Every finding on record at Care Connection Rahway

Based on observation, interview, and review of facility provided documents, it was determined that the facility failed to 1). label food packages when opened and 2). protect food by covering or closing opened packages to minimize the risk for contamination or the development or growth of pathogens that could result in food-borne illness.This deficient practice was evidenced by the following: On 12/16/25 at 8:32 AM, the surveyor toured the kitchen with the Director of Food Service (DFS) and observed:1. Two (2) opened containers of spices (pickling spice and black pepper) on a top shelf in the dry storage area. The DFS was not able to identify the date either container was opened and acknowledged that the containers should have been dated when opened. The DFS removed both containers from the dry storage area. 2. One (1) opened, approximately half full, ten-pound bag of uncooked pasta with the top of the bag tied in a knot. The DFS acknowledged there was no date marked on the package to identify when the bag was opened, and there should have been. She removed the bag from the dry storage area. 3. An unlabeled, undated bulk item with the top of the bag tied closed, on a shelf in the produce refrigerator. The DFS identified the item as chopped onions and acknowledged the bag should have been dated when opened, but was not. She removed the bag from the refrigerator shelf.4. An opened container labeled as hummus on a shelf in the produce refrigerator. The lid had 11/14 hand-written in black ink. When asked by the surveyor what the shelf life of this opened product was, the DFS stated that's expired and removed the container from the refrigerator shelf. She did not provide any additional information about the item at that time. On 12/16/25 at 8:51 AM, in the presence of the DFS and surveyor, the Regional Food Service Director (RFSD) joined the kitchen tour. The surveyor observed the following:5. There was an opened (product exposed to the air), undated box of sausage links on a shelf in the stand up refrigerator. The RFSD stated the sausage was probably used for breakfast and acknowledged the box should not have been left opened to the air. The DFS acknowledged the product should have been dated when opened, and the package should have been closed. 6. There was an unlabeled, undated plastic bag with the top twisted closed on a shelf in the stand up refrigerator. The bag contained 6 whole white oval items in a liquid. The DFS stated this product was precooked hard boiled eggs, and they come that way from the distributor. The DFS acknowledged that the bag should have been dated when opened. The DFS removed the bag from the refrigerator. At that time, the DFS stated, I don't know why we don't have open dates. The DFS stated their process was to write the date on any package of food when it was opened. She acknowledged that the kitchen staff would refer to the opened date to determine whether an item could be used or needed to be discarded. The surveyor reviewed the following facility provided documents.A policy and procedure titled Role of Food Service Director dated 11/02 revealed the food service director responsibilities included directing and coordinating the daily activities of the department. in carrying out the department's established policies.An undated policy and procedure titled Kitchen Food dating/Expiration policy reflected that dry products that have been opened and wrapped to save the rest of the container will have an opened date, and will have 30 days from the date opened. This did not pertain to condiments, dry spices, dry herbs, or dry pasta. which would go to the product recommended expiration date as first priority. If no expiration date could be read, then 6 months would be the secondary date.On 12/18/25 at 11:51 AM and on 12/19/25 at 9:44 AM the surveyor requested additional information specifically with regard to safe food storage, policy and procedure for opened temperature sensitive/refrigerated food, and food hygiene standards used to identify and control potential hazards during food production that could result in food contamination or food borne illness. The DFS, RFSD, and administrator were aware of this request. No additional information was provided that was pertinent to food safety and food hygiene standards. According to the Food and Drug Administration 2022 Food Code, Adoption of the Food Code represents a successful federal/state/local/tribal partnership in improving food safety. However, adoption without instituting meaningful foodborne illness interventions and a strong regulatory program infrastructure is not effective. With the current initiative to reduce the occurrence of risk factors known to cause foodborne illness, the primary focus is appropriately shifting to measures of success beyond Food Code adoption. These include tracking risk factor occurrences over time by comparing baseline improvements in inspection data and follow-up inspection findings; use of risk- based inspections; applying HACCP principles; and uniformly implementing Food Code provisions. NJAC 8:39-17.2 (g)

Based on observations, interviews and review of facility documents, it was determined that the facility failed to ensure that the centrally located call bell device used to identify call bell notifications at the nurse's station was functioning properly.This deficient practice was evidenced by the following:On 12/17/2025 at 12:41 PM, the surveyor observed a white call bell light illuminate over the door for room [ROOM NUMBER], while standing at the nurse's station. The surveyor observed a call bell device system at the nurse's station. The system's screen was blank and there was no alarm indicating a call bell was on.On 12/17/2025 at 12:49 PM, while the surveyor was standing behind the nurse's station, she heard a call bell alarm. The centrally located call bell system at the nurse's station screen was blank and there was no alarm indicating a call bell was on. The surveyor walked around the unit and observed the white call bell for room [ROOM NUMBER] was illuminated.On 12/17/2025 at 1:06 PM, the surveyor interviewed Certified Nursing Aide (CNA) #1, who stated when a resident used their call bell, she would hear the alarm and then she would have to walk around the unit to find out what room had the call bell on. On 12/17/2025 at 1:08 PM, the surveyor interviewed CNA#2, who stated if a resident needed assistance they sometime would yell for help or use their call bell. He stated he would hear the call bell alarm and look for the light. He added he could also look at the call bell system at the nurse's station to determine what room needed assistance.On 12/17/2025 at 1:15 PM, the surveyor interviewed the Licensed Practical Nurse, who stated if she heard a call bell alarm she would look for the light but if she was sitting at the nurse's station she would look at the call bell device to see what room needed assistance, she added, if it was working, they may be in the process of