenced by the following: On 8/6/25 at 11:52 AM, the surveyor toured the facility's main dining room in the presence of the Activities Director (AD) and observed a bug in the second drawer of the kitchenette, as well as a black, ground substance in the fourth drawer, which the AD identified as coffee. The fourth drawer was also sticky to the touch. On 8/6/25 at 11:56 AM, in the presence of the Food Service Director (FSD), the surveyor observed that all five steam table wells in the Main and Dogwood dining rooms had residual water marks approximately half an inch above the water level. The wells also contained dirty water with food debris that was not consistent with the day's lunch meal. A review of the facility's Monthly Cleaning List for week one of 08/25 showed a check mark that the kitchen wells were cleaned with soap A review of the manufacturer's Electric Hot Food Table with Sealed-in [NAME] (SHT Series) Operations Manual and Instructions indicated that the inside of the water compartment and outer shell should be washed daily, using a clean cloth or sponge and mild detergent. On 8/6/25 at 12:00 PM, the surveyor interviewed the Food Service Director (FSD), who acknowledged that the kitchenette drawers were unclean and should not contain bugs or spilled substances. The FSD confirmed that the steam table wells should be cleaned according to the manufacturer's specifications but was unable to provide cleaning records or accountability logs. On 8/6/25 at 12:22 PM, the surveyor interviewed the Housekeeping and Laundry Director (HLD), who stated that staff deep clean both dining rooms monthly. However, the HLD was unable to specify when the dining rooms were last deep cleaned. On 8/11/2025 at 12:24 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA). The LNHA stated that there should be no bugs or spills in the dining room kitchenette drawers, that the steam table wells and water should be clean and free of food particles, and that cleaning schedules should be in place for the drawers and steam tables. The LNHA emphasized that clean dining rooms are important for resident safety and for preventing illness. A review of the facility's Dietary Equipment Cleaning policy, dated 3/1/24 and revised 2/28/25 indicated that all kitchen equipment will be cleaned and sanitized regularly following manufacturer guidelines and facility-specific schedules. NJAC 8:39-31.4(a)

Based on observations, interview, record review, and review of pertinent facility documents it was determined that the facility failed to interact with residents in a dignified and respectful manner by failing to provide privacy to Resident #8 during wound care. This deficient practice was identified for 1 of 44 residents reviewed for dignity and was evidenced by the following:During a tour of the Dogwood Unit on 8/5/2025 at 11:53 AM, the surveyor observed room [ROOM NUMBER] with the door open and two nurses inside performing wound care to Resident #8 whose bed was next to the window. The surveyor noted that resident's privacy curtain was not pulled and the window shades were not pulled down for privacy. The surveyor continued to observe the room and at no time was Resident #8's privacy maintained.On the same date at 12:01 PM, the surveyor approached the Assistant Director of Nursing (ADON) who was seated at the nursing station. The ADON stated that during wound care, privacy was to be maintained by either closing the door or pulling the privacy curtain. When asked about the window bed, the ADON confirmed that the window shade should be pulled down to maintain privacy. The surveyor requested that the ADON accompany them to room [ROOM NUMBER]. Upon approaching room [ROOM NUMBER], one of the nurses stated that the door was closed. When the surveyor stated that they have been standing at the doorway the nurse stated that she believed the door was closed. The second nurse then approached the treatment cart and while the ADON was providing education, it was confirmed that the door was not closed. On 8/6/2015 at 10:56 AM, the surveyor spoke with Resident #8 who confirmed that the nurses did not pull the curtain, shut the door, or pulled the window shade during wound care.The surveyor reviewed Resident #8's medical record:A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included fracture of the left femur and infection following procedure/surgical site.A review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool, dated 7/17/2025, reflected a brief interview for mental status (BIMS) score of 14 out of 15, which indicated that the resident was cognitively intact.During an interview with the surveyor on 8/11/2025 at 9:48 AM, the Infection Preventionist confirmed that privacy was to be maintained during wound care by closing the door, pulling the privacy curtain, and pulling the window shades if the resident is in a window bed.During an interview with the surveyor on 8/11/2025 at 12:20 PM, the Director of Nursing, in the presence of the Licensed Nursing Home Administrator, Regional Administrator, and Administrator in Training, confirmed that privacy was to be maintained during wound care by closing the door, pulling the privacy curtain, and pulling the window shades if the resident is in a window bed.A review the facility policy titled, Promoting/Maintaining Resident Dignity, last revised 11/2024, revealed that: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident 's quality of life by recogniziing each residents individuality. The policy further revealed the following under Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights [ .]; 12. Maintain resident privacy [ .].A review the facility policy titled, Wound Care, last revised 12/20205, revealed the following under Procedures: [ .] 8. Ensure privacy by pulling the privacy curtain or shutting the door if in a private room [ .] . NJAC 8:39-4.1(a)12

Based on observations, interview, record review, and review of pertinent facility documents it was determined that the facility failed to provide appropriate and sufficient care urinary catheter care, specifically by having the catheter drain bag not secured in a manner to maintain infection control, outside of a privacy bag, and improperly positioned at the foot of the bed in manner to potentially cause pain to resident. The deficient practice was identified for 1 of 3 Residents (Resident # 13) reviewed for Urinary Catheter or Urinary Tract Infections and was evidenced by the following:During initial tour of the facility on 8/4/2025 at 10:52 AM, the surveyor observed the resident's catheter drainage bag draped over the foot of the Resident #13 bed. The draining catheter bag was not fully contained inside the privacy bag and resident's urine was visible inside the bag. The resident stated that he was not sure how long the drainage bag has been in this manner and confirmed that they do not have any pain at this current time. The surveyor reviewed the medical record for Resident #18.A review of the [admission Record], an admission summary, revealed the resident had diagnoses which included, but were not limited to: Rhabdomyolysis (a muscle injury where the muscles break down into the blood), and hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (a group of disorders that affect blood vessels and blood supply to the brain). A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/3/2025, included that Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS under Section H for Bladder and Bowel revealed the resident had an indwelling catheter.A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 5/28/2025, that the resident required insertion of indwelling urinary catheter due to urinary retention and has indwelling catheter. Interventions included, but were not limited to: Position catheter bag and tubing below the level of the bladder and away from entrance room door and privacy cover.On 8/7/2024 at 10:10 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that urinary drainage bags should be fully encased in the privacy bags, not touching the floor, and that they should be secured on the side of the bed with the provided hook.On 8/7/2024 at 10:15 AM,, the surveyor interviewed the Registered Nurse/Charge Nurse (RN/CN #1) who confirmed that urinary drainage bags were to be secured on the side bed frame fully inside the privacy bag. Upon review of the picture obtained of Resident #18's urinary drainage bag on initial tour of the facility, the RN/CN #1 acknowledged that the urinary catheter bag should have been parallel to the resident to allow gravitation pull into the bag. RN/CN #1 further explained that the bag being positioned at the end of the bed could potentially cause a pulling sensation and pain to the catheter site. On 8/11/2025 at 9:48 AM, the surveyor interviewed the Infection Preventionist, who upon review of the picture, confirmed that the urinary drainage bag should have been fully contained within the privacy bag, placed parallel to the resident, and secured with the provided hook to allow proper drainage. On 8/11/2025 at 12:20 PM, the survey team interviewed the Director of Nursing, in the presence of the Licensed Nursing Home Administrator, Regional Administrator, and Administrator in Training, acknowledged that it is the expectation of the facility that urinary drainage bags should be fully contained within the privacy bags, placed parallel to the resident, and secured with the provided hook on the bed frame. A review the facility policy titled, Urinary Catheters, last revised 2/4/2025, revealed the following under Procedures: [ .] 6. Indwelling catheters should be properly secured to prevent movement and urethral traction; [ .]15. Keep the collection bag below the level of the bladder and place in a privacy bag [ .]. N.J.A.C. 8:39-19.4 (a)

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 1 of 4 nursing units (Birch Unit) and was evidenced by the following: On 4/10/24 at 10:35 AM, the surveyor entered resident room Birch #17 and observed the doorknob backplate was not secured properly to the resident's entrance door or bathroom door, which resulted in the backplate hanging loosely with a gap between the doorknob and the door. On 4/10/24 at 10:37 AM, the surveyor entered resident room Birch #15 and observed the doorknob backplate was not secured properly to the resident's entrance door which resulted in the backplate hanging loosely with a gap between the doorknob and the door. On 4/10/24 at 11:02 AM, the surveyor observed in resident room Birch #11, the packaged terminal air unit (PTAC) (a self-contained through-the-wall air conditioning and heating unit) with the cover detached and was placed next to the unit, which left the internal components of the unit exposed. The resident stated that the PTAC unit had been in this condition for a couple days. On that same date and time, the surveyor observed two holes in the wall, one to the left of the PTAC unit and one on the far wall between the residents' beds. On 4/12/24 at 11:33 AM, the surveyor entered resident room Birch #1 and observed the doorknob backplate was not secured properly to the resident's entrance door which resulted in the backplate hanging loosely with a gap between the doorknob and the door. On 4/12/24 at 11:36 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that broken items or building issues were to be reported to the Unit Manager (UM) or Unit Clerk who entered the concerns into the computer system. When asked who was responsible for the overall appearance of the building, CNA #1 responded, everyone. On 4/18/24 at 10:10 AM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who stated that broken items and building issues were reported to Maintenance through the computer system. LPN #1 explained that everyone on the floor was responsible to identify and report any building issues that may be a safety concern. On 4/18/24 at 10:36 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated that any concerns with the building were to be reported right away to Maintenance through the computer system. The UM/LPN confirmed that regularly scheduled floor staff, supervisors, clerks, and/or unit managers had access to the system and could directly enter their concerns. At this time, the surveyor and UM/LPN toured the unit and the UM/LPN confirmed that the doorknobs should not be loosely attached to the door. When the surveyor showed the UM/LPN pictures of the PTAC unit with the cover removed and interior components exposed, the UM/LPN confirmed that it should have been addressed immediately. The UM/LPN also confirmed that resident rooms should not have holes in the wall. On 4/18/24 at 10:50 AM, the surveyor interviewed the Director of Maintenance (DOM) who stated that the Maintenance Department had a maintenance care application on their computer that identified building concerns and their location. The DOM explained that the issues were addressed as soon as possible dependent on the situation, and confirmed that everyone in the building had the responsibility to ensure that the building was maintained in a safe and homelike environment. The DOM further confirmed that the doorknobs, the PTAC unit, and holes in the resident room should not have been in that condition. On 4/24/24 at 10:02 AM, the Director of Nursing (DON), in the presence of the Regional Nurse and Assistant Director of Nursing (ADON), confirmed that the doorknobs, PTAC unit, and holes should have been previously identified and addressed and that they should not have been found in that condition. A review of the facility provided Resident Rights policy, with dated January 2023 included .the resident has a right to a safe, clean, comfortable and Homelike environment NJAC 8:39-4.1 (a), 11

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure appropriate storage for respiratory equipment for infection prevention. This deficient practice was identified for 1 of 4 residents reviewed for respiratory care (Resident #61), and was evidenced by the following: On 4/15/24 at 11:01 AM, the surveyor observed Resident #61 in bed and their nebulizer mask and tubing placed directly on the nebulizer machine (a device used for producing a fine spray of liquids). Resident #61 informed the surveyor that after their nebulizer treatment (breathing treatment), they removed their nebulizer mask and placed it on the machine. On 4/15/24 at 11:15 AM, the surveyor interviewed the resident's License Practical Nurse (LPN) who stated she had administered the resident's nebulizer treatment earlier, but she never went back to the resident's room to verify if the treatment was completed. At that time, the LPN accompanied by the surveyor went into Resident #61's room, and the LPN took the resident's nebulizer mask off of the machine and placed it directly into a plastic bag that she placed inside the resident's nightstand. The surveyor observed no disinfecting of the nebulizer equipment. The surveyor asked the LPN what the facility's policy was for nebulizer equipment cleaning and storage, and the LPN stated the mask and tubing was placed into a bag for storage after use. On 4/15/24 at 11:20 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) regarding the facility's policy for usage and storage of nebulizer equipment. The UM/LPN stated when the resident's treatment was complete, the nurse placed the mask and tubing into a storage bag. On 4/15/24 at 11:35 AM, the surveyor interviewed the Director of Nursing (DON) who stated the nurse was expected to administer the nebulizer treatment per physician's order; staying with the resident until the treatment was completed. The nurse then cleaned the nebulizer with water and dried it with a paper towel prior to placing it in a bag for storage The surveyor reviewed the medical record for Resident #61. A review of the Admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), pleural effusion (a buildup of fluid between the tissue that line the lungs and the chest), and diabetes mellitus. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/8/24, included that the resident had a Brief interview for Mental Status (BIMS) score of 14 out of 15, which indicated a fully intact cognition. A review of the current Physician's Orders included a physician's order (PO) dated 8/21/23, for albuterol sulfate inhalation nebulization solution 2.5 milligram (mg)/3 milliliters (mL) 0.0083% (albuterol sulfate) to administer every twelve hours. An additional PO dated 4/16/24, indicated to change nebulizer mask/hand-held and nebulizer tubing weekly every night shift. On 4/22/24 at 9:45 AM, the surveyor interviewed the Infection Preventionist/LPN (IP/LPN) who stated stated the nurse administered the nebulizer treatment to order, and stayed with the resident until the treatment was complete. The nurse then removed the medication dispenser and rinsed the chamber, as well as rinsed the mask with water and placed the equipment on a clean paper towel to dry. When the equipment was dry, the nurse placed it in a bag for storage. On 4/24/24 at 10:02 AM, the DON in the presence of the Assistant Director of Nursing, Regional Nurse, and survey team who stated the nurse should have rinsed the nebulizer mask, tubing, and medication dispenser under running water after the resident's treatment was complete, and placed it on a clean paper to dry prior to placing in the bag for storage. A review of the facility's Cleaning Respiratory Equipment policy dated last revised 2/1/24, included supplies .when not in use, store masks and cannulae in plastic bags labeled with the resident's name and date .small volume nebulizers: cleaning a. begin with a sterile (disposable) nebulizer for each resident; b. rinse with water and air dry small volume medication nebulizers between treatments on same residents . A review of the undated facility provided Medication Nebulization (AARC # 2720) policy included this policy is to instruct the proper use of aerosolized medication to the lower airways via small volume nebulizer .Disassemble parts after ever treatment. Remove tubing from the compressor and set it aside. The tubing should not be washed or rinsed. Rinse the nebulizer cup and mouthpiece with either sterile or distilled water after each use and shake dry. Store in zippered or drawstring bag . NJAC 8:39-19.1(a)

Based on observation, interview, and review pertinent facility documents, it was determined that the facility failed to maintain complete and accurate skin assessments. This deficient practice was identified for 1 of 35 resident medical records reviewed (Resident #61), and was evidenced by the following: On 4/15/24 at 11:01 AM, the surveyor interviewed Resident #61 who stated he/she did not receive their scheduled shower on Friday 4/12/24. The surveyor reviewed the medical record for Resident #61. A review of the Admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), pleural effusion (a buildup of fluid between the tissue that line the lungs and the chest), diabetes mellitus, edema (swelling caused by too much fluid trapped in the body tissues), and end stage renal disease (the kidneys lose the ability to remove waste and balance fluids). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/8/24, included that the resident had a Brief interview for Mental Status (BIMS) score of 14 out of 15, which indicated a fully intact cognition. On 4/15/24 at 11:01 AM, the surveyor received from the Unit Secretary Resident #61's Weekly Skin Assessments which were dated 3/4; 4/8; 4/12; 4/15; and 4/22. A review of the assessment sheet indicated on 3/4 the nurse documented no abnormalities/skin clear and intact and signed their initials. There initials for the Certified Nursing Aide (CNA) and Supervisor initials were blank. For the dates of 4/8, 4/12, and 4/15, there was no documentation for the resident's skin, and/or initials for the nurse, supervisor, or CNA. A review of the 3-11 Birch Six Person Assignment: E indicated, sign the weekly skin assessment form Monday through Friday. On 4/17/24 at 9:37 AM, the Director of Nursing (DON) provided the surveyor with copies of the resident's Weekly Skin assessment dated ,d+[DATE], 3/11, 3/18, 3/25, 4/1, 4/8, 4/15, and 4/22. The assessments were now completed for all the dates, as well as 3/11, 3/18, and 3/25 were added. The surveyor showed the DON the skin assessment copies they received on 4/15/24, and asked why they were different from the copies the DON just provided. The DON stated after the surveyor spoke to the Unit Secretary on 4/15/24, the Unit Secretary informed the DON about the missing documentation, so she had staff go back and change the forms to add the incomplete documentation. On 4/22/24 at 12:00 PM, the DON provided the surveyor with a statement from the Registered Nurse (RN) that indicated on 4/8/24 during the 3:00 PM to 11:00 PM (3-11) shift, a skin assessment was completed on Resident #61 with no concerns. On 4/23/24 at 10:46 AM, the surveyor interviewed the CNA who stated after a resident received a shower, the aide notified the nurse to complete a body assessment. On 4/24/24 at 10:02 AM, the DON in the presence of the Assistant Director of Nursing, Regional Nurse, and survey team acknowledged that the skin assessments were not complete at the time of survey, and she had staff change the documentation. The DON confirmed she did not had staff date the assessment at the time the documentation was updated, and acknowledged staff should not back date assessments that were not completed. The DON acknowledged records were to be maintained accurately and complete. A review of a facility's Activities of Daily Living (ADL), Supporting policy dated January 2024, included residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Appropriate care and services will be provided for residents who are unable to carry out ADLs . A review of a facility's Weekly Skin Checks policy dated 12/10/23, included the nurse will inspect the resident skin once weekly during bath days for sign of skin breakdown or injury Will complete the Weekly Skin Check form after performing skin inspections NJAC 8:39-35.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness; b.) maintain kitchen equipment in a clean and sanitary manner; and c.) maintain cold food in acceptable temperatures during meal service. The deficient practice was evidenced by the following: 1. On 4/10/24 at 9:10 AM, the surveyor in the presence of the Food Service Director (FSD) and the Dietary Manager (DM) conducted a kitchen tour and observed the following: 1. In the walk-in freezer, an opened box of sliced cheese pizza. The box contained a bag with two slices of pizza outside of the bag, and the box was unsealed exposing the contents to air. The surveyor observed ice crystals on all the pizza slices. There was no observed date when the box was opened. The FSD was unsure when the box was opened. 2. In the walk-in freezer, an opened box of Salisbury steaks. The box contained a bag that was opened exposing the contents to air. The surveyor observed ice crystals on the food product. There was no observed date of when the box was opened. The FSD was unsure when the box was opened. 3. The cooktop catch tray had hard, thick, flaky black sediment on the pan and soiled aluminum foil on top of the sediment. The FSD and DM acknowledged that it needed to be thoroughly cleaned. The FSD also stated, it did not meet expectations on his staff. 4. The fryer had sediment around the cook top area and the oil was dark brown in color with sediment floating on the surface. The FSD and DM acknowledged that it needed to be thoroughly cleaned. The FSD also stated, it did not meet expectations on his staff. 5. The double door steamer box had sediment in the catch tray and built-up debris in the filter on the right side of the tray. The FSD and DM acknowledged that it needed to be thoroughly cleaned. The FSD also stated, it did not meet expectations on his staff. On 4/11/24 at 8:52 AM, the surveyor interviewed the DM who stated the freezer items should have been labeled with an opened date. The DM also acknowledged that once a product was opened, if all the content in the bag was not used, it should be resealed and dated. The DM further stated that the cooking equipment should have been cleaned and maintained in a sanitary manner to prevent food borne illness and contamination. On 4/11/24 at 9:11 AM, the surveyor interviewed the FSD who stated the facility's process and policy was to seal any opened packaging that was partially used and label the packaging with an opened date to ensure the product was used in a timely fashion to prevent waste and sealing to prevent exposure to air which caused contamination, ice crystal formation, and food born illnesses. The FSD also acknowledged the cooking equipment should have been cleaned and maintained in a sanitary manner to prevent food borne illness and contamination according to regulations. On 4/22/24 at 11:44 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON) acknowledged the above concerns. A review of the facility's undated Food Storage: Cold Foods policy included .all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . A review of the facility's Environment policy dated revised July 2023, included it is the center policy that all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Action Steps: 1. The FSD will ensure that the physical plant is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation; 2. The FSD will ensure that all employees are knowledgeable in the proper procedures for cleaning all food services equipment and services; 3. The FSD will ensure that all food contact surfaces are cleaned and sanitized after each use; 4. The FSD will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces . 38080 2. On 4/17/24 at 11:07 AM, the surveyor informed the Food Service Director (FSD) that they wanted to observe food temperatures for the lunch trayline. At this time, the FSD calibrated a thin probe thermometer in an ice bath to 32 degrees Fahrenheit (F). The FSD informed the surveyor that cold food should be maintained at 41 F or below. The surveyor observed the following food items held above 41 F: Cantaloupe 43 F. The cantaloupe was in a portion control (PC) cup with a label that indicated prepared 4/17/24 at 6:08 AM. The containers were directly on a tray with no measures to maintain coldness. Pudding 44 F. The pudding was in a PC cup with a label that indicated prepared 4/17/24 at 6:57 AM. The containers were being held directly on a tray with no measure to maintain coldness. Ham and cheese sandwich 51 F. The sandwich had a label that indicated prepared 4/17/24 at 7:03 AM. The sandwich was being held directly on the trayline with no measure for maintaining coldness. Turkey sandwich 49 F. The sandwich was being held directly on the trayline with no measure for maintaining coldness. On 4/17/24 at 11:15 AM, the surveyor interviewed Dietary Aide (DA#1) who stated another DA prepared the cold items, and she printed the label at the time the other DA prepared the items and placed them in the refrigerator. On 4/17/24 at 11:20 AM, the surveyor interviewed DA #2 who stated he removed the sandwiches from the refrigerator at approximately 11:05 AM, and placed them on the trayline. On 4/17/24 at 11:21 AM, the FSD acknowledged that the cantaloupe, pudding, and sandwiches were not being held at 41 F or below. On 4/24/24 at 10:02 AM, the Director of Nursing (DON) in the presence of the Assistant Director of Nursing, Regional Nurse, and survey team acknowledged the cold food items were not being held at the appropriate temperature. A review of the facility's Food Temperatures policy dated reviewed August 2023, included the temperature of hot foods at the point of service (steamtable) during tray assembly will be 135 degrees Fahrenheit or above for hot foods and 40 or below for cold foods .the cook is responsible to see all food is at proper temperature .chilled food and beverages recommended temperature range 40 F or below . NJAC 8:39-17.2(g)

Complaint NJ# 160883 Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident received showers as scheduled. This deficient practice was identified for 1 of 2 residents reviewed for activities of daily living (Resident #61), and was evidenced by the following: On 4/15/24 at 11:01 AM, the surveyor interviewed Resident #61 who stated he/she did not receive their scheduled shower on Friday 4/12/24 during the 3:00 PM to 11:00 PM (3-11) shift. The resident stated their showers were scheduled weekly for Mondays and Fridays. The surveyor reviewed the medical record for Resident #61. A review of the Admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), pleural effusion (a buildup of fluid between the tissue that line the lungs and the chest), diabetes mellitus, edema (swelling caused by too much fluid trapped in the body tissues), and end stage renal disease (the kidneys lose the ability to remove waste and balance fluids). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/8/24, included that the resident had a Brief interview for Mental Status (BIMS) score of 14 out of 15, which indicated a fully intact cognition. A further review in Section GG. Functional Abilities and Goals, indicated the resident required set-up assistance for showering. A review of the 3-11 Birch Six Person Assignment:E sheet dated 4/12, indicated Resident #61 received a shower on Mondays and Fridays during the 3-11 shift. A review of the Progress Notes for 4/12/24, did not include the resident refused a shower. On 4/17/24 at 1:15 PM, the surveyor interviewed the Director of Nursing (DON) who stated the Certified Nursing Aides (CNA) provided resident showers on their assigned days and shifts. On 4/17/24 at 3:00 PM, the surveyor attempted to interview CNA #1 who was assigned to Resident #61 on 4/12/24 via telephone. There was no answer. On 4/18/24 at 9:00 AM, the surveyor attempted to interview CNA #1 via telephone with no answer. On 4/18/24 at 9:10 AM, the surveyor informed the DON they attempted to speak to CNA #1 on multiple occasions, and the DON stated CNA #1 had called out for their assigned shift today. On 4/18/24 at 9:15 AM, the DON informed the surveyor that CNA #1 who stated she had four residents to give showers to on that day, and the aide should have informed the Nurse Supervisor if she was unable to provide care. On 4/23/24 at 10:46 AM, the surveyor interviewed CNA #2 who stated they received their daily assignments which included which residents needed to be showered. CNA #2 stated if a resident refused a shower, they were to notify the Unit Manager. On 4/23/24 at 11:00 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated resident shower days were indicated on the CNA's assignment sheets, and if the resident refused to be showered, the CNA would notify her. On 4/24/24 at 10:02 AM, the DON in the presence of the Assistant Director of Nursing, Regional Nurse, and survey team stated she spoke to CNA #1 on the telephone and confirmed Resident #61 did not receive a shower on 4/12/24. The DON continued that CNA #1 informed her that she ran out of time to shower the resident, and the DON acknowledged the aide did not inform anyone. The DON acknowledged residents should receive showers as scheduled. A review of a facility's Activities of Daily Living (ADL), Supporting policy dated January 2024, included Supporting This policy indicate Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently with consent of the resident and in accordance with the plan of care . NJAC 8:39- 27.1 (a)

Complaint NJ # 157609; 157901; 160396 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to administer medications within scheduled time parameters on various shifts for two residents in accordance with professional standards of practice. This deficient practice was identified for 2 of 35 residents reviewed for professional standards of practice (Resident #20 & Resident #213). Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as follows: 1. On 4/12/24 at 8:35 AM, during medication pass observation, the surveyor observed the Licensed Practical Nurse (LPN) on Birch Unit prepare morning medications for Resident #20. The resident had medications which included an order for glipizide (medication used for diabetes) with directions which included give 30 minutes prior to meal. On 4/12/24 at 8:56 AM, as the surveyor and the LPN entered the Resident #20's room for medication administration, the surveyor observed the Dietary Staff removing the resident's breakfast tray from the overbed table. The surveyor asked the Dietary Staff to raise the lid of the meal plate, and the surveyor observed the resident had consumed 100% of their morning meal. The LPN then proceeded to administer the resident their morning medications. The surveyor reviewed the medical record for Resident #20. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included chronic kidney disease, heart failure and diabetes. A review of the April 2024 Medication Administration Record (MAR) included the physician's order (PO) dated 12/6/23, to administer at 7:30 AM glipizide tablet 5 milligram (mg); give one tablet by mouth one time a day related to Type 2 diabetes. Give 30 minutes prior to meal. A review of the corresponding April 2023 Medication Admin Audit Report revealed that on 4/12/24 the 7:30 AM dose was administered at 8:52 AM. On 4/12/24 at 11:40 AM, the surveyor interviewed the LPN who stated the Birch Unit was served breakfast usually around 7:30 AM. At that time, the LPN and surveyor reviewed the April 2024 MAR, and the LPN acknowledged the order stated give 30 minutes before meal. The LPN further acknowledged she should have given the glipizide before the resident had their breakfast. On 4/12/24 at 11:50 AM the surveyor interviewed the Director of Nursing (DON) who stated breakfast on the Birch Unit was served at 8:00 AM. The DON then stated the nurses should prioritize the order in which residents were administered their medications based on residents whose medications were due earliest such as diabetic medications. At that time, the DON and the surveyor reviewed the MAR for Resident #20. The DON acknowledged the glipizide should be given 30 minutes prior to a meal. The DON further acknowledged the nurse should have given the glipizide before the resident had eaten breakfast to ensure the blood sugar levels were regulated properly and to help prevent any potential adverse reactions. On 4/23/24 at 12:59 PM, the surveyor re-interviewed the DON who stated the allowance for medication administration time was one hour before and one hour after the scheduled medication administration time. 2. On 4/23/24 the surveyor reviewed the closed medical record for Resident #213. A review of the Admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included diabetes, chronic pulmonary embolism (blood clot in the lung), and a history of venous thrombosis and embolism (blockage of a vein due to a blood clot). A review of the December 2022 Order Recap Report revealed the resident had the following physician's order (PO) to be administered at 9:00 AM: PO dated 12/21/22, for Xarelto tablet 15 milligrams (mg); give one tablet by mouth one time a day related to personal history of venous thrombosis and embolism. A review of the December 2022 Medication Admin Audit Report reflected on 12/22/22, the 9:00 AM dose was administered at 10:39 AM. On 4/23/24 at 1:04 PM, the surveyor reviewed the Medication Admin Audit Report for December 2022 with the DON who acknowledged the Xarelto scheduled for 12/22/22 at 9:00 AM was not administered until 10:39 AM. The DON stated a medication can be given up to one hour before or one hour after a medication administration time and confirmed the Xarelto had been given outside the one-hour parameter. A review of the facility's Medication Administration policy dated last reviewed January 2024 included .Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice .administer within acceptable time frame . NJAC 8:39-27.1(a)