fixing it. She was unable to tell the surveyor if the call bell device at the nurse's station was currently working. On 12/17/2025 at 1:23 PM, while at the nurse's station, the surveyor heard another type of an alarm. The centrally located call bell system at the nurse's station screen was blank and there was no alarm indicating a call bell was on. The surveyor walked around the unit and observed a flashing red light call bell for room [ROOM NUMBER] was illuminated. On 12/17/2025 at 1:30 PM, the surveyor interviewed the Director of Nursing (DON), who stated if a call bell was activated, staff would hear an alarm and walk around to look for the alarm. She added, there would be a beep at the call bell system at the nurse's desk to see where the call bell was. She stated the call bell device system would light up. On 12/17/2025 at 1:33 PM, the Licensed Nursing Home Administrator (LNHA) pressed the call bell for room [ROOM NUMBER]. The white call bell illuminated above the door. The DON showed the surveyor the call bell system at the nurse's station. The LNHA and the DON both acknowledged the call bell device at the nurse's station was not working. The LNHA checked to make sure the system was plugged in, in which it was. The DON stated it should illuminate with the room number and alarm.On12/17/2025 at 1:40 PM, while the surveyor was standing behind the nurse's station, she heard a call bell alarm. The centrally located call bell system at the nurse's station screen was blank and there was no alarm indicating a call bell was on. The surveyor walked the unit and observed the white call bell illuminated for room [ROOM NUMBER]. The call bell light was unable to be visualized from the nurse's station because the room was located on the other side of the double doors.On 12/17/2025 at 1:44 PM, the surveyor observed CNA #2 standing in the hallway between the nurse's station and the Men's bathroom. CNA#2 looked down the hallway towards room [ROOM NUMBER] but turned around and walked the opposite way. At 1:49 PM, CNA #2 answered the call bell for room [ROOM NUMBER]. On 12/18/2025 at 10:20 AM, the surveyor interviewed the DON, in the presence of the LNHA. The DON stated we called maintenance. The LNHA stated the system was not functioning. He stated they called the hospital maintenance, who came and checked it but could not get it (the call bell device) working. On 12/18/2025 at 11:51 AM, in the presence of the survey team, the surveyor made the LNHA, the DON and the Regional Nurse (RN) aware of the above concerns.On 12/18/2025 at 12:06 PM, in the presence of the RN and the survey team, the staff member responsible for overseeing the system, stated We (the facility) have no control over the call bell system. It is an old phone system phone on the nurses' desk, but we found a replacement part and were able to fix it. A review of the facility's policy Call Bell Response Policy reviewed 1/2025 revealed Policy: It is the policy of Alaris Health at Care Connections to ensure that all residents have timely access to staff assistance through a functioning call bell system in order to promote resident safety, dignity, comfort, and quality of care.N.J.A.C 8:30-31.2 (e)

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure communication forms between the facility and a contracted dialysis facility were consistently completed according to facility policy and procedure. This deficient practice was identified for 1 of 1 resident reviewed for dialysis (Resident #6). The deficient practice was evidenced by the following: On 12/16/25 at 9:07 AM, during initial tour of the facility, the surveyor observed Resident #6 being transported out of the facility by a transport company to a dialysis center. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; end stage renal disease (kidneys have permanently lost their ability to function) and type two diabetes mellitus (body does not use insulin properly). A review of the comprehensive Minimum Data Set, an assessment tool dated 11/17/25, revealed a Brief Interview for Mental Status score of 4 out of 15, which indicated the resident had severely impaired cognition. Further review of Section I revealed diagnoses of renal insufficiency, renal failure, and end stage renal disease and Section O, Resident #6 received dialysis while residing at the facility. A review of the Order Summary Report included a physician's order (PO) dated 11/11/25, for dialysis at [dialysis center name redacted] on Tuesday, Thursday, and Saturday at 9:30 AM. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 10/5/25, that the resident needed hemodialysis related to renal failure. Interventions included but were not limited to; change dialysis site dressing as needed and do not draw blood or take blood pressure in the arm with the graft. The ICCP also included a focus area dated 10/5/25, that the resident had renal failure related to end stage disease. Interventions included: assess for presence of bruit and thrill every shift and notify the physician if absent and assist the resident with activities of daily living (ADL's) and ambulation as needed On 12/17/25 at 12:40 PM, the surveyor reviewed Resident #6's dialysis communication book that was to be sent with the resident on dialysis treatment days. The communication forms were reviewed from November 2025 to December 2025. On the following dates the dialysis communication forms were not completed by the facility nurse upon the resident's return from dialysis: 11/6/25, 11/13/25, 11/15/25, 11/17/25, 11/20/25, 11/22/25, 11/24/25, 11/29/25, 12/4/25, 12/9/25, 12/11/25, and 12/13/25. The dialysis communication forms were not completed by the dialysis center on 11/20/25, 11/29/25, and 12/13/25. A review of the skilled need noted in the eMAR (electronic medical record) did not reveal a full set of vital signs or assessment of bruit or thrill upon return from dialysis for the following dates: 11/6/25, 11/13/25, 11/15/25, 11/17/25, 11/20/25, 11/22/25, 11/24/25, 11/29/25, 12/4/25, 12/9/25, 12/11/25, and 12/13/25. On 12/17/25 at 1:05 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated Resident #6 went out for dialysis on Tuesday, Thursday, and Saturday. The LPN further stated that prior to Resident #6's departure the nurse would give the resident their medications, obtain vital signs, monitor the access site, and document it on the dialysis communication form that was to be sent to the dialysis visit with the resident. The LPN also stated that when the resident returned from dialysis, the nurse would obtain vital signs, monitor the access site for drainage, bruit and thrill and document it in section three of the communication form. The LPN stated that if the dialysis center does not fill out their section, the facility would call the center to see what they did at the dialysis center and if there were any new orders or changes to care. She also stated that upon return from dialysis, the nurse would obtain vital signs and review the dialysis communication form. She stated the importance of the