COMPLAINT # NJ162053 Based on interviews, medical records review, and review of other pertinent facility documentation on 9/12/23, it was determined that the facility failed to follow their policies and procedures for a facility-initiated discharge. A resident (Resident #1) was involved in an altercation with another resident and sent to the hospital for a behavioral evaluation. When the resident was discharge from the hospital, the facility would not permit a return back to the facility. The deficient practice was identified for Resident #1, 1 of 3 residents reviewed for transfer/discharge and was evidenced by the following: According to the Admission Record, Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to lack of coordination, dementia with behavioral disturbances, schizophrenia, anxiety disorder, and Parkinson's Disease. Review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/13/22, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 08, which indicated the resident had moderate cognitive impairment. The MDS also showed that the resident had no behaviors. Review of Resident #1's 12/1/22 PASRR Level II Determination Notification, (Pre-Admission Screening and Resident Review) (a comprehensive evaluation required as a result of a positive Level I Screening and is necessary to determine whether placement or continued stay in a nursing facility is appropriate) reflected that the resident had mental health treatment needs that could be met at a nursing facility. The following recommendations were made for Resident #1: psychiatric consult upon admission, routine follow-up visits with primary care provider and psychiatrist, medication monitoring, supportive counseling, routine laboratory testing, formulate and implement a behavioral modification plan to address any behavioral disturbances, provide education to client and family on mental illness and medication, and develop a crisis intervention/safety plan with the client. Review of Resident #13's Care Plan (CP) revealed a Focus, initiated on 12/6/22, that Resident #1 used psychotropic medications (Clozaril, Abilify (an antipsychotic medication used to treat schizophrenia) and Depakote (medication used to treat bipolar disorder) related to behavior management and schizophrenia. Under Interventions/Task, indicated to monitor occurrences of target behavior symptoms and to document per facility protocol. Target behaviors included pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff and others. The CP revealed a Focus, initiated on 12/19/22, that Resident #1 was admitted to long-term placement secondary to decline in previous level of function. Under Interventions/Tasks, reflected to administer medications per physician's order. The CP revealed a Focus, initiated on 12/19/22, that the resident was at risk for adjustment due to new admission to long term care placement. Under Interventions/Tasks, reflected to encourage resident to discuss feelings, monitor for triggers that may indicate need to adjust plan of care to assist the resident in compliance, and to monitor reaction to placement. Review of Resident #1's Incident Report, dated 2/9/23 at 11:36 PM, completed by the Registered Nurse Supervisor (RNS), revealed that she was called to the unit and informed that Resident #2 was on the floor in Resident #1's room. The RNS spoke with Resident #1, who stated that Resident #2 came into their room and that he/she asked the resident to leave. Resident #1 further stated that Resident #2 put their hands up and that he/she had to defend themselves. Resident #1 hit Resident #2 in the face and the resident fell to the floor. Under the Immediate Action Taken section revealed that Resident #1 was determined to be the aggressor and was transferred to the Psychiatric Emergency Screening Services (PESS) at the local hospital for evaluation. During an interview with the Licensed Practical Nurse/Unit Manager (LPN/UM) on 9/12/23 at 12:42 PM, the LPN/UM stated that Resident #1 required limited assistance with activities of daily living. The surveyor asked about Resident #1's behaviors. The LPN/UM responded that Resident #1 would at times display sexually inappropriate behaviors and be verbally abusive towards staff and daughter. The LPN/UM continued that Resident #1 also would shadow box (sparing with an imaginary opponent as a form of training) in the day room. The LPN/UM stated that she was informed of the 2/9/23 incident by the nurse and that Resident #1 was transferred to PESS for evaluation. The LPN/UM added that Resident #1 did not return to the facility. During an interview with the Director of Social Services (DSS) on 9/12/23 at 2:14 PM, the DSS stated that Resident #1 was admitted to the facility from the community with behavioral issues. The resident was transferred out for an evaluation at PESS due to the 2/9/23 incident. The DDS stated that Resident #1 was on Clozaril, and the facility psychiatrist felt that it was not an appropriate medication to be manage at the facility. The DDS further stated that the facility psychiatrist was uncomfortable with managing Resident #1 while on that particular medication [Clozaril]. An administrative meeting was conducted to discuss the facility's ability to manage Resident #1 behaviors at the facility and discussions were also conducted with PESS in reference to the medication. The DDS added that they were willing to allow Resident #1 to return to the facility, but the concern was the medication. The resident was eventually admitted to another facility. During an interview with the RNS on 9/12/23 at 2:48 PM, the RNS stated that she was the nursing supervisor during the 2/9/23 incident and that she interviewed Resident #1 about what happened. The RNS stated Resident #1 informed her that Resident #2 entered his/her room and that he/she asked Resident #2 to leave the room. Resident #1 stated that the other resident hit him/her and in return had hit Resident #2 back. A body assessment was completed for both residents. Resident #1 did not have injuries, but the other resident had injuries. The physician was called, and Resident #1 was sent out for a PESS evaluation at the hospital. The RNS stated she initiated 1:1 monitoring of Resident #1 until transferred out. During an interview with the DON and Administrator on 9/12/23 at 3:02 PM, the DON stated that Resident #1 had an altercation and hit another resident. The DON added that with Resident #1 hitting Resident #2, along with his/her diagnosis of schizophrenia, and use of Clozaril, they felt Resident #1's readmission would be unsafe for the other residents. The Administrator stated the facility psychiatrist was not comfortable with Clozaril being administered within the long-term care (LTC) setting and felt there was a danger to the other residents. The Administrator reiterated that the facility psychiatrist was worried for the safety of the other residents on the unit. The surveyor asked when the last time Resident #1 was evaluated by the facility psychiatrist. The Administrator stated the resident was admitted to the facility on Clozaril in December of 2022 and that he could not remember if the current facility psychiatrist evaluated the resident prior to the incident. The surveyor inquired about Resident #1's readmission to the facility after the PESS evaluation was completed. The Administrator responded that he was in communication with the hospital the entire time and that the facility physician wanted Resident #1 to be admitted as in-patient, so the resident would be weaned off of Clozaril. The Administrator stated he was in constant communication with PESS and never stated that they were not going to take Resident #1 back. At that point in time, they were uncomfortable taking the resident back. They would be more comfortable readmitting the resident after the resident stabilized during an in-patient stay. The Administrator further stated PESS gave them a hard time about admitting the resident and wanted the resident to return to the facility the same day. The Administrator further stated that he spoke with the PESS supervisor and inform her that they could not accommodate Resident #1. They were worried about the other residents and the facility psychiatrist did not want to prescribe the medication [Clozaril]. Once Resident #1 had the altercation and was sent out for the PESS evaluation, the physicians did not feel comfortable continuing the medication. The Administrator added that both the facility psychiatrist and the primary physician did not want to prescribe the medication [Clozaril]. The Administrated stated that he was back and forth with PESS and at a certain point the resident was admitted . The surveyor asked if Resident #1 was issued a 30-day discharge notice. The Administrator stated that Resident #1 was not issued a discharge notice because the discharge was immediate. The resident just needed to be stabilized and weaned off the medication so that the facility psychiatrist would them take him/her back on. The surveyor asked what were Resident #1's behaviors and if the resident had any other altercations while at the facility. The DON stated that Resident #1's behavior included shadow boxing and at times would come up close to people's faces. The DON added that Resident #1 did not have any other physical altercations while at facility. During an interview with the facility psychiatrist on 9/12/23 at 4:10 PM, the facility psychiatrist stated that he was not sure why the resident's medication was being referenced and that this had nothing to do with Clozaril. He was informed that Resident #1 hit another resident on the unit, and it was more about the safety of the other residents. The resident could end up hitting another resident and that there were other facilities that could handle the resident. Review of Resident #1 Progress Notes (PN) from 12/6/22 to 2/10/23 revealed a Behavior Note, (BN) dated 1/17/23 at 10:30 PM, that Resident #1's psych med [medication] changed, Clozaril increased from 100 mg to 200 mg. No adverse reactions noted. No behavior issues noted throughout the shift. The PN revealed a second BN, dated 1/20/23 at 6:52 PM, that Resident #1 was alert and confused. The resident was exit seeking and cursing at staff. Redirected when necessary. The PN did not include any physician documentation of the specific needs that could not be met at the facility for Resident #1. The PN also did not include any documentation of the facility's attempts to meet the Resident #1's needs. Review of the facility's 2/9/23 Reportable Event Record/Report, (Reportable) provided by the Director of Nursing (DON), included an Investigational Summary (IS) of the 2/9/23 incident. The IS reflected under the Conclusion section that based on the facility's thorough investigation, interviews of the resident and staff involved, it was concluded that the physical altercations were triggered by [Resident #2] entering [Resident #1's] room. Resident #1 indicated that Resident #2 hit him/her but there were no witnesses to corroborate the allegation. The IS indicated that The incident was an isolated event and there were no prior altercations that were reported. The IS included a CP with a Focus, initiated on 2/10/23, that Resident #1 was physically aggressive (hitting) related to dementia, schizophrenia, poor impulse control. Easily gets angry when someone enters into [his/her] room weather a staff member or another resident. Under the Goals section reflected that Resident #1 would demonstrate effective coping skills, seek out staff/caregiver when agitation occurs, not harm self or others, verbalize understanding of need to control physically aggressive behavior through the review date. Under Interventions/Tasks, included the following interventions, initiated on 2/10/23: administer medications as ordered, analyze time of day, places, circumstances, triggers, and what de-escalates behavior and document. Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation assist to set goals for more pleasant behaviors, encourage seeking out of staff member when agitated. When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff walk calmly away and approach later. The IS also included a Psych Service Notes (PSN), dated 2/10/23 at 9:23 AM, completed by the facility psychiatrist for Resident #1. Under the Plan/Recommendation section indicated to continue with current treatment, Depakote level, neurology consult to review need for Amantadine (medication used to treat Parkinson's disease), and to follow up in one month. The risks and benefits of treatment were considered, and the recommendations were reviewed with staff. The PSN did not reveal any documentation that Resident #1's needs could not be met at the facility. Review of Resident #1's Transfer/Bed Hold Notice Prior to hospitalization s or Therapeutic Leave form, dated 2/10/23, reflected that the resident's belongings would be safeguarded until resident's return. The resident currently occupies a Medicaid covered bed. Per State regulation, your bed must be held for 10 days at no charge for hospitalization s and 24 days per calendar year for therapeutic leave. Review of the facility's Transfer/Discharges, last revised on 11/2002, reflected that the Purpose was to protect the rights of each resident in accordance with state and federal guidelines and applicable laws in regard to transfers and discharges from and to the facility. The policy revealed under the Facility elected transfer/discharges section that a resident and/or legal representative will be given a 30-day advance notice of an impending transfer or discharge from the facility, except as specified below: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility, c. The safety of other residents and employees is endangered, d. The health of residents and employees in the facility would otherwise be endangered. The resident, and/or legal representative will be provided with the reason for the transfer or discharge, and the effective date of the transfer or discharge. The resident and/or legal representative has the right to appeal transfer or discharge notices through the State agency and appeals must be filed within five days of receiving the notice. NJAC 8:39 4.1(a)32 NJAC 8:39 5.1(d)

Based on interview, record review, and policy review, the facility failed to ensure that two (Resident (R) 3 and R4) of six residents reviewed for immunizations were educated and offered a pneumonia vaccine due to either their age and/or having chronic medical conditions. This failure has the potential for the residents to be unprotected from developing a life-threatening illness (pneumonia), which can require hospitalization for treatment. Findings include: 1. Review of R3's Admission Record, from the facility's electronic medical record (EMR) Profile tab showed an admitted [DATE] at the age of 66, with medical diagnoses that included emphysema and heart failure. Review of an Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/07/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident was cognitively intact. Review of R3's EMR Immunization tab showed that it was marked as Consent Refused for the pneumococcal vaccine. Review of the EMR Miscellaneous tab did not show documentation that indicated, at a minimum, that the resident or their representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. Further review of all other sections of the EMR, as well as the resident's hard (paper) chart also revealed no documentation that the resident and/or their representative was provided education about the vaccination and made an informed decision to decline it. In response to a request for the documentation R3 had received education and declined the vaccine, the Director of Nursing (DON) provided a form which was dated at the resident's admission admit and had not been in the hard (paper) chart or EMR chart. During an interview on 05/16/23 at 4:55 PM regarding education regarding the vaccine, R3 stated he was not educated at admission. R3 added that the supervisor came today (05/16/23) and had him sign something. R3 continued that he had not received any education in writing and did not provide further information on this topic. 2. Review of R4's Admission Record, from the EMR Profile tab showed an admitted [DATE] at age 54 and a readmission to the facility on [DATE], with medical diagnoses that included diabetes and COPD. Review of an MDS, with an ARD of 05/01/23, revealed the resident had a BIMS score of 15/15, indicating the resident was cognitively intact. Review of R4's EMR Immunization tab showed Not Eligible for the pneumonia vaccine. Further review of R4's hard chart and EMR did not reveal documentation of education regarding the vaccine or documentation as to why the resident was not eligible for the pneumonia vaccine. In response to a request for documentation of R4's vaccine education and reason that the resident was not eligible for the vaccine, the DON provided an Immunization Informed Consent Record dated on the readmitted and signed by R4. The only vaccine indicated on this form was the influenza vaccine, and there was no information as to why the resident was not eligible to receive the pneumococcal vaccine. During an interview on 05/16/23 at 4:40 PM, when asked if she had received education regarding the pneumonia vaccine, R4 responded Just now, indicating that this education was not provided until after the initiation of the Focused Infection Control survey. , In an interview on 05/16/23 at 4:46 PM, the DON stated the form (Immunization Informed Consent Record) is filled out when the resident comes in and should be given to the resident at the time they decline. The DON continued that she found those forms in a stack at the nurse's station and confirmed R3 and R4 had just signed them, saying that she knew both residents had declined when they came in. Review of the facility policy titled Pneumococcal Vaccine (Series), revised 02/17/22, revealed: It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC [Centers for Disease Control] guidelines and recommendations. Policy Explanation and Compliance Guidelines . 3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. a. The individual receiving the immunization, or the resident representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine . 7. A pneumococcal vaccine is recommended for all adults [AGE] years' and older. 8. A pneumococcal vaccination is recommended for adults 19 to [AGE] years' old who have certain chronic medical conditions or other risk factors which may include: c. Chronic heart disease, including CHF [congestive heart failure] and cardiomyopathies .e. Chronic lung disease, including COPD [chronic obstructive pulmonary disease] emphysema and asthma .k. Diabetes mellitus. NJAC 8:39-19.4 (i)

Based on observations, interviews, and review of facility documentation, it was determined that the facility failed to ensure respiratory equipment was kept in a clean and sanitary condition, and stored properly to reduce the risk of infection for 1 of 1 residents reviewed for respiratory equipment, Resident #18. The deficient practice was evidenced as follows: According to the facility's Admission Record, Resident #18 was admitted to the facility in 11/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Quarterly Minimum Data Set (MDS), an assessment tool dated 11/30/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated that the resident's cognition was intact. Review of the resident's Order Summary Report revealed an order dated 11/25/21 for [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) milligrams per 3 milliliters orally via nebulizer (a machine that delivers aerosol medication) every 6 hours related to [CONDITION(S)], Unspecified. Review of Resident #18's December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/07/21 at 12:04 PM, during the initial tour of the Birch Unit, the surveyor observed a nebulizer machine on a side table in Resident #18's room. The dry nebulizer mask was exposed, connected to the dry medication cup, and the tubing was connected to the nebulizer machine. The mask was resting on top of a book and a tissue box with a headband resting on the mask. On 12/08/21 at 11:48 AM, the surveyor observed a nebulizer machine on the resident's side table. The dry nebulizer mask was exposed, connected to the dry medication cup, and the tubing was connected to the nebulizer machine. The mask was resting in the opened top drawer of the side table with a hairbrush resting on the mask. On 12/09/21 at 10:18 AM, the surveyor observed a nebulizer machine on the resident's side table. The dry nebulizer mask was exposed, connected to the wet medication cup, and the tubing was connected to the nebulizer machine. The mask was resting on a black charger with a book resting on the mask. During an interview at that time, the resident stated she had worn the mask to receive her nebulizer treatment that morning and that the nurse removed the mask and placed it on the side table when the treatment was completed. On 12/09/21 at 11:12 AM, the surveyor brought the assigned Licensed Practical Nurse (LPN) to Resident #18 's room. The nebulizer mask, medication cup, and tubing were connected to the nebulizer machine. The exposed mask was resting on the side table. The LPN lifted the mask off the table and placed it on a hook on the nebulizer machine and stated that the mask was usually stored on the machine. During an interview with the surveyor on 12/09/21 at 11:20 AM, the LPN Unit Manager (UM) stated that the nebulizer mask should be washed with soap and water after each use and placed on a paper towel to air dry. The UM acknowledged the exposed mask should not be stored on the table and that proper cleansing of the nebulizer mask was important for infection control. During an interview with the surveyor on 12/09/21 at 11:42 AM, the Director of Nursing (DON) stated that the nebulizer mask should be cleansed with soap and water after each use and stored in a plastic bag at the resident's bedside. The DON further stated it was important to keep the nebulizer mask clean so that the resident doesn't get a respiratory infection. The facility was unable to provide a policy regarding cleaning and storage of the nebulizer machine. NJAC 8:39-15.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medication was administered without significant medication error. This deficient practice was identified for 1 of 35 residents (Resident #24) reviewed for medications and was evidenced by the following: On 2/5/20 at 10:51 AM, during the initial pool process, the surveyor observed Resident #24 sitting in a wheelchair in their room. The resident had an intravenous (IV) medication infusing into a peripherally inserted central catheter (PICC) line in their right upper arm. The surveyor observed that the medication infusing was the antibiotic [MEDICATION NAME] 1 gram (gm) in 250 milliliters of [MEDICATION NAME] 5% in water (D5W). The name on the IV bag was not the name of Resident #24. On the same day at 10:54 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) about the medication that was currently infusing via a pump for Resident #24. LPN #1 confirmed that she had hung the medication for infusion, a little before 10:00 AM, and then she went into the room of Resident #24 and stated that the medication bag hanging was prescribed to Resident #270. The surveyor then interviewed LPN #2, who reviewed Resident #24's current medication orders with the surveyor, which revealed that Resident #24 was also prescribed 1 gm [MEDICATION NAME] in 250 ml of NaCl (sodium chloride), not the D5W. At 10:59 AM, LPN #1 stated that she had stopped the infusion on Resident #24 and that she made her supervisor aware. At 11:05 AM, LPN #1 stated that she had spoken with the resident's physician and made him aware of the medication error, as mentioned above. According to LPN #1, the physician stated that because the resident had a [DIAGNOSES REDACTED]. At that same time, the surveyor observed Resident #24 sitting in a WC in their room, working on their computer. At 11:15 AM, LPN #1 identified the bag that had been hanging on Resident #24 was the IV bag prescribed for Resident #270. The nurse added that both residents had 1 gm of [MEDICATION NAME] ordered and that Resident #24's was mixed in NaCl, and Resident #270's was mixed in D5W. The nurse then added that approximately 100 ml's of the [MEDICATION NAME] in D5W had infused into Resident #24 before the surveyor brought it to the attention of the nurse. At 11:18 AM, the surveyor reviewed that facility form titled, Order Summary Report, that revealed an order dated 1/16/20 for [MEDICATION NAME] HCL Solution Reconstituted 1 gm intravenously every 12 hours related to [DIAGNOSES REDACTED] (an infection of the bone) until 2/25/20 running at 100 ml/hr. The surveyor then reviewed the facility form titled Admission Record, that revealed Resident #24 had been admitted to the facility in January of 2020 with a [DIAGNOSES REDACTED]. At 11:52 AM, the surveyor interviewed the Consultant Pharmacist (CP), who stated that Resident #24 had a [DIAGNOSES REDACTED]. At 2:00 PM, the surveyor reviewed the Medication Administration Record [REDACTED]. At 2:08 PM, the surveyor observed Resident #24 sitting in a WC in the unit hallway. The resident stated that they were waiting to get weighed and that they then planned to go back to their room to draw and color because I find it very relaxing. The resident offered no complaints. On 2/6/20 at 8:38 AM, the surveyor reviewed a narrative nursing note dated 2/5/20 at 22:17 (10:17 PM) that read: On 2/5/20 at 10:30 the physician was made aware that patient received 87 ml of IV [MEDICATION NAME] HCL 1 gm via PICC to the right upper extremity. The patient denies any complaints of discomfort. Per (Residents Physician) discontinue 0900 dose for today of IV [MEDICATION NAME]. Monitor blood sugars as ordered, call MD for blood sugars above 400. Blood sugar obtained, reading, was 158. Also noted was that the resident and their daughter had been made aware. At that same time, the Director of Nursing (DON) provided the surveyor with facility forms titled, Inservice Form, and dated 2/5/20 that included an inservice that was presented by the DON/UM (Unit Manager)/Supervisor to the nursing staff that included LPN #1. The Topic was the Five Rights-Medication Pass, and the Five Rights per handout were: Right Drug, Right Patient, Right Dose, Right Route, and Right Time. On 2/13/20 at 2:00 PM, the surveyor reviewed the facility policy titled, General Guidelines for the Administration of Medications, with a reviewed date of 8/20/19 and under, Medication Administration it read: 2. Nurse reviews each patient's/resident's MAR indicated [REDACTED]. The nurse observes the five rights in administering each medication: a. The right resident; The nurse identifies the resident by name, if appropriate, identification bracelet, and resident photo on MAR. b. The right time; c. The right medications; All medications are to be available for administration as ordered by the physician. If not, notify the pharmacy. All medications are to be checked against the eMAR. Know the medications being administered. All medications are to be given by a physician's orders [REDACTED]. d. The right dose; e. The right method of administration-route/form, and; 6. The nurse compares the MAR indicated [REDACTED] a. From the cart b. when he/she pours the medication and, c. when he/she returns the medication to the cart. The surveyor then reviewed the form titled with the name of the facility pharmacy of the Medication Pass Observation for LPN #1 dated 5/14/2019 that identified a zero percent medication error rate and under Medication Administration Errors: 1. Resident identified before medication is poured and, 7. The correct drug, correct amount, correct dosage form administered. The surveyor then reviewed Resident #24's Care Plan, which revealed a care plan with the focus: I was placed on IV Vanco ([MEDICATION NAME]) and [MEDICATION NAME] for my [DIAGNOSES REDACTED].e., lethargy, anxiousness, elevated temperature, loose stool, rash, and flush face) and provide ABT (antibiotic) per MD order. N.J.A.C. 8:39-11.2(b)