communication form was for communication and to know how the resident had tolerated the dialysis treatment. On 12/18/25 at 10:26 AM, the surveyor interviewed the Director of Nursing (DON), who stated that prior to a resident going out to dialysis, the nurse would monitor and assess the dialysis site, obtain vital signs and fill out the dialysis communication form. She stated the dialysis center would review and complete their section of the dialysis form with vital signs and pre and post weights. She also stated that the nurse was responsible to complete and review the dialysis communication form upon return from dialysis. She further stated that the purpose of the dialysis communication form was to ensure communication between the facility and dialysis center and for continuity of care. The surveyor asked the DON if the dialysis center were to leave section two blank, what should the nurse do. The DON replied that the nurse should call the dialysis center to find out if there were any new orders, medications that were given, or any concerns. The DON acknowledged that the dialysis communication forms were not filled out completely on the following dates: 11/6/25, 11/13/25, 11/15/25, 11/17/25, 11/20/25, 11/22/25, 11/24/25, 11/29/25, 12/4/25, 12/9/25, 12/11/25, and 12/13/25. On 12/18/25 at 11:00 AM, the DON, in the presence of the Licensed Nursing Home Administer (LNHA), Assistant Director of Nursing (ADON), and the survey team, stated the importance of the dialysis communication forms was to ensure communication between the facility and the dialysis center. The DON also stated that the dialysis communication form should be completed in its entirety and should have no blank areas. A review of the facility's Dialysis policy reviewed, 1/2025, included orders for checking of the dialysis access site, presence of bruits and thrills, checking site/area for bleeding, redness, etc will also be included.a dialysis progress notebook will be sent with the resident during dialysis day to be completed by the center and may be returned to the facility with the latest lab result and any other recommendation from the center/clinic. receiving nurse will review communication form and update MD and update residents care if necessary. A review of the facility's Documentation policy, reviewed on 1/2025, included.to ensure accurate, timely, and complete documentation of each resident's care in the medical record.documentation must be completed as soon as possible. Documentation must include, date and time of entry, description of the resident's condition or care provided, resident response, when applicable, signature, initials, and title of the staff member. Documentation must follow facility guidelines for either electronic or paper medical records. N.J.A.C. 8:39-27.1 (a)

Based on observation, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order for oxygen therapy provided to one of one resident (Resident #1) reviewed for oxygen therapy. This deficient practice was evidenced by the following: On 12/16/25 at 9:03 AM, during the initial tour of the unit, the surveyor observed Resident #1 seated in a wheelchair in their room, receiving oxygen (O2) via nasal cannula at 5 liters per minute (lpm). On 12/17/25 at 10:47 AM, the surveyor observed Resident #1 lying in bed receiving O2 at 5 lpm. There was a sign on the door to the room which read No smoking/no open flames for oxidizing gases.The surveyor reviewed the electronic medical record (EMR) and the hybrid chart (printed and handwritten medical records) for Resident #1.A review of the admission record revealed diagnoses which included but were not limited to; pneumonia (an infection that inflames the air sacs in one or both lungs), acute respiratory failure with hypoxia (a condition in which the body's tissues do not get enough oxygen), and pleural effusion (buildup of excess fluid between lungs and chest wall). A review of the comprehensive Minimum Data Set (a resident assessment and care screening tool) dated 12/3/25, revealed the resident had a Brief Interview for Mental Status of 10 out of 15, indicating the resident was moderately cognitively impaired. Further review reflected the resident received a respiratory treatment of continuous oxygen therapy on admission and while a resident. A review of the individual comprehensive care plan (ICCP) revealed a focus of oxygen therapy r/t (related to) ineffective gas exchange, date initiated 11/3/25, with an intervention of give medications as ordered by physician. A review of the Medication Review Report [an electronic summary of all active and discontinued physician orders] did not reflect a physician's order for oxygen. A review of the November 2025 and December 2025 electronic medication administration record (EMAR) and electronic treatment administration record did not reflect an order for oxygen. A review of the Physician's Orders forms from 11/28/25 at 12:00 AM until 12/17/25, did not reflect an order for oxygen. On 12/17/25 at 11:36 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who stated Resident #1 was on her assignment today. LPN #1 stated Resident #1 was on O2 at 5 lpm continuously via nasal cannula since they were readmitted from the hospital. On 12/17/25 at 11:45 AM, the surveyor interviewed the Director of Nursing (DON), who stated if a resident was receiving oxygen, they would have an order from the physician in the EMR. In the presence of the surveyor, the DON reviewed the EMR for Resident #1 and acknowledged the EMR did not contain a physician's order for oxygen. On 12/17/25 at 11:50 AM, the surveyor re-interviewed LPN #1, who stated there should be a physician's order for oxygen in the EMR for Resident #1. At this time LPN #1, in the presence of the surveyor, reviewed the EMR. LPN #1 acknowledged there was not an order for oxygen for the resident. She stated their (the facility) process was to add all physician orders to the EMR when the resident arrived on the unit from the hospital. LPN #1 stated she would call the physician now to obtain an oxygen order for Resident #1.On 12/18/25 at 9:38 AM, the surveyor re-interviewed the DON, who stated that each nurse, during their shift, should have compared the resident's oxygen flow meter to the physician orders and if there was a discrepancy, they (the nurse) should have called the doctor to clarify the order. On 12/18/25 at 11:51 AM, during a meeting with the survey team, the DON acknowledged Resident #1 was on oxygen since they were admitted from the hospital, and there should have been a physician's order. The DON stated there was a transcription error by the nurse, that the order was not put in. A review of the policy and procedure for Admission with last reviewed date of 9/2025, revealed it was the policy of the facility that a resident is received, made comfortable, assessment completed, and orders written upon admission. The purpose was to ensure that all needs were identified, and medications/treatments were ordered based on the assessment and transfer documentation. A review of the policy and procedure for Oxygen Administration, with a last reviewed date of 9/2025, revealed the purpose of this procedure was to provide guidelines for safe oxygen administration. Preparation:1.Verify there was a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration, (for new admission check hospital discharge summary for oxygen orders and verify with admitting MD).Documentation: 1. After completing the oxygen setup or adjustment, the nurse should sign the resident's record/EMAR. N.J.A.C. 8:39-11.2 (a)

Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care for 1 of 2 residents reviewed for Activities of Daily Living ( Resident #75 who required extensive assistance from staff for care. The deficient practice was evidenced by the following: On 08/20/24 around 8:45 AM, the surveyor toured the North Wing of the facility. At 8:49 AM, while touring the unit, a strong malodorous odor of feces was permeated in the hallway next to Resident #75's room. The surveyor observed a Certified Nursing Assistant (CNA) exited the room. Resident #75 was in the bed fully covered. Resident #75 nodded the head to the surveyor's greetings and kept the head down. The surveyor asked the resident how was life here at the facility, Resident #75 did not answered. The surveyor met the CNA in the next hallway and summoned her to the room. The surveyor informed the CNA that she would like to perform a care tour. The CNA entered the room, checked Resident #75 for incontinence. Resident #75 was soiled with urine and feces. The surveyor and the CNA we both observed that Resident #75 had 2 adult briefs on which were saturated with urine Resident #75 had a dressing to the sacral area that was saturated with urine and bloody drainage. The bed padding were saturated with urine. the The CNA informed the surveyor that she reported to work at 7:00 AM this morning, she got report from the nurse and did not receive report from the CNA who worked from the 7:00 PM-7:00 AM shift. The CNA added that she had not provided care yet to Resident #75. The surveyor asked the CNA to call the charge nurse. At 8:55 AM, the charge nurse entered the room and verified that Resident #75 had 2 adult briefs on which were saturated with urine. The blue pads used to protect the bed were all saturated with urine. The surveyor then interviewed the charge nurse who stated that all residents were to have one brief on. When asked how the staff will know, the charge nurse replied, The staff had been educated. On 08/21/24 at 10:30 AM, the surveyor reviewed Resident #75's electronic medical record. The Admission Face Sheet (an admission summary) reflected that Resident #75 was admitted to the facility with diagnoses which included but were not limited to; acute respiratory failure with hypoxia, depression, unspecified dementia, unspecified severity without behavioral disturbances, mood disturbance and anxiety. The Admission Minimum Set ( MDS) dated [DATE], reflected that Resident #75 received a score of 15 on the Brief Interview for Mental Status (BIMS) indicative of intact cognition. However interview with staff revealed that Resident #75 was confused. Review of Resident #75's plan of care revealed a focus for decline in Activities of daily living Self Care Performance related to Activity Intolerance, impaired balance, limited mobility and musculo-skeletal impairment due to recent hospitalization , initiated 08/02/24. The goal was for Resident #75 will improve current level of function in Mobility, transfers, dressing, toilet use and personal hygiene also initiated 08/02/24. Resident #75 had also a focus for incontinence related to disease process, initiated 08/15/24. The goal was for Resident #75 to decrease frequency of urinary incontinence through the next review date of 10/31/24. The interventions included, uses disposable briefs. Change frequently and as needed. An intervention added on 8/20/24, was that Resident #75 prefers using 2 adult briefs to wick away urine and keep feeling dry. According to the care plan history, the Director of Nursing added this intervention on 8/20/24 after the charge nurse verified with the surveyor that Resident #75 had 2 adult briefs on which were saturated with urine. On 08/21/24 at 09:34 AM, the surveyor interviewed the CNA who cared for Resident #75 on 8/20/24. The CNA stated that Resident #75 can partially assist with care, can stand and pivot and sometimes was aware of their incontinence needs. The CNA stated that the CNA who provided care to the resident from 11:00 PM- 7:00 AM shift left the resident with the 2 briefs on. The CNA added that she got report from the nurse regarding the resident. The CNA stated that on the morning of 8/20/24 she served and set the breakfast tray for Resident #75 and did not checked Resident #75 for incontinence prior to breakfast. The CNA added that she was not familiar with Resident #75's routine. The CNA stated that she did not get report from the CNA who worked the night shift and was not aware of the time that incontinence care was last provided. On 08/21/24 at 10:30 AM, the surveyor again interviewed the Registered Nurse (Charge nurse) who was in the room with the CNA and witnessed Resident #75 with the two adult briefs. The RN stated that Resident #75 should not have 2 adult briefs on. On 08/22/24 at 12:50 PM, the above concerns were discussed with the DON in the presence of the Licensed Nursing Home Administrator and the Regional Nurse. The surveyor asked the DON regarding her expectations regarding incontinence care. In the presence of the survey team, the DON stated that residents were to have one adult incontinent brief on. The DON further added, that heavy wetter at times would have 2 adult briefs on when requested The DON added that Resident #75 would not allowed staff to provide incontinence care while playing cards. The surveyor informed the DON that in the morning of 8/20/24 at 8:40 AM, Resident #75 was in bed fully covered. The CNA admitted that she set up the breakfast tray and did not checked Resident #75 prior to breakfast. According to staff breakfast was served around 7:30 AM-7:45 AM on 8/20/24. Resident #75 assessed by the facility as having impaired cognitive function related to dementia or impaired thought process was totally dependent on staff for all activities of daily living. During the survey, the surveyor attempted to interview Resident #75 on 8/20/24 at 8:35 AM and again on 8/21/24 at 10:30 AM, Resident #75 was unable to proceed with the interview. On 08/23/24 at 11:52 AM, the CNA who worked the 7:00 PM-7:00 AM shift, returned the call. The CNA informed the surveyor that she did not provide care to the resident in the morning. The CNA stated that another CNA who worked the 3:00 PM- 11:00 PM cared for Resident #75 and placed the double briefs on the resident around 12:00 PM. The CNA stated on 8/20/24 around 4:00 AM when she went to the room Resident #75 was sleeping and did not want to be checked for incontinence care. She did not return to the room nor inform the nurse that Resident #75 was not cared for during the shift. According to the interview with the CNA, almost 9 hours had elapsed since Resident #75 was provided with incontinence care. The surveyor then asked the CNA how often that she would observed other residents who were incontinent with 2 briefs on. The CNA stated the residents that were incontinent would have two adult briefs on. The first brief will be placed inside the second brief to contain the urine and would not be snapped. When asked if she reported the concerns to the nurses or the DON she stated, No. A review of the policy for Activities of Daily Living last revised 1/2024, provided by the facility on 8/21/24 indicated the following: Residents shall receive assistance with activities of daily living (ADLs) every shift, as appropriate. The facility's policy for incontinence care indicated that the facility shall provide care for all incontinent residents. NJAC 8:39-27.1(a),