Based on observation, interview and record review, it was determined that the facility failed to maintain appropriate infection control protocol during wound treatment observations. This deficient practice was identified on 2 of 5 units, for 3 of 6 residents (Resident #7, #123, and #267), reviewed for infection control practices as was evidenced by the following: 1.) On 1/28/19 at 9:55 a.m., the surveyor observed Resident #123 in their bed with their eyes closed. The resident was in no apparent distress. On 1/28/19 at 10:23 a.m., the surveyor reviewed the medical record which revealed that a wound had been identified during wound rounds on 1/22/19 on Resident #123's left buttock. Resident #123 was admitted to the facility with noted redness on their sacrum on 11/13/18 with [DIAGNOSES REDACTED]. On the same day at 12:28 p.m., the surveyor observed Resident #123 in bed with the head of bed elevated. Oxygen was administered via nasal cannula. The resident's spouse was at their bedside setting up the lunch meal. The resident was in no apparent distress. On 1/31/19 at 7:58 am., the surveyor requested to observe the wound on Resident #123's buttock. The Licensed Practical Nurse (LPN) reviewed the Treatment Administration Record (TAR) which revealed that the resident had [MEDICATION NAME] (a skin protectant) Cream ordered to be applied to the sacrum (an area at the end of the spine). On the same day at 8:06 a.m., the surveyor observed the LPN, assisted by a second LPN that was on orientation, remove a diaper from Resident #123 that was wet with urine. At that time, the LPN informed the resident that she was going to provide incontinence care and retrieved the necessary supplies (towel and washcloths) after washing her hands with soap and water for 30 seconds outside the flow of water. The LPN then filled a basin with warm water and donned a clean pair of gloves. At that time, Resident #123 was on their side and had a bowel movement. The LPN began to clean the residents private area with a wet wash cloth. The LPN, with the same gloved hands that she used to clean the resident, was observed moving the over bed table with the basin on it, to the other side of the bed. The second LPN put the [MEDICATION NAME] Cream on the residents buttocks. The resident then turned to their back and the LPN then washed the peri-area of Resident #123 and put a clean diaper on after the resident rolled side to side. At 8:30 a.m., The LPN, with the same gloved hands, picked up the basin of dirty water, walked across the room and opened the bathroom door by touching the bathroom door knob. The LPN then discarded the dirty basin water into the bathroom sink, removed her gloves and washed her hands with soap and water for 30 seconds outside the flow of water. A that time the surveyor interviewed the LPN who confirmed that she should have removed her gloves and washed her hands prior to touching the table and door knob. The overbed table was then returned to the right side of Resident #123's bed, and the LPN stated to the resident that she wanted to wipe down the table and left the room. At that time, Resident #123's breakfast meal was brought in to the room. The LPN informed the staff member that delivered the tray that she needed to wipe down the table so the tray was put off to the side. 2.) On 1/24/19 at 11:13 a.m., the surveyor observed Resident #267 in bed with their eyes closed. Respirations were even and unlabored, no distress was noted. There was a stop sign on the door as well as personal protective equipment (PPE - included gown, gloves, and masks). According to the Registered Nurse (RN), Resident #267 was on isolation for a bacterial infection known as Pseudomonas that required staff and visitors to wear a gown, gloves and mask upon entering the room. The surveyor observed that the resident had a [MEDICAL CONDITION] with tubing attached to an Airvo machine (a humidifier with integrated flow generator that delivers warmed and humidified respiratory gases to spontaneously breathing patients). The resident was in bed with their eyes open, was non-verbal and was not able to respond to verbal stimuli. On 1/28/19 at 10:02 a.m., the door to the residents room was partially closed and the medication cart was outside the door. The surveyor observed the RN wearing the appropriate PPE (gown, gloves and mask). At that same time, the surveyor observed Resident #267 in bed with their eyes closed. There was an air mattress on their bed and suction equipment and a canister behind the bed that contained clear secretions. On 1/29/19 at 8:22 a.m., the surveyor observed Resident #267 in bed leaning to their right side. The head of bed was elevated, the resident had bilateral hand splints in place, and the call bell was in reach. The TV was on in the room. On 1/29/19 from 11:25 a.m. till 12:35 p.m., the surveyor observed the RN at the treatment cart. The RN checked the treatment administration record (TAR) and then gathered 4 x 4 gauze, two border gauze dressings, a dressing upon which she applied Santyl (a [MEDICATION NAME] ointment) and on a second dressing that the RN applied Hydrogel (a gel to provide hydration to a wound). The RN donned a gown, gloves and mask and entered the room after she closed the door. The RN then placed the supplies on the over bed table. The surveyor did not observe the RN clean the table nor did the RN put a barrier down on the table before placing the supplies on it. Resident #267 was on her side being assisted by two Certified Nursing Assistant's (CNA's) after morning care had been completed. The surveyor then observed the RN wash her hands with soap and water for 15 seconds outside the flow of water and then rinsed her hands. The RN then proceeded to clean the wounds, one on the left buttock and the second on their right buttock, using the same gloved hands between the wounds. The RN then patted the wounds dry with 4 x 4 gauze. Without removing her gloves, the RN placed the dressing with the Santyl on to the resident's right buttock and then placed the dressing with the Hydrogel on to the resident's left buttock. With the same gloved hands, the RN placed the border gauze dressing over the medicated dressings and secured them to the resident's skin. The surveyor did not observe the RN perform hand hygiene between wounds, nor did the surveyor observe hand hygiene between cleaning the wounds to the applications of the clean dressings. The surveyor then observed the RN apply [MEDICATION NAME] Cream to the skin surrounding the dressings. The surveyor then observed the RN remove her gloves and washed her hands with soap and water for six seconds outside the flow of water. The RN then donned a clean pair of gloves. The surveyor then observed the RN and two CNA's reposition Resident #267 in bed. The surveyor then observed the RN remove her gloves and washed her hands for 10 seconds outside the flow of water. At that time, the RN donned a clean pair of gloves and assisted the Respiratory Therapist (RT) suction and complete [MEDICAL CONDITION] (a surgical airway in the trachea) care for Resident #267. After the completion of the [MEDICAL CONDITION] care, the surveyor observed the RN wash her hands for 15 seconds outside the flow of water. The RN then donned a clean pair of gloves and proceeded to prepare the resident for the administration of a scheduled medication and water flush via a gastrostomy (a feeding tube) tube located on Resident #267's abdomen. After administering the medications and water for hydration, the RN connected the feeding tube from the pump to the gastrostomy tube and turned on the pump to administer the feeding. The surveyor then observed the RN remove her gloves and wash her hands for 10 seconds outside the flow of water. On 1/30/19 at 9:50 a.m., the surveyor observed Resident #267 in bed, leaning to their left side. The head of the bed was elevated. The resident had their eyes closed and no distress was noted. On 1/30/18 at 1:55 p.m., the surveyor interviewed the Director of Nursing/Infection Preventionist (DON/IP) who stated that the procedure for handwashing was to wet their hands and apply soap, rub for 20 seconds outside the flow of water, rinse and dry with a paper towel and use another paper towel to turn off the faucet. On 1/31/19 at 8:56 a.m., the surveyor interviewed the DON/IP and informed her of the observations made on 1/29/19 for Resident #267. The DON/IP stated that the RN was off today. The surveyor then requested the following policies: Handwashing and Wound treatment and the last competency conducted. On the same day at 11:28 a.m., the surveyor reviewed the RN/LPN Competency Evaluation that identified that the RN was deemed competent in handwashing and treatments on 9/4/18. The surveyor then reviewed the (YEAR) Skills Fair sign in sheet that the DON/IP stated had been completed by the licensed nursing staff and CNA's on 6/13/18, 6/27/18 and 8/2/18 which included wounds and prevention. On 2/1/19 at 9:30 a.m., the surveyor reviewed the facility policy, revised 12/15/18, titled, Handwashing, which read under policy interpretation and Implementation: * Wet your hands with warm running water and apply soap. Rub hands together for 20 seconds. Rinse hands well under running water. Dry your hands using a paper towel. Use a paper towel to turn off water faucet. The policy continued, Handwashing must be performed under the following conditions: * When hands are soiled. * Before performing invasive procedures. * Before handling clean or soiled dressing, gauze, etc. * After contact with blood or body fluids, excretions, secretions, mucous membranes, or non-intact skin. * After removing gloves. * Before and after resident contact. * Whenever in doubt. * Upon completion of duty. * The use of gloves does not replace handwashing. 3.) On 1/28/19 at 10:21 a.m., the surveyor observed the wound treatment of [REDACTED]. After the removal of the resident's dressing and appropriate handwashing, the surveyor observed the Licensed Practical Nurse (LPN) put on gloves. The LPN then reached into a bag of 4 X 4 dressings and removed a 4 X 4 dressing. The LPN cleansed the resident's wound with the 4 X 4 dressing that was moistened with normal saline solution with one hand while holding up the resident's buttock with the other hand. The LPN then discarded the used 4 X 4 dressing and proceeded to again reach into the bag of 4 X 4 dressings and remove another dressing. The LPN then used that 4 X 4 dressing to dry the wound with one hand while holding up the resident's buttock with the other hand. After the wound treatment, the surveyor observed the LPN put on gloves after appropriate handwashing. The LPN then proceeded to use two fingers to scoop some zinc oxide cream out of the jar and then applied it to the resident's buttock. The LPN then removed her gloves, put the zinc oxide cream jar and the bag of 4 x 4 dressings in the treatment cart and performed appropriate handwashing. The LPN left the resident's room and did not wipe the bedside table that was used during the wound treatment. The surveyor then interviewed the LPN who stated that she usually takes the 4 X 4 dressings out of the bag before the wound treatment begins and that she usually wipes the table at the end of the wound treatment. On 1/31/19 at 1:35 p.m., during surveyor interview, the Director of Clinical Services confirmed that it was not best practice to reach into a bag of 4 X 4 after touching a resident, scooping medication out a jar with gloved fingers and not wiping a table with a disinfect after a procedure. On 2/1/19 at 10:00 a.m., the surveyor reviewed the facility policy titled, Pressure Ulcer Preventative Guidelines and Treatment Protocols with a revised date of 5/15/2018. The policy did not address how to set up supplies, how to obtain medication from a jar and/or, when to disinfect the table. N.[NAME][NAME]C. 8:39 - 19.4(a)

Based on observation, interview and record review, it was determined that the facility failed to develop a care plan for 1 of 4 (Resident #39) residents reviewed with a [DIAGNOSES REDACTED]. This deficient practice was evidence by the following: On 1/23/19 at 10:26 a.m., the surveyor observed the resident seated in a wheelchair in the dayroom. The resident was confused and was continuously asking to go home. The Unit Manager (UM) attempted to redirect the resident with a cookie and juice. This satisfied the resident and she stopped crying. The UM also put on a movie for the resident to watch, which she seemed to enjoy. On 1/31/19 at 11:59 a.m., the surveyor reviewed the medical record of Resident #39. The resident's face sheet (an admission summary), revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Annual Minimum Data Set (MDS), an assessment tool, dated 8/07/18 reflected in Section I4800: (The resident) had an Active [DIAGNOSES REDACTED]. Further review of the resident's medical record and most recent Quarterly MDS dated [DATE], also indicated in Section : (The resident) had an Active [DIAGNOSES REDACTED]. A review of the resident's care plan revealed a resolved focus for resident's Activities of Daily Living (ADL) self-care performance deficit related to Dementia initiated on 8/30/16 and resolved 8/14/18. The surveyor was unable to locate a care plan addressing Dementia Care at that time. On 1/31/19 at approximately 1:30 p.m., the survey team spoke with the facility concerning the fact Resident #39 had a [DIAGNOSES REDACTED]. On 2/01/19 at 9:17 a.m., the Unit Manager (UM) told the surveyor that she usually created the resident care plan, and other disciplines had input such as dietary, activities, social worker and therapy. The UM confirmed that there was no current care plan for Dementia. The UM further stated, that once the care plan for ADL decline related to Dementia was resolved on 8/14/18, a new care plan for Dementia should have been created. N.[NAME][NAME]C 8:39-45.1(a)

Based on observation, interview and policy review, it was determined that the facility failed to store medications and biological's in a safe manner. This was found in 1 of 2 medication room refrigerators, and in 2 of 4 medication carts. The deficient practice was evidenced by the following: 1.) On [DATE] at 11:33 a.m., the surveyor inspected the medication room on the Birch unit in the presence of the Unit Manager (UM). Inside of the medication refrigerator, the surveyor observed a thermometer that read 12 degrees Fahrenheit. The UM confirmed that the thermometer read 12 degrees Fahrenheit. The UM stated, that maybe the prior shift changed the dial. The UM stated that she would check it in an hour. The surveyor then observed that there were eight medications: [REDACTED]. The medications did not appear to be frozen. The surveyor reviewed the refrigerator temperature log that noted on [DATE], the thermometer read 37 degrees Fahrenheit. On [DATE] at 1:06 p.m., the surveyor returned to the Birch Unit and inspected the medication refrigerator in the presence of Licensed Practical Nurse (LPN) #1. The surveyor observed the thermometer inside the medication refrigerator still registered 12 degrees Fahrenheit. As the door was kept open the thermometer rose to 20 degrees Fahrenheit. LPN #1 confirmed the initial reading of 12 degrees Fahrenheit and the temperature rise to 20 degrees Fahrenheit. The surveyor observed that the eight medications were still in the medication refrigerator. The medications did not appear to be frozen. On [DATE] at 1:12 p.m., the UM entered the medication room and adjusted the dial on the medication refrigerator. The UM also stated that she had previously adjusted the dial. On [DATE] at 8:29 a.m., the surveyor again inspected the medication refrigerator on the Birch unit in the presence of the UM. The surveyor observed the thermometer inside the medication refrigerator registered 22 degrees Fahrenheit. The UM confirmed that the thermometer read 22 degrees Fahrenheit. The surveyor observed that the eight medications were still in the medication refrigerator. The medications did not appear to be frozen. The UM stated that maintenance were notified and planned to was look at the refrigerator. The UM further stated, that the reading was 39 degrees that morning when she observed it with the night shift nurse. The UM then placed a second thermometer in the medication refrigerator. On [DATE] at 10:10 a.m., the surveyor returned and inspected the medication refrigerator on the Birch unit in the presence of the UM. The surveyor observed that both of the thermometers inside the medication refrigerator read 40 degrees Fahrenheit. The UM confirmed that both of the thermometers read 40 degrees Fahrenheit. The surveyor observed that the eight medications were still in the medication refrigerator. The UM stated that she would make sure the staff kept the setting at the l in cool. The UM then placed a mark with a black marker on the refrigerator wall where the dial should be set. On [DATE] at 1:47 p.m., the surveyor returned and inspected the medication refrigerator on the Birch unit in the presence of the LPN #2. The surveyor observed that the eight medications were not in the medication refrigerator. LPN #2 stated that the medications were moved to the Supervisor's medication refrigerator that morning. LPN #2 then stated, that the medication refrigerator was ok during the night shift but that this morning the thermometer registered 30 degrees Fahrenheit. 2.) On [DATE] at 11:46 a.m., the surveyor inspected the high side medication cart on the Birch unit in the presence of LPN #3. Inside of the fourth drawer of the medication cart, the surveyor observed a bottle of chlorhexadine [MEDICATION NAME] 0.12% oral rinse that had a handwritten open date of [DATE], but the surveyor could not locate an expiration date. LPN #3 confirmed that the bottle had an open date but did not have an expiration date. LPN #3 then stated that she would call the pharmacy to inquire about the lack of expiration date on the bottle. 3.) On [DATE] at 1:06 p.m., the surveyor inspected the low side medication cart on the Dogwood unit in the presence of LPN #4. Inside of the left top drawer of the medication cart, the surveyor observed two medications that were opened and not dated with the opening date: a.) a vial of humolog insulin with no date on the vial or the plastic bag containing the vial. LPN #4 confirmed that the vial did not have an open date written on it. LPN #4 then stated that it was received from the pharmacy on [DATE], and that the resident rarely used it. b.) an insulin kwikpen with no date on the pen but there was a handwritten open date of [DATE] on the plastic bag containing the pen. LPN #4 confirmed that the kwikpen did not have an open date written on it. The surveyor then observed in the left fourth drawer of the same medication cart a container of Microkill wipes (disinfectant pre-moistened wipes) with an expiration date of ,[DATE]. LPN #4 confirmed that the Microkill wipes had expired and that they should have been discarded. On [DATE] at 10:30 a.m., the surveyor reviewed the facility's policy titled, Medication Storage with a revised date of [DATE]. The policy read under: number 3. Medications with storage requirements for temperature, light or humidity controls must be stored to meet specifications for the medication. Temperature for refrigeration must be maintained at a temperature between ,[DATE] degrees Fahrenheit. Refrigeration temperature will be monitored on a daily log; number 4. Medications will be monitored by the Unit Nurse, Charge Nurse, and consultant pharmacist to assure that they are not expired, contaminated or unusable. On [DATE] at 10:40 a.m., the surveyor reviewed the facility's policy titled, General Guidelines for the Administration of Medications with a revised date of [DATE]. The policy read under: number 2. e. 3. All insulin vials are to be dated when opened and with expiration date, 27 days post opening. On [DATE] at 12:47 p.m., the Director of Nursing stated that the facility just switched over to the insulin pens, so they currently did not have a policy for dating the insulin pens at that time. The facility did not provide the surveyor with a policy related to the insulin kwikpen. N.[NAME][NAME]C. 8:,[DATE].4 (a)(h)

Based on observation, interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS-an assessment tool) for 3 of 34 residents, Residents #12, #27 and #128, reviewed for assessments: This deficient practice was evidenced by the following: 1. On 1/24/19 at 9:38 a.m., the surveyor reviewed the medical record of Resident #12. The resident's face sheet (an admission summary), revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. At that time, the surveyor reviewed Resident #12's current care plans which included a care plan created 6/20/16. The care plan revealed that the resident required assistance with Activities of Daily Living (ADL's) such as Bed Mobility and Transfers as a result of a history of stroke and [MEDICAL CONDITION]. For Bed Mobility, the resident was totally dependent on one staff member for repositioning and turning in bed. For Transfers, the resident was totally dependant on two staff for transferring utilizing a Hoyer lift. The surveyor reviewed the Annual MDS for Resident # 12 dated 4/19/18, Section G- Functional Status, under G0110: Activities of Daily Living Assistance [NAME] Bed Mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) was coded 4 which meant Total Dependence, and 3 two persons physical assist. B. Transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) was coded 4 Total dependence, and 3 Two+ persons physical assist. The surveyor also reviewed Quarterly MDS for Resident # 12 dated 7/19/19, which revealed an improvement in Section G- Functional Status, under G0110: Activities of Daily Living Assistance [NAME] Bed Mobility was coded 3 Extensive assistance and 3 Two+ persons physical assist, and B. Transfer was coded 3 Extensive assistance and 3 Two+ person physical assist. Further record review of the resident's Quarterly MDS dated [DATE], revealed further improvement in Section G- Functional Status, under G0110: Activities of Daily Living Assistance [NAME] Bed Mobility was coded 3 Extensive assistance and 2 One person physical assist. B. Transfer was coded 3 Extensive assistance and 3 Two+ person physical assist. The surveyor reviewed the resident's most recent Quarterly MDS dated [DATE] which revealed a decline in Section G- Functional Status, under G0110: Activities of Daily Living Assistance [NAME] Bed Mobility was coded 4 Total Dependence and 3 Two+ persons physical assist. B. Transfer 4 Total dependence and 3 Two+ persons physical assist. On 1/29/19 at 9:26 a.m.,the surveyor observed the resident in his/her bed, with the head of bed elevated 45 degrees. The resident was beneath a blanket with legs crossed at the ankle and both hands severely contracted. On 1/29/19 at 9:31 a.m., the resident's Licensed Practical Nurse (LPN) stated the resident was non verbal and had a history of [REDACTED]. The resident had always been a Hoyer lift and couldn't bear any weight and had not been able to assist with transfers. On 1/31/19 at 10:00 a.m., the surveyor interviewed the Registered Nurse (RN) MDS coordinator, who acknowledged the inaccurate and inconsistent assessment for Bed Mobility and Transfer recorded on the Quarterly MDS on 7/19/18 and 10/18/18. The RN MDS coordinator stated as far as she was aware the resident had always required total assistance and had not had an improvement in condition. She stated the dates of the quarterly on 10/18/18 and 7/19/18, should have reflected total assistance required. On 1/31/19 at 10:17 a.m., the surveyor interviewed the resident's Certified Nurses Assistant (CNA) who stated that she had cared for the resident for about one year. The CNA further stated the resident could not assist in any transfer, and had always been required to use a Hoyer lift. The resident had no improvement in his/her ADL's. On 1/31/19 at 1:40 p.m., the Administrator, in the presence of the survey team, stated that the usual MDS coordinator had been away and someone was filling in for her. On 2/1/19 at 9:40 a.m., in the presence of the survey team, the Director of Nursing (DON) stated Resident #12's MDS had been modified to identify that the resident required total assistance and that there had been no improvement in the resident's ADL's. 2. On 1/31/19 at 9:38 a.m., the surveyor reviewed the medical record of Resident #27. The resident's face sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/29/19 at 8:44 a.m., the surveyor observed that Resident #27 was alert and verbally responsive. During the interview, Resident #27 stated she/he was not sure whether she/he took medications for mood. On 1/31/19 at 10:21 a.m., further review of the residents record revealed that the Discharge MDS dated [DATE], Section N- Medication, under N0410: Medications Received-Indicate the number of Days the resident received the following medication by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. B. Antianxiety was coded 6 which meant the resident received the medication for 6 days from 10/22/18 to 10/28/2018, C. Antidepressant was coded 5 which meant the resident received the medication for 5 days from 10/22/18 to 10/28/18, E. Anticoagulant was coded 5 which meant the resident received the medication for 5 days from 10/22/18 to 10/28/18, and [NAME] Diuretic coded 5 which meant the resident received the medication for 5 days from 10/22/18 to 10/28/18. On 1/31/2019 at 10:46 a.m., the surveyor reviewed the Medication Administration Record [REDACTED] An anti anxiety medication, Klonopin tablet 0.5 mg ([MEDICATION NAME]) was administered on (MONTH) 22, 23, 24, 25, 26, 27, and 28, (YEAR) which meant the resident was given the medication for 7 days between 10/22/18 and 10/28/2018, not for 6 days as the MDS had indicated. An antidepressent medication, [MEDICATION NAME] Suspension 10 MG/5ML ([MEDICATION NAME] HCL) was administered on (MONTH) 22, 23, 24, 25, 26, and 27, (YEAR) which meant the resident was given the medication for 6 days between 10/22/18 and 10/28/2018, not for 5 days as the MDS had indicated. An anti coagulant medication, Xarelto Tablet 20mg (Rivaroxaban) was administered on (MONTH) 22, 23, 24, 25, 26, and 27, (YEAR) which meant the resident was given the medication for 6 days between 10/22/18 and 10/28/2018, not for 5 days as the MDS had indicated. A diuretic, [MEDICATION NAME] Tablet 40mg ([MEDICATION NAME]) was administered on (MONTH) 22, 23, 24, 25, 26, and 27, (YEAR) which meant resident was given 6 days between 10/22/18 and 10/28/2018, not for 5 days as the MDS had indicated. On 1/31/19 at 10:21 a.m., further review of the residents record revealed that the Quarterly MDS dated [DATE], Section N- Medication, under N0410: Medications Received-Indicate the number of days the resident received the following medication by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. [NAME] Antipsychotic was coded 3 which meant the resident received the medication for 3 days from 10/31/2018 to 11/02/18. On 1/31/2019 at 8:46 a.m., the surveyor reviewed the MAR for Resident #27 for the month of (MONTH) which indicated that an anti psychotic medication, [MEDICATION NAME] tablet 2 mg was administered on (MONTH) 1 and 2, (YEAR) which meant the resident was given the medication for 2 days between 10/31/2018 to 11/2/2018, not for 3 days as the MDS had indicated. On 1/31/2019 at 10:21 a.m., the Licensed Practical Nurse (LPN) MDS Coordinator confirmed that the MDS assessment dated (MONTH) 28, (YEAR) and 11/2/2018 section N0410 was not coded correctly. On 2/1/2019 at 10:27 a.m., a review of the MDS dated [DATE] and 11/2/2018, revealed that the assessment section N0410 had been modified. 3. On 1/29/19 at 9:31 a.m., the surveyor reviewed the medical record of Resident #128. A nurses progress note dated 11/28/18 indicated that a fall had occurred on that day. The surveyor reviewed the Comprehensive MDS dated [DATE] Section J - Health Conditions, under J1800: Any Falls since Admission/Entry or Reentry or Prior Assessment was coded with a 0 which meant No in response to the written question: Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent? On 1/29/19 at 9:31 a.m., the surveyor reviewed a Progress Note titled Incident Note with effective date of 11/28/18 at 15:33:00 (military time) that the resident was found sitting on the floor on their buttocks leaning back against the bed with no injury. The surveyor then reviewed the current care plans for Resident # 128 which included a care plan initiated on admitted d 11/27/18, which revealed that Resident #128 was at risk for falls related to poor safety awareness, dx (diagnosis) of dementia, impulsivity and [MEDICAL CONDITION] drug use. On 1/30/19 at 10:33 a.m., the surveyor observed Resident #128 seated in a wheel chair, participating in activities with other residents, well groomed, and in no apparent distress. On 1/31/19 at 10:05 a.m., the surveyor observed Resident #128 in a wheel chair in the dining room attending an activity, dressed and groomed. No distress noted. On 1/30/19 at 12:13 p.m., the surveyor interviewed the MDS Coordinator who stated that the Comprehensive MDS dated [DATE] would have to be modified because it did not reflect the fall history for Resident #128. N.[NAME][NAME]C. 8:39-33.2 (d)

Based on observation and interview, it was determined that the facility failed to post signage in the facility to direct residents, families, and visitors to the state survey inspection report. The deficient practice was evidenced by the following: On [DATE] at 10:10 a.m., the surveyor conducted the group meeting with six residents in attendance. During the meeting the surveyor asked the residents if they knew where the state survey report was kept. Four out of six of the residents in attendance stated that they did not know where it was kept. One of the six residents stated they thought it was by the finance office, on the wall. On [DATE], after the group meeting, the surveyor reviewed the minutes from the resident council meetings for the months of (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). The (MONTH) minutes, under Social Services read: (The Activities Director) reviewed some of the residents rights, and told the residents that the annual survey results were up at the front desk, and they could read them at any time. The (MONTH) minutes, under Social Services read: Resident Rights were reviewed, and residents were reminded that the annual survey results from the DOH were up in the front for anyone to read. The (MONTH) minutes didn't mention anything about the survey results. On [DATE] at 10:15 a.m., the surveyor looked at the reception desk for the survey results. There was a green binder with the spine facing in toward the receptionist, the surveyor asked what the green binder was. The receptionist said, The state book? The surveyor took it out and reviewed it. The spine of the binder was labeled with state survey inspection. The surveyor asked her if residents or families ever came to her and asked to see it or took it down to look. The receptionist said, No. Well, one time a family member came and looked at it, but her family member died , so I don't know. The surveyor then asked her where were the signs were to direct residents, families and visitors to the survey results. She said she didn't know. On [DATE] at 10:20 a.m., the surveyor asked the Social Worker where the signs were to direct residents, families, and visitors to the results of the state survey inspection. She said, The binder is behind this partition in a cabinet, they can ask for it if they want. The surveyor told her the binder was on the receptionists desk. The surveyor then asked her where were the signs were that directed residents, families, and visitors to the inspection results. She replied she did not know. On that same day at approximately 10:30 a.m., the surveyor asked the Administrator where the signage was to direct residents, families, and visitors to the inspection results. The Administrator showed the surveyor the binder at the reception desk and said it had a label on it that said what it was. She explained that during resident council meetings, the staff tell the residents where the survey results were and that during the family meetings they tell families where to find it. She further said, there was no sign to direct anyone to the inspection report because the binder was labeled. N.[NAME][NAME]C. 8:,[DATE]

Based on interview and record review, it was determined that the facility failed to follow the prescribed care for the safe transfer of Resident #25, that resulted in an injury. This deficient practice was identified for 1 of 7 residents reviewed for falls. The deficient practice was evidenced by the following: The surveyor reviewed the closed medical record of Resident #25 on 11/17/17. Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed Resident #25's Progress Note (PN) dated 8/11/17 which indicated at 12 pm called by certified nursing assistant (CNA) to the resident's room noted blood on the floor and skin tear on lower leg. The PN indicated that the resident was sent to the hospital and returned from the hospital with 12 sutures to the left lower leg. A review of the New Jersey Universal Transfer Form dated 8/11/17 documented Laceration to Left Lower Extremity (LLE) bumped lateral LLE on wheelchair (w/c) during transfer out of bed. The surveyor reviewed the Minimum Data Set (MDS) an assessment tool, dated 8/2/17. A Brief Interview for Mental Status (BIMS) was performed to assess the resident's cognition. The BIMS scale ranged from 0-15. Resident #25 was assessed to have a cognition level score of 12 out of 15 which indicated the resident was alert, oriented and able to make themselves understood and understands. The MDS also indicated under the Functional Ability section that the resident required extensive assistance with two persons physical assistance for transfer. The surveyor reviewed the nurse's statement included in the Skin Report investigation dated 8/11/17, in the presence of the Administrator which indicated Called to room by nurse. Resident received in wheel chair with skin tear left lateral leg. Returned to bed by staff left leg elevated. Director of Nursing called to room. Made (relative) aware. Send to (hospital) emergency room for evaluation. CNA transferred without EZ Disk (a device that is used by the facility to easily pivot a resident once standing) and bumped leg on w/c with leg rests clip during transfer. The Skin Report investigation did not include statements from Resident #25 who was alert, orient and able to understand and make themselves understood or the CNA that was involved with the incident. The surveyor reviewed the resident's care plan (CP) initiated on 11/22/17 and revised on 6/6/17 titled Falls/Nursing Functional Nursing Program which indicated the Focus as Resident #25 is at risk for falls related to limited mobility due to [DIAGNOSES REDACTED]. The CP stated (Resident) will be assisted with toileting on awakening, before and after meals and activities, before bedtime and during the night if wakes up. The Interventions also included Remind (Resident) to use the call bell for assistance before attempting to get out of bed or transfer and supervise when transferring. At 12:40 p.m., the surveyor interviewed the Administrator who stated that the CNA transferred Resident #25 with only 1 person assist even though the resident was a two person assist. The Administrator also stated that the CNA did not use the EZ Disk to transfer the resident from the bed to the wheelchair. The Administrator explained to the surveyor that the EZ Disk is an assistive device to pivot the resident from the bed to the wheelchair. The Administrator informed the surveyor that the Resident's CP was updated to include the EZ Disk. The Administrator also informed the surveyor that education and disciplinary action was taken towards the CNA, including re-education for nursing staff regarding proper and safe transfer of all residents who require assistance with transfer. Refer to F282 NJAC 8:39-27.1(a)