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store dry foods in a safe and sanitary environment to prevent the development of food borne illness. The deficient practice was observed and was evidenced by the following: On 05/11/21 at 09:48 AM, during the initial tour of the kitchen in the presence of the Director of Food and Environmental Services (DFES) and the Food Service Manager (FSM), the surveyor observed the following: 1. A Mixer that was on a table next to the robo-coupe had multi-colored substance splash marks on it. The FSM stated that the substance was probably from the robo-coupe as the station was not wiped down well. The wall behind the mixer and robo-coupe table had areas of multiple multi-colored dried substance on the wall. The FSM used a paper towel to wipe the wall, nothing came off on the paper towel. The FSM stated that they should have done a better job cleaning. On the same wall, there was an electronic exterminator trap with multiple areas of multi-colored dried substance on the exterior. The DFES stated we are responsible for the exterior; it should not have the splash marks on it. 2. A standing Mixer located next to the robo-coupe table had multi-colored dried substance splash marks on the outside of it. The arm in which the outside of the mixing bowl rests in, had a black substance and brown debris on it. The FSM used his finger to wipe the arm, the brown debris came off but the black substance did not. The guard located above the mixing bowl had a white substance on it. The FSM stated that it should have been dissembled and cleaned to make sure that there was no cross-contamination. 3. There were several silver serving trays and pans nested on top of each other on the drying rack. The surveyor asked the FSM to separate the silver trays and pans. There was moisture observed between them. The FSM stated that the trays should have been separated to allow proper drying because water can sit and harbor bacteria. 4. In walk-in fridge # 1, there was a bag of opened Mesclun mix salad, an opened bag of classic salad mix and an opened bag of shredded carrots that did not have an opened date. The DFES was unable to locate an opened date on either bag. The DFES stated that they all should have contained an opened date. There was a heavy build up of black and grayish material on the ceiling above the fans. The FSM stated the ceiling should be kept clean so that mold and dust does not fall into the food. 5. The serving tray storage rack had multiple stacked servings trays that had moisture between them when the DFES separated them. He stated that the trays should be completely air dried before stacking and placing on the storage rack. 6. In walk-in fridge #4, there was a heavy build up of black and grayish material on the ceiling above the fans. The FSM stated the ceiling should be kept clean so that mold and dust does not fall into the food. 7. A cook was transferring cooked meat to another tray. The cook had a face mask on with facial hair that was exposed around the side and the bottom of the mask. The cook and the FSM stated that he should have had a beard net on so that his facial hair did not fall in the food and contaminate it. 8. A cook performed hand washing. He turned on the water, wet his hands, applied soap, lathered for 2 seconds, rinsed his hand, dried his hands and then with a new paper towel turn the water off. The surveyor asked the cook to wash his hands again. He turned on the water, wet his hands, applied soap, lathered for 7 seconds, rinsed his hand, dried his hands and then with a new paper towel turn the water off. The FSM stated, the cook needs proper hand washing technique to stop contaminates from getting in food. 9. In the dry storage room, there were two storage bins, the FSM stated one was flour and one was rice. Inside the flour bin there was a blue scoop resting directly on the flour. Inside the rice bin, there was a blue scoop resting directly on the rice. The FSM stated that the scoops should be stored in holders and not be stored inside the bins to avoid contamination. 10. A food service worker (FSW) poured salad dressing into little cups wore a hair net but her bangs were not contained within the hair net. The FSW stated that they always should wear a hair net to cover their hair so hair doesn't get into food. The DFES and the FSM confirmed that the FSW hair bangs were not contained in the hair net as required. A review of the facility's undated Daily Cleaning schedule with person and time, revealed Daily Cleaning: All equipment on Patient service line-Toaster, Turbo chef, Grill, Stove top, Outside of Ovens, Plate warmers, Steam table, Steamers, and all tables. Slicer, Mini Robo-coupe, kettles are to be done by cook using equipment last. Cook 3pm to 7 pm shift: Detail cleans daily the Slicer, back wall of station, Mixers (standing & Tabletop models), shelves underneath, and Large Robo coupe. Stockroom clerk: cleaning stockroom, all shelving, soda equipment, flour/rice bins, Scoops to be placed in holders, walk-ins maintained and cleaned, clean stockroom floor. Tues-walk in #1, Wednesday-walk in #3, Friday-walk in # 4. This should be done by the end of each meal period DAILY. A review of the facility's Policy and Procedure Dishes and Silverware, dated 1/01, revealed Cleaning and Sanitizing-Washing Pots and Pans, #6 Allow to air dry. Do not dry with a towel. A review of the facility's undated Policy and Procedure Kitchen Food dating/Expiration Policy, revealed Food dating guidelines: All food in production/preparation will have a 72-hour shelf life. A review of the facility's Policy and Procedure Receiving and Storage of Food and Supplies, dated 5/11/21, revealed Standards/Guidelines: Bulk dry food (Rice, Breadcrumbs, Flour, etc.) scoops should be stored outside of the food in storage bin. Standards/Guidelines: Items that are clearly identifiable do not need to be labeled with name of product but must be dated. A review of the facility's Policy and Procedure Personal Hygiene, with a supersedes date of 3/26/06, revealed Procedure: Hair Nets, Beard Guards and Caps to be worn at all times. Hair and beards need to be covered and restrained when preparing food. Hand Washing Procedures: # 3 Lather hands and wrists with soap for at least 20 seconds. NJAC 8:39-17.1(a);17.2(g)