Based on observation, interview and record review it was determined that the facility failed to ensure a.) a blood glucose monitoring device was cleaned between residents, and b.) that agency staff was oriented to facility policy and procedure in the use and disinfection of equipment. This deficient practice was observed during a medication pass of 3 of 3 residents (#25, #31, #32) ordered for glucose monitoring on 1 of 4 nursing units as evidenced by the following: On 12/12/ 16 on the Birch nursing unit from 11:00a.m. to 11:38a.m. the surveyor observed Nurse #1 during medication pass perform 3 blood glucose monitoring fingersticks with the glucometer on three residents ( #25, #31 and #32). The surveyor observed that Nurse #1 failed to the clean the glucometer after it was used on each resident. The surveyor interviewed Nurse #1 the same day at 11:45 a.m., about when does she clean the glucometer . The nurse stated to the surveyor I think the machine is cleaned after every thrid resident. On 12/13/16 at 8:10 a.m., the Director of Nursing ( DON ) provided to the surveyor a copy of the Blood Glucose Monitoring policy dated 8/2016 that was created on 11/2010 and revised 8/2016 and approved. The policy indicated under Maintain blood glucose system: Clean and disinfect multi-use glucometers after each resident/patient use. Also, at this time it was revealed to the surveyor that Nurse #1 is employed by agency and is not a employee of this facility and had being working at the facility when needed since 8/14/16. On 12/14/16 at 10:00 a.m., the surveyor requested from Administrator (ADM) documented evidence that Nurse #1 was oriented to facility policy and procedures for Blood Glucose Monitor. That same day, the ADM and Vice President of Quality Management ( VPQM) provided surveyor a copy of an in-service that Nurse #1 had completed for another provider. The ADM and VPQM confirmed that Nurse #1 was not oriented to facility's policy and procedures for blood glucose monitoring. On 12/15/16 at 11:30 a.m., in the conference room the ADM, DON and VPQM agreed that Nurse #1 should have been oriented to facility policies and procedures for glucose monitoring. The surveyor at this time was presented with documented evidence that Nurse #1 was recently given a in-service on the facility's blood glucose monitoring policies and procedures on 12/14/16. NJAC 8:39 19.4(a)1, (l)

Based on observation, interview and record review, it was determined that the facility failed to provide adequate supervision and interventions for a resident with a known history of maladaptive behavior of wandering and grabbing food from other residents and eating foods to which he/she was allergic. This deficient practice was identified for Resident #6, 1 of 8 residents reviewed and who, on six different occasions from December 2014 to September 2015, experienced unnecessary allergic reactions including red patches on the skin, body rash, lethargy, coughing, and low oxygen saturation that required the administration of medication and oxygen as treatment to arrest the allergic reaction. This deficient practice resulted in an Immediate Jeopardy situation for Resident #6, identified on 10/22/15 at 5 p.m. and corrected on 10/22/15 at 8:45 p.m., based on an acceptable Plan of Correction which had been implemented by the facility. The evidence included the following: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Face Sheet revealed that Resident #6 was allergic to Penicillin, an antibiotic, and also had food allergies to Chocolate, Orange and Orange Juice. The surveyor reviewed an 8/9/14 nursing Progress note written at 10:34 a.m. that stated a Dietitian called this morning and stated that Resident #6 is allergic to chocolate and oranges and breaks out in a rash if consumed. Residents allergy list has been updated. Will continue to monitor. On 10/14/15 at 2:10 p.m., the surveyor observed the resident in the room as he/she self-propelled back and forth in the wheelchair. On 10/15/15 at 9:30 a.m., the surveyor observed the resident in the room eating breakfast. On 10/19/15 at 9:15 a.m., the surveyor observed the resident in the room eating breakfast. On 10/21/15 at 11:30 a.m., the surveyor further reviewed the clinical record and the following incidents were documented: 1. On 12/24/2014 at 3:44 p.m., Resident #6 drank another resident's beverage that contained hot chocolate. The progress note indicated that Resident #6 consumed approximately two ounces of the hot chocolate before staff stopped the resident. At that time, staff checked the resident's vitals signs which were stable. They also notified the physician who then ordered the anti-histamine, Benadryl, to be given as needed. That same day at 4:30 p.m. the following entry was made by the nurse: Resident #6 noted in the dayroom leaning over on table slightly lethargic but arousable and responsive to verbal and tactile stimuli. The staff took the following vital signs: Blood pressure was 126/70 mmHg (normal 120/80); pulse 53 (normal range 60-100); and oxygen saturation 88%, (normal range 95 to 100%.) Staff placed the resident in bed and applied oxygen at 2 liters/minute through nasal cannula. The Progress note stated that Resident #6 was awake and alert and Benadryl was given as ordered at 8 p.m. Resident #6 ate 50% dinner. Blood pressure was 143/76 and Oxygen saturation was 92%. 2. An entry dated 2/3/2015 and timed 5:49 p.m., revealed the following: At dinner time Resident #6 was observed eating another resident's chocolate cake. Staff administered Benadryl at 5:45 p.m. There was no documentation after this incident as to how the resident was monitored. 3. Incident number three was documented on 4/7/2015 and timed 11:29, and read: Resident #6 may have consumed pieces of an orange from a fruit cup at dinner tonight. After eating in the dayroom, Resident #6 self propelled into the hallway where (I) the nurse identified a small rash and red patches on the skin to the resident's face, neck and arms. Benadryl at 6:15 p.m. was administered and no additional symptoms of allergic reactions were noted through the end of the shift. 4. Another Progress Note dated 6/12/2015 at 17:50 p.m. (5:50 p.m.) documented the following: Activity staff reported Resident #6 ate oranges during dinner. Resident #6's face was red but no respiratory distress. 5. An entry dated 7/24/2015 at 10:20 (am.) indicated the following: Activities staff reports resident had a cup of someone else's orange juice. Resident face is red. At 10:35 Resident #6 received Benadryl for allergic reaction. 6. The last entry dated 9/3/2015 timed 11:41 (a.m.) recorded the following: Resident (Resident #6) was given a chocolate chip cookie by activity staff, (he/she) took a bite of it before nurse manager noticed and took away the cookie. Resident was medicated with Benadryl as ordered. No adverse effects noted. No vitals were noted in the medical record. The following were behaviors documented in the medical record from December 2014 to October 2015: 12/13/2014 08:00 p.m. Resident #6 self propelled around the unit, banging the wheelchair into other residents and staff, going in and out of other resident's rooms. Resident #6 was in another resident's room removing his/her clothing and trying on theirs. 01/08/2015 10:54 p.m. Resident #6 was calling out, yelling, at staff, refused to go to bed. Resident #6 began to self propel into other residents' rooms, attempting to touch sleeping residents. 01/10/2015 11:29 p.m. Resident was administered an as needed medication due to yelling in the dayroom. Resident self propelled into other resident's rooms, yelling. Resident could not be redirected. 01/17/2015 12:16 a.m. Resident #6 was calling out, self propelling into furniture, disrobing, in the dayroom and in the hallway. Was toileted, offered snacks but continued to yell. Ativan administered. 02/13/2015 11:05 p.m. Resident #6 self propelled around the unit this shift. He/she was disrobing in other residents' rooms. 04/16/2015 5:21 p.m., a Complete Nursing Progress Note indicated the following: Resident #6 had Long term and Short term memory loss. His/her behavior included, calling out, yelling and self propelling throughout the unit, going into other residents' rooms. and touching items. 04/24/2015 22:51 Resident #6 was heard calling out from the room. Staff found that the resident removed all his/her clothing. The resident was assisted with toileting and checked for comfort. Was assisted to wheelchair and was self propelling, continued to call out. interventions not effective. 06/09/2015 16:00 Resident #6 was self propelling in the hallway and shouting at staff and other residents. Resident #6 was toileted and continued to yell out. Was offered activity but refused to engage. 06/16/2015 22:32, The Monthly Comprehensive Note revealed the following: Resident #6 had both Long and Short term memory impairment as well as developmental disabilities. Resident #6 had behavior of screaming, wandering the unit, going in and out of other residents' rooms and getting undressed. 07/16/2015 21:36 Resident #6 had both Long and Short term memory impairment as well as developmental disabilities. Resident #6 had behavior of screaming, wandering the unit, going in and out of other residents' rooms and getting undressed. 09/02/2015 23:06 Resident #6 was self propelling around the unit this evening. He/she was found in another resident's room, he/she had removed the tab alarm and all his/her clothing. Staff assisted to dress and removed form the room. 09/09/2015 Behavior: Continues to wander into other residents' rooms and touched their personal belongings, self transferred onto other beds and removed alarms. 09/30/2015 14:30 Behavior : yelling out, wandering into other residents rooms. crying. Number of occurrences was daily. 10/07/2015 20:31 Behavior: Wandering in and out of peers' rooms. Yelling out unprovoked. Number of occurrences : daily many times while out of bed. 10/14/2015 20:09 Behavior: Screaming, episodes of pacing, removing objects from peers rooms. Number of occurrences: screaming observed this evening and throughout other shifts. 10/16/2015 22:57 The Monthly Comprehensive Notes revealed the following: Resident #6 is developmentally disabled., displayed such behaviors as going into other residents' rooms, and gathering their belongings, screaming out loud, at staff. Most often was easily redirected to activities. On 10/21/15 at 4:42 p.m., the surveyor requested the investigative report that was completed for the above incidents. The Director of Clinical Services ( DCS) stated that she would provide the information the next morning. On 10/22/15 at 10:30 a.m., the surveyor again asked for the investigative reports. On the same day at 2:30 p.m., the DCS returned to the conference room and informed the surveyor that the above incidents were not investigated. She further stated that the administrative staff, including the Director of Nursing and the Administrator, were not made aware of any of the above incidents. On 10/22/15 at 3:30 p.m., the surveyor interviewed the Unit Manager who revealed that all incidents were recorded on the 24 hour report form which the administrative staff normally reviewed during the morning meetings, and entered into the computer. The facility did not provide the 24 hour report for review. On 10/26/15 at 10:30 a.m., the surveyor interviewed the Administrator and inquired about the 24 hours report. The Administrator stated that the 24 hours report was not part of the clinical record and would not be submitted for review. A review of the resident's clinical record lacked evidence that the resident's health concerns related to food allergy were discussed with the Interdisciplinary Team. There was no documented evidence that the facility addressed the resident's behavior of grabbing food and consistently wandering in other resident's rooms to prevent repeated exposure to these food products. The facility did not have measures in place to prevent recurrences. The facility was repeatedly asked through the survey to provide documentation regarding actions taken to prevent further incidents. The facility provided Resident #6's care plan which addressed different care areas for the resident, but did not address the specific behaviors related to grabbing food and wandering behavior of the resident and how they would protect the resident. During an interview with the Activity Director on 10/26/15 at 9:51 a.m., she stated that she was only made aware of the incidents last week after the survey team brought the concern to their attention. She further stated that they have now instituted an allergy book and that she would continue to in-service the staff. On 10/26/16 at 9:30 a.m., the surveyor reviewed the sign-in sheet and interviewed staff to validate the elements of the Plan of Correction. On 10/27/2015 the facility forwarded an email document in which the facility stated that it was the resident's right to consume these foods, despite being allergic to them. The facility implemented the following Plan of Correction to correct he immediacy: 1. The Care Plan and Certified Nursing Assistant ( CNA ) Task List was immediately reviewed and updated as needed to further clearly note the food and drug allergies of Resident #6. In addition, the resident list provided to Activities that identified food allergies or other dietary restrictions was reviewed to confirm these food allergies for Resident #6 were on the list. Nursing and Activity staff that provided care to this resident received immediate re-education about her/his allergies and the revisions to his/her Care Plan and Resident Task List. Nursing and Activity staff received immediate re-education concerning monitoring and direct supervision of residents with allergies to foods and any dietary restrictions. For Resident #6, there will be direct supervision when chocolate and oranges are to be served. This education will be ongoing. 2. A report of residents with food and/ or drug allergies was run and reviewed with the dietary restriction list to reconfirm any residents with allergies. The Care Plan and Resident Task List for any resident with allergies was reviewed and updated. 3. The allergy list will continue to be run weekly and reviewed with activity and nursing staff. All new admissions will be added to the food allergy list in the interim between weekly reports and this information will be communicated to the IDC team at morning meeting. The dietary and food allergy binder has been placed on each unit in the dining room for easy reference by staff. Nursing, Activity and Dietary staff received re-education about the use of this binder. Allergic reactions will be documented on the twenty-four report used by staff, shift to shift, to monitor residents and will be reviewed by facility management so they are aware of occurrences and can implement actions as needed. 4. Weekly, for the next quarter, the RD will review and update as needed the allergy and dietary restriction list in the binder to be sure information provided to nursing and activity will be current. The Registered Dietitian (RD) will communicate changes in the binder to the interdisciplinary team on an ongoing basis. NJAC 8:39-27.1 (a)