Based on observation, interview, and record review it was determined that the facility failed to a.) follow a physician's order for Accuchecks (blood glucose monitoring) with insulin administration, b.) consistently follow a physician order (PO) related to monitoring a supplement intake and delineate the time according to the resident's [MEDICAL TREATMENT] schedule, and c.) document the clarification of a PO for an antibiotic in regards to a stop date. This deficient practice was identified for 1 of 2 resident's (Resident #167) reviewed for [MEDICAL TREATMENT]. This deficient practice was evidenced by the following: On 8/13/18 at 6:32 p.m., during the initial tour, the surveyor observed Resident #167 seated in the bed. The resident had a right upper arm intravenous (IV) line dressing intact. The resident stated that he/she was on [MEDICAL TREATMENT] and planned to go [MEDICAL TREATMENT] the next day. On that same day at 6:33 p.m., the Registered Nurse/MDS Coordinator (RN/MDS Coordinator) stated that Resident #167 was alert and oriented with some forgetfulness. The RN/MDS Coordinator confirmed that the resident goes to [MEDICAL TREATMENT] every Tuesday, Thursday, and Saturday. She further stated that the resident was picked up for [MEDICAL TREATMENT] at 9:30 a.m. and returned to the facility approximately between 1-1:30 p.m. On 8/14/18 at 10:46 a.m., the surveyor interviewed the Registered Nurse (RN). The RN informed the surveyor that she was the nurse for Resident #167, and that the resident goes to [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday at 8:30-9:00 a.m., and returned to the facility approximately 1:30 p.m. A review of the resident's Face sheet revealed that Resident #167 was admitted to the facility on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) Electronic Medical Record (eMAR) revealed an order dated 8/11/18 for Humalog (a medication given for DM) solution 100 unit/ml, inject as per sliding scale before meals for DM 11:30 a.m. FSBG (Finger Stick Blood Glucose) and insulin coverage will be done at [MEDICAL TREATMENT] center on [MEDICAL TREATMENT] days. Review of the eMAR revealed the Accu-check was plotted for 7:30 a.m., 12:30 p.m. and 4:30 p.m. There was no indication that the accucheck order was plotted separately to indicate the 11:30 a.m., FSBG and insulin coverage would be done at the [MEDICAL TREATMENT] center on [MEDICAL TREATMENT] days. Further review of the (MONTH) (YEAR) eMAR, revealed an order dated 8/13/18 for Ensure pudding 4 ounces (oz) three times a day for supplement and to document amount consumed by entering 1-4 as follows: 1=1-25%, 2=26-50%, 3=51-75%, 4=75-100%. Review of the 8/2018 eMAR, revealed the Ensure pudding was plotted for 7:30 a.m., 11:30 a.m., and 5:00 p.m. Further review of the eMAR indicated that on 8/13/18, the nurse documented the resident consumed 237 at l1:30 a.m. There was no documentation explaining what 237 meant. The 11:30 a.m. Ensure supplement was not plotted according to the resident's [MEDICAL TREATMENT] schedule. Further review of the (MONTH) (YEAR) eMAR, revealed an initial order dated 8/3/18 for [MEDICATION NAME] Sod-Tazobactam ([MEDICATION NAME]) 2.25 gram (gm), an antibiotic that fights bacteria in the body to be given intravenously (IV) every six hours for pneumonia. The 8/3/18 order for IV [MEDICATION NAME] did not indicate a stop date and was plotted to be given at 12 a.m., 6 a.m., 12 p.m. and 6 p.m. The order for IV [MEDICATION NAME] on 8/3/18 was changed on 8/13/18 to accommodate [MEDICAL TREATMENT] days and was plotted to be given at 2 a.m., 8 a.m., 2 p.m. and 8 p.m. However, the 8/13/18 order for IV [MEDICATION NAME] did not indicate a stop date. The surveyor reviewed Resident #167's discharge hospital medical records, provided by the Director of Nursing (DON), that contained a Patient Care Summary dated 8/2/18, which revealed that the IV [MEDICATION NAME] start date was 7/30/18 and discontinue date on 8/6/18. A review of the Progress Notes showed that from 8/2/18 through 8/15/18, there was no documentation indicating that a stop date order for IV [MEDICATION NAME] was clarified. In addition, there was no documentation that the 8/6/18 stop date from the hospital record was communicated to the doctor upon admission. A review of a personalized care plan dated 8/9/18, for Antibiotic Therapy related to pneumonia, indicated an intervention for MD to order stop date of medication. On 8/15/18 at 8:36 a.m., the surveyor interviewed the DON in the presence of the survey team. The DON informed the surveyors that she was the one who obtained the order on 8/10/18 from the doctor regarding the FSBG at 11:30 a.m. and insulin coverage at [MEDICAL TREATMENT]. The DON stated that she should have informed the doctor at that time, that the [MEDICAL TREATMENT] center does not do accuchecks and does not administer insulin. The DON also stated that it was why the accucheck order was not followed. On 8/15/18 at 1:33 p.m., the surveyor in the presence of the survey team, informed the Administrator, DON, Regional Quality Assurance (QA) Nurse and the Regional Licensed Nursing Home Administrator (LNHA) were made aware of the findings. On 8/16/18 at 9:08 a.m., the surveyor interviewed the DON in the presence of the survey team. The DON informed the surveyors that it was the responsibility of the admitting nurse to call the doctor on admission to verify orders and obtain a stop date for the IV [MEDICATION NAME]. The DON stated that it was the admitting nurses responsibility to document the response from the doctor with regards to the stop date of the IV [MEDICATION NAME]. On that same day at 9:25 a.m., the surveyor conducted a telephone interview with the RN who admitted the resident on 8/2/18 on the 3-11 shift. The RN informed the surveyor that she was the nurse who admitted the resident on 8/2/18. The RN stated that she was responsible for an assessment but did not call the doctor for orders. The RN stated that she was not sure who verified the admitting orders at that time. On 8/16/18 at 9:53 a.m., the surveyor attempted to conduct a telephone interview twice with the LPN who obtained and carried out the order for IV [MEDICATION NAME] dated 8/3/18, but the LPN was unavailable. On 8/16/18 at 9:55 a.m., the surveyors met with the facility's Administrator, DON, Regional QA Nurse and Regional LNHA. The Administrator informed the survey team that after investigation, the nurse failed to follow the eMAR order Ensure pudding instruction for supplement intake documentation and the plotting of supplement order to accommodate the [MEDICAL TREATMENT] days schedule. The Regional QA Nurse stated that the only problem was the facility failed to document the conversation with the doctor regarding the stop date of the antibiotic and the reason why it was continued. A review of the [MEDICAL TREATMENT] Policy with an effective date of (MONTH) 2002 provided by the Administrator indicated that For all [MEDICAL TREATMENT] residents, facility nurse will discuss all medications with Primary MD to determine the timing of medications and which medications will be held on [MEDICAL TREATMENT] days and which will be given at a later time. In addition, a review of undated Transcribing Provider Orders into the Facility EMR system Policy indicated that Telephone and Verbal communication of orders that follow this policy will be considered valid orders and will be executed as if the authorized prescriber wrote them, and Telephone and verbal orders must have the following components verbalized, read back to prescriber, transcribed and noted by responsible practitioner: date and time of order, generic and brand name of drug, drug dose, quantity and duration. NJAC 8:39-27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to accurately assess residents using the federally mandated Resident Assessment Instrument, a portion of which is the Minimum Data Set (MDS) assessment tool used to collect data specifically related to the resident. The deficient practice was noted for 3 of 10 residents sampled, Resident #2, 10, 5, as evidenced by the following: 1. The surveyor observed Resident #2 seated in a wheelchair at the bedside on 5/15/17 at 9:30 a.m. The Director of Nursing (DON) stated the resident had no memory deficits. The surveyor interviewed the resident on 5/16/17 at 11:15 a.m. The resident discussed his/her progress with rehabilitation and denied the presence of pain. The resident stated he/she was familiar with scoring the level of pain on a 1 - 10 scale, with 1 signifying the least pain and 10 signifying the worst pain. The surveyor reviewed the electronic medical record on 6/16/17. The 4/5/17 and 5/3/17 MDS documented the resident had no deficits with understanding others or being understood by others (Section B). Staff indicated they conducted the Brief Interview for Mental Status (BIMS) with the resident. However, dashes were placed after each question, indicating assessment was not done (Section C). Similarly, staff indicated a pain assessment interview would be conducted, however, dashes indicated the assessment was not done. Staff assessment for pain indicated staff assessed the resident from his/her verbal complaints of pain (Section J). 2. On 5/17/17 at 11:39 a.m. the surveyor reviewed Resident #10's electronic closed medical record. The Admission MDS of 3/28/17 indicated that the resident had no deficits with speech clarity, understanding others, or having others understand the resident (Section B). Staff indicated that they conducted the BIMS with the resident. However, dashes were placed after each question, indicating that the assessment was not done (Section C). Similarly, staff indicated a pain assessment interview would be conducted, however, dashes indicated that the assessment was not done. The staff assessment for pain indicated that the staff assessed the resident from his/her verbal complaints of pain (Section J). 3. The surveyor observed Resident #5 seated in a wheelchair at the bedside on 5/15/17 at 9:30 a.m. The Director of Nursing (DON) stated the resident had no memory impairment. The surveyor interviewed the resident on 5/15/17 at 11:30 a.m. The resident discussed with the surveyor his/her progress and the goal for discharge after rehabilitation. The surveyor reviewed the electronic medical record on 5/16/17. The 4/17/17 MDS indicated the resident had no deficits with understanding others or having others understand the resident (Section B). Staff indicated they conducted the Brief Interview for Mental Status (BIMS) with the resident. However, dashes were placed after each question, indicating assessment was not done (Section C). Similarly, staff indicated a pain assessment interview would be conducted, however, dashes indicated the assessment was not done. Staff assessment for pain indicated staff assessed the resident from his/her verbal complaints of pain (Section J). The surveyors interviewed the Administrator on 5/17/17 at 12:30 p.m. regarding the conflicting MDS information. The Administrator responded with additional information on 5/18/17 at 9:00 a.m. explaining the dashes were a glitch and the person (responsible) was re-educated. NJAC 8:39-11.2(e)1

Based on interview, observation, and record review, it was determined that physician orders [REDACTED]. This deficient practice was noted for 2 of 10 residents sampled, Resident #7, 8, 2 as evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. The surveyor observed Resident #7 on 5/15/17 at 11:00 a.m. sitting up in bed and watching television. The resident stated he/she is new to the facility and receiving rehabilitation for strengthing and ambulation following a [MEDICAL CONDITIONS] at home. The resident stated he/she frequently experiences moderate pain in the left shoulder and back areas. The surveyor reviewed the electronic medical record on 5/15/17. The 5/2017 Physician order [REDACTED]. The resident had 2 physician orders [REDACTED]. 2 tabs every 4 hours as needed for mild pain; [MEDICATION NAME] 5-325 mg. 1 tab every 8 hours as needed for moderate pain. 2. The surveyor observed Resident #8 on 5/15/17 at 9:30 a.m. in bed wearing a cervical neck collar. The resident stated he/she had spinal surgery and was at the facility for rehabilitation. The surveyor reviewed the electronic medical record on 5/16/17. The resident had a care plan for pain related to recent spinal surgery. The Physician order [REDACTED]. The resident had a 5/12/17 physician order [REDACTED]. 3. The surveyor observed Resident #2 on 5/15/17 at 9:30 a.m. seated in a wheelchair at the bedside. The Director of Nursing (DON) stated the resident had no memory deficits, used continuous oxygen, and was receiving rehabilitation. The surveyor interviewed the resident on 5/16/17 at 11:15 a.m. The resident stated he/she had no pain. The resident was familiar with rating pain on a 1 to 10 pain scale, where 1 is the least pain and 10 is the worst pain. The surveyor reviewed the electronic medical record on 5/16/17. The resident was care planned for pain related to a [DIAGNOSES REDACTED]. The 5/2017 Physician order [REDACTED]. The Summary included a 4/26/17 order for Tylenol 325 mg. 2 tablets every 6 hours as needed for mild pain. The surveyor interviewed the Administrator and Director of Nursing (DON) on 5/17/17 at 11:00 a.m. regarding the method used by nursing to evaluate the severity of pain prior to administering pain medication, especially when there were 2 or more 'as needed' pain medications ordered. The DON stated on 5/18/17 at 9:00 a.m. nurses should use the 1 to 10 numeric pain scale with alert and oriented patients and the physician orders [REDACTED]. The 7/5/14 Pain Management Policy and Procedure and accompanying Pain Assessment Scale provided by the DON specified the use of the Numeric Scale and Wong Baker (facial) Scale for pain assesment. NJAC 8:39-27.1(a)