A. Based on observation, interview and medical record review, it was determined that the facility failed to develop interventions to address safety measures for a resident with a history of food allergy and who had the behavior of wandering and taking other residents's food. Resident #6 experienced unnecessary allergic reactions including red patches on the skin, body rash, lethargy, coughing, and low oxygen saturation that required the administration of medication and oxygen as treatment to arrest the allergic reaction. Despite multiple entries in the Progress Notes, from December 2014 to September 2015, describing the multiple incidents when Resident #6 grabbed and ate foods to which he/she had an allergic reaction, there was no documented evidence that the Interdisciplinary Team (IDT) identified and developed specific measures to address the behaviors and protect the resident from future episodes. This resulted in an Immediate Jeopardy situation that was identified on 10/22/15 at 5 p.m., and corrected on 10/22/15 at 8:45 p.m., based on an acceptable plan of correction that was implemented by the facility. This deficient practice posed a threat to the safety of Resident #6 as evidenced by the following: The surveyor reviewed the medical record of Resident #6 on 10/16/15 at 10:30 a.m. which indicated that the resident had [DIAGNOSES REDACTED]. According to a Quarterly Minimum Data Set (MDS) an assessment tool dated 9/29/15 and a Significant Change MDS dated [DATE], Resident #6 had severe cognitive impairment. A Monthly Comprehensive Note dated 9/17/15 described Resident #6 as having developmental disabilities and Dementia with behaviors. The surveyor reviewed the clinical record which revealed the resident had allergies to certain food items that included chocolate, orange and orange juice. The resident's allergy was identified in the medical record upon admission on the Admission Face Sheet and communicated to the staff caring for the resident. The surveyor reviewed the resident's care plan. The plan did not address the resident's behaviors that predisposed Resident #6 to the danger of accessing and eating foods to which the resident was allergic. The care plan did not address how the resident would be supervised during meals and activities to prevent recurrence. According to multiple entries in the medical record, Resident #6 had been exposed to chocolate, orange and orange juice while residing at the facility resulting in skin reactions, low oxygen saturation and change in mental status. According to an entry in the medical record dated 12/24/14 timed 3:44 p.m., the resident drank some of another resident's hot chocolate. According to the Progress note, the Physician was notified and [MEDICATION NAME] (an antihistaminic) was ordered for allergic reaction. (refer to F323). Following the incident of 12/24/14, while the facility received an order for [REDACTED]. The resident was exposed to these products and consumed the products on five other occasions including: 2/3/15, 4/7/15, 6/12/15, 7/24/15 and 9/3/15. (refer to F323). There was no documentation after each of the incidents to show that any interventions were developed to address how the resident would be supervised to prevent recurrences. There was also no documentation as to what interventions were developed to prevent the resident from accessing and eating food products to which he/she was allergic. On 10/19/15 at 1:30 p.m. the Director of Clinical Services (DCS) indicated that the resident had another care plan in the eMR (Sigma System) and stated this plan would be provided the next morning for surveyor review. On 10/20/15 at 12:30 p.m., the DCS told the surveyor that the care plan would be provided later for review. On 10/21/15 at 12:30 p.m., the surveyor reviewed a care plan in the current eMR (Point Click Care) system dated 6/29/15 for Nutrition identified as Weight loss focus. The surveyor reviewed the care plan that was stored in the former eMR (Sigma Care) on 10/21/15 at 1:30 p.m. Interventions included: Give Magic Cup Bid (twice) a day with lunch and supper,Vanilla Flavor; and Recommend increasing Boost Plus 240 ml (milliliters) at 10 a.m. and 8 p.m. -no chocolate. There was no care plan addressing the maladaptive behaviors of wandering and grabbing food from others. On 10/22/15 at 4:30 p.m., the Administrative staff, consisting of the Director of Clinical Services (DCS), the Administrator, and the Director of Nursing (DNO) told the survey team that they were not made aware of any of the incidents in which Resident #6 was given or when the resident grabbed and ate foods to which the resident was allergic, and so did not develop a care plan to address the behaviors. The DCS further stated that the nurse should have reported the incident to the supervisor. The DCS indicated that in-services would start immediately. (Refer to F323) The facility submitted the following Plan of Correction: The Care Plan and Certified Nursing Assistant ( CNA ) Task List was immediately reviewed and updated as needed to further clearly note the food and drug allergies of Resident #6. In addition the resident list provided to Activities that identifies food allergies or other dietary restrictions was reviewed to confirm these food allergies for Resident #6 are on the list. Nursing and Activity staff that provides care to this resident received immediate re-education about her/his allergies and the revisions to his/her Care Plan and Resident Task List. Nursing and Activity staff received immediate re-education concerning monitoring and directly supervise of residents with allergies to foods and any dietary restrictions. For Resident #6 there will be direct supervision when chocolate and oranges are served. This education is ongoing. A report of residents with food and/ or drug allergies was run and reviewed with the dietary restrictions list to reconfirm any residents with allergies. The Care Plan and Resident Task List for any resident with allergies was reviewed and updated. The allergy list will continue to be run weekly and reviewed with activity and nursing staff. All new admissions are added to the food allergy list in the interim between weekly reports and this information is communicated to the IDC team at morning meeting. The dietary and food allergy binder has been placed on each unit in the dining room for easy reference by staff that provides care to the the residents. Nursing, Activity and Dietary staff received re-education about the use of this binder. Allergic reactions are documented on the twenty-four hour report used by staff shift to shift to monitor residents and reviewed by facility management so they are aware of occurrences and can implement actions as needed. Weekly for the next quarter the Registered Dietitian (RD) will review and update as needed the allergy and dietary restriction list in the binder to be sure information provided to nursing and activity is current. The RD will communicate changes in the binder to the interdisciplinary team on an ongoing basis. On 10/26/15 at 10:30 a.m., the surveyor confirmed via sign-in sheet and interviews with staff from different disciplines that training had been conducted according to the POC. A new care plan was developed which identified the concerns with the food allergy for Resident #6. B. This deficient practice continued as a deficiency at a lower scope and severity of an E level for the following: Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive plan of care to address the behaviors of 1 resident, Resident #6, from November 2014 through October 2015. This deficient practice was evidenced by the following: Resident #6 also exhibited inappropriate social behavior of wandering in and out of other resident's room, disrobing in public areas, defecating on the floor and other resident's beds. According to the Progress notes, these behaviors occurred almost daily. There were no care plan interventions to address the above behaviors. On 10/18/15, the surveyor reviewed the care plan for [MEDICAL CONDITION] medication initiated 04/01/2014 that indicated Resident #6 had a history of [REDACTED]. The following were documented in the medical record from 11/27/2014 to October 2015: On 11/27/2014 at 9:46 p.m., Resident #6 disrobed in resident room one (1). The resident attempted to self transfer to the other resident's bed. When staff attempted to redirect, Resident #6 began yelling, calling staff, dummy. 11/30/2014 at 11:50 p.m., Resident #6 after dinner began to yell out at staff and other residents, began to remove his/her clothing in the dayroom refused to attend activity. Later on he/she began removing his/ her clothing again in the dayroom. 12/12/2014 at 10:48 p.m., the resident was found resting on top of a different resident's bed. Resident #6 's clothes, abdominal binder, and diaper were scattered throughout the floor of resident room [ROOM NUMBER]. Resident #6 was dressed in the other resident's clothing. 12/13/2014 at 8:00 p.m., Resident #6 self propelled around the unit, banging the wheelchair into other residents and staff, going in and out of other residents' rooms. Resident #6 was in another resident's room removing his/her clothing and trying on their clothing. 01/01/2015 at 04:15 a.m., Resident #6 was found in the room with the diaper off and had a BM (Bowel Movement) on the floor. 01/08/2015 at 10:54 p.m., Resident #6 was calling out, yelling at staff, refused to go to bed. Resident #6 began to self propel into other residents' rooms, attempting to touch sleeping residents. 01/10/2015 at 11:29 p.m., Resident #6 was administered an as needed antipsychotic medication due to yelling in the dayroom. Resident self propelled into other residents' rooms and was yelling. Resident could not be re-directed. 01/17/2015 at 12:16 a.m., Resident #6 was calling out, self propelling into furniture, disrobing in the dayroom and in the hallway. Was toileted, offered snacks but continued to yell. [MEDICATION NAME], an antipsychotic, was administered. 01/22/15 at 3:19 (no time documented), Resident #6 received [MEDICATION NAME], an antianxiety medication, after disrobing twice in the hallway. 01/23/2015 at 11:36, Resident #6 was calling out, self propelling into furniture, removing his/her clothing in the hallway. [MEDICATION NAME] was administered with effective result. 01/24/2015 at 9:42 p.m. Resident #6 began to call out and removed his/her clothing during activities Resident #6 began propelling the wheelchair into furniture and other residents and staff. 02/13/2015 at 11:05 p.m. Resident #6 self propelled around the unit this shift. He/she was disrobing in other resident's rooms. 04/16/2015 at 5:21 p.m., a Complete Nursing Progress Note indicated the following: Resident #6 had long term and short term memory loss. His/her behavior included calling out, yelling and self propelling throughout the unit, going into other residents's rooms, and touching items. 04/24/2015 at 22:51(10:51 p.m.), Resident #6 was heard calling out from the room. Staff found that the resident removed all his/her clothing. The resident was assisted with toileting and checked for comfort. Was assisted to wheelchair and was self propelling, and continued to call out. Staff documented that interventions were not effective. 06/09/2015 at 16:00 (4 p.m.), Resident #6 was self propelling in the hallway and shouting at staff and other residents. Resident #6 was toileted and continued to yell out. Was offered activity but refused to engage. 06/16/2015 at 22:32 (10:32 p.m.), The Monthly Comprehensive Note stated: Resident #6 had both Long and Short term memory impairment as well as developmental disabilities. Resident #6 had behavior of screaming, wandering the unit, going in and out of other residents' rooms and getting undressed; and on 07/16/2015 at 21:36 (9:36 p.m.) : Resident #6 had both Long and Short term memory impairment as well as developmental disabilities. Resident #6 had behavior of screaming, wandering the unit, going in and out of other residents' rooms and getting undressed. 09/02/2015 at 15:11 (3:11 p.m.), Resident #6 found sitting on another resident's bed with feces on the bed. Resident #6 was removed from the room, cleaned and placed in the dayroom. Resident #6 was later found in another resident's room with a broken picture frame in his/her hands. Resident was removed and taken to the dayroom. 09/02/2015 at 23:06 (11:06 p.m.), Resident #6 was self-propelling around the unit this evening. He/she was found in another resident's room, he/she had removed the tab alarm and all his/her clothing. Staff removed the resident from the room. 09/09/2015, a Behavior note stated : Continues to wander into other resident's rooms and touched their personal belongings, self transferred onto other beds and removed alarms. 09/30/2015 at 14:30 (4:30 p.m.) a Behavior note stated : yelling out, wandering into other residents rooms. crying. Number of occurrences was daily. 10/07/2015 at 20:31 (8:31 p.m.) a Behavior note stated: Wandering in and out of peers rooms. Yelling out unprovoked. Number of occurrences : daily many times while out of bed. 10/13/2015 at 14:32 (2:32 p.m.), Resident #6 was making hurtful comments to staff and peers, calling staff ugly monkey, and yelling out. The resident was placed in the dayroom. 10/14/2015 at 20:09 (8:09 p.m.) a Behavior note stated: Screaming, episodes of pacing, removing objects from peers rooms. Number of occurrences: screaming observed this evening and throughout other shifts. 10/16/2015 at 22:57 (10:57 p.m.) The Monthly Comprehensive Notes revealed the following: Resident #6 was developmentally disabled, displayed such behaviors as going into other residents' rooms, and gathering their belongings, screaming out loud at staff. Most often was easily redirected to activities. On 10/21/15 the surveyor interviewed the 3:00-11:00 p.m. shift staff who stated that the resident was difficult to redirect, would try to jump out of bed, creating trouble with other residents. They also stated that Resident #6 wandered to other residents' rooms, taking other resident's belongings. On 10/21/15 at 6:30 p.m. the surveyor interviewed the nurse who stated the resident was a challenge and declined to comment further. The surveyor observed the resident on 10/16/15 (no time documented) wandering aimlessly in the hallway and attempting to enter other residents rooms. On 10/22/15 at 10:05 a.m.,the surveyor observed Resident #6 wandering aimlessly in the hallway while an activity was in progress. 10/22/15 at 11 a.m., the surveyor observed the resident wandering in and out of other residents' rooms. The unit nurse attempted to redirect the resident to an activity, but the resident returned shortly back to the hallway and started entering other resident's rooms. On 10/26/15 at 11:30 a.m., the surveyor interviewed the DCS who stated that the resident's behavior was addressed in the care plan. A review of the resident care plan for [MEDICAL CONDITION] medications provided on 10/22/15 lacked evidence that the inappropriate social behaviors of wandering, disrobing and defecating on the floor and onto other residents' beds, were addressed on the care plan. Resident #6's care plan lacked specific interventions to address these behaviors and ways of protecting Resident #6 and other residents in the facility. NJAC 8:39-11.2

C#NJ Based on staff interviews and a review of medical records and other facility documentation, it was determined that the facility failed to consistently implement an identified intervention for 1 of 5 sampled residents (Resident #4) who was at high risk for falls. Subsequently, the resident fell and sustained a hip fracture requiring hospitalization and pain management. This deficient practice was evidenced by the following: 1. According to a Resident Face Sheet, Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool which was dated 3/24/10, Resident #4 was confused, required assistance with transfers and activities of daily living and did not ambulate. Acccording to a Fall Risk Assessment on 3/15/11, the resident was a high risk for falls. A Physician order [REDACTED]. A Summary of Resident #4's incident of 3/29/11 submitted by the Administrator, dated 4/5/11, noted that on 3/29/11 at 6:15PM, Resident #4 was placed in bed. At 6:45PM, Resident #4's bed alarm was ringing and the unit nurse immediately responded. She found the resident on the floor with a slight superficial bleed from her head. Resident #4 responded "yes" when asked if she had pain. The physician was notified and ordered the resident be sent to the hospital. The resident was sent back from the hospital at 3:15AM with a [DIAGNOSES REDACTED]. On 3/30/11, the attending physician notified the facility that he wanted the resident sent back to the hospital to be seen by an orthopedic physician as the resident was experiencing discomfort. She was transported back to the hospital and admitted with a left hip fracture and atrial fibrillation. According to a written statement from the Certified Nursing Assistant (statement read by the Administrator on 4/7/11 at 10:50AM), on 3/29/11 at 6:15PM, Resident #4 was attempting to get out of her wheelchair in her room. The CNA toileted the resident, provided PM care, and put the resident to bed. She ensured the bed was in low position, bed alarm on, and placed the mat to the floor. At 6:30PM, the nurse called the CNA into Resident #4's room. The bed alarm was sounding and the resident was found on the floor on the other side of the floor mat. There was no indication that the 1/2 rail was applied. An interview was conducted by the surveyor on 4/7/11 at 8:32AM with the Licensed Practical Nurse (LPN) Charge Nurse who stated that Resident #4 was a high fall risk, was restless in bed and tossed and turned while in bed. She indicated that Resident #4 had interventions in place to prevent falls which included a low bed, bed alarm, and floor mat. She verified that she did not have 1/2 side rails up while she was in bed. When the Certified Nursing Assistant (CNA) was interviewed by the surveyor on 4/7/11 at 11:25AM, she stated that she took care of Resident #4 on 3/29/11 on the 3PM-11PM shift. She stated that she passed her room, she saw that she was trying to get up from her wheelchair, she entered the room, took the resident to the bathroom and provided PM care. She then put her to bed, placed the mat on the floor, placed the bed alarm on. The resident had a low bed and the bed was against the wall. She denied that the resident's 1/2 side rail was put up. She verified that the resident fell and she complained of pain to her hip area. During a post survey telephone interview with the unit nurse Registered Nurse (RN) by the surveyor on 4/8/11 at 3:00PM, she verified that on 3/29/11 she responded to Resident #4's call out for help and the bed alarm ringing in the room. Resident #4 was found on the floor and the 1/2 rail was not up. She further stated that because the resident had a low bed and a mat to the floor, the staff would not put 1/2 rail up. She stated the resident complained of pain and also showed facial grimacing indicating pain. NJAC 8:39-27.1(a)