Based on observation, interview and review of the medical record it was determined that the facility failed to maintain the dignity and respect of the resident especially during wound care. This deficient practice was noted for 2 of 2 residents sampled for wound care, Residents # 7 and # 5, as evidenced by the following 1. During tour of the unit on 6/13/16 at 6:40 p.m. the surveyor observed Resident #7 in bed, oxygen via nasal canula in place, indwelling urinary catheter to bedside drainage bag in a privacy bag, and the resident was noted on a low air mattress. The licensed staff nurse informed the surveyor that the resident was alert and oriented, was a new admission, and usually stayed in bed. Review of the medical record on 6/13/16 at 8:05 p.m revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. During wound care observation on 6/14/16 at 11: 22 a.m. the surveyor observed the Registered Nurse (RN) and Certified Nursing Assistant (CNA) position the resident, remove the covers, and prepare to perform wound care treatments to the resident's pressure ulcers of the right hip, sacrum and left hip. The covers remained off the resident for the entire treatment which was completed at 11:55 a.m During a meeting with the Administrator and Regional Nurse at 2:30 p.m. the surveyor informed them of these findings. 2. During tour of the unit on 6/13/16 at 6:50 p.m. the unit nurse informed the surveyor that Resident #5 was alert and oriented with some forgetfulness, had a stage II pressure ulcer to the left buttock, had a Urinary Tract Infection, had an indwelling urinary catheter for [MEDICAL CONDITION], and was receiving intravenous antibiotics. The Surveyor observed a Registered Nurse (RN) perform wound care to Resident #5 on 6/4/16 at 10:15 a.m. The RN applied the [MEDICATION NAME] dressing to the resident's wound on the left buttocks. The RN removed her gloves then removed a pen her pocket and wrote the date on the wound dressing while it was adhered to the resident's body. During a meeting with the Administrator and the Regional Nurse on 6/14/16 at 2:30 p.m. the surveyor informed them of the findings. NJAC 8:39-4.1(a)(12)

Based on observation, interview and review of the medical record it was determined that the facility failed to provide a documented [DIAGNOSES REDACTED]. This deficient practice was noted for 3 of 9 residents sampled, Residents #1, #5, and #7. The facility also failed to follow a physician's orders [REDACTED]. This deficient practice was noted for 1 of 2 pressure ulcer treatments observed, Resident #5, as evidenced by the following: 1. During tour of the unit on 6/13/16 at 6:40 p.m. the surveyor observed Resident #7 in bed, oxygen via nasal canula in place, indwelling urinary catheter to bedside drainage bag in a privacy bag, and the resident was lying on a low air mattress. The licensed staff nurse informed the surveyor that the resident was alert and oriented, was a new admission, and usually stayed in bed. Review of the medical record on 6/13/16 at 8:05 p.m revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. During review of the physician's orders [REDACTED]. b) During wound care treatment on 6/14/16 at 11:22 a.m. the surveyor observed the Registered Nurse (RN) perform treatment to the 3 pressure ulcers of Resident #7. The RN cleansed all 3 wounds with normal saline, but the physician's orders [REDACTED]. c) During the wound care treatment of [REDACTED].#7 at 11:34 a.m. the RN removed the dressing, and then removed her gloves and went to the treatment cart. Upon return to the room the RN applied hand sanitizer and re-gloved. She started the treatment to the sacral wound and then placed a circular sponge like substance in the base of the wound. The surveyor questioned what the circular sponge was and the RN showed the surveyor the package which indicated it was [MEDICATION NAME] dressing. Review of the POS [REDACTED]. 2. The surveyor reviewed Resident #1's medical record on 6/13/16. The resident was admitted to the facility on [DATE] with a physician's orders [REDACTED]. every 12 hours for antibiotic. The care plans, initiated 6/3/16, did not include any reference to an infection or the use of an antibiotic. The 5-day Minimum Data Assessment tool ((MDS) dated [DATE] indicated the resident was receiving an antibiotic (Section N), however, in Section I (active diseases) no entry was made for an infection. The surveyor requested clarification from the Administrator on 6/14/16 at 2:30 p.m. regarding the medical [DIAGNOSES REDACTED]. The Administrator responded the same day at 3:30 p.m. with a photocopy of a hospital Patient Transfer Record 3. During tour of the unit on 6/13/16 at 6:50 p.m. the unit nurse informed the surveyor that Resident #5 was alert and oriented and was forgetful, had a stage II pressure ulcer to the left buttock, had a Urinary Tract Infection, had an indwelling urinary catheter for [MEDICAL CONDITION], and was receiving intravenous antibiotics. On 6/4/16 at 10:15 a.m. the Surveyor observed a Registered Nurse (RN) perform wound care to the stage II pressure ulcer of Resident #5. During the wound care observation, the surveyor observed the RN remove a Border Gauze dressing from the resident's left buttock area. During the record review for Resident #5, on 6/13/16 at 8:00 p.m. the surveyor noted a physician's orders [REDACTED]. On 6/4/16 at 10:15 a.m. the surveyor and the RN reviewed the order for wound care on the computer confirming the order prior to the RN performing the wound dressing change. The surveyor informed the Regional Nurse and the Administrator on 6/14/16 at 2:30 p.m b) During record review on 6/13/16 at 8:00 p.m. the surveyor noted an order for [REDACTED]. The surveyor informed the Regional Nurse and the Administration on 6/14/16 at 2:30 p.m NJAC 8:39-11.2 (b)

Based on observation, interview and medical record review it was determined the facility failed to administer medication and perform treatments around the times the resident was out of the facility at [MEDICAL TREATMENT] (HD). This deficient practice was noted for 1 of 1 residents sampled on HD, Resident # 9, as evidenced by the following: On 6/14/16 Resident #9 was observed in bed, alert, wore bilateral hearing aids. The resident told the surveyor he/she went to HD 3 days a week (Tuesday, Thursday and Saturday), had an access site on the right arm, and left the facility around 5:00 a.m Review of the medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. During review of the physician's orders [REDACTED]. Interview of the resident on 6/14/16 at 1:30 p.m. revealed the resident was picked up to go to HD at 4:50 a.m. and returned to the facility at 10:30 a.m Also during the interview the surveyor asked Resident #9 if he/she ate before leaving the facility and the resident stated that no breakfast was provided before leaving and no food was provided upon return to the facility. The resident stated the first meal offered was on 6/14/16 was the lunch meal. The POS dated 6/14/16 revealed [MEDICATION NAME] was plotted and signed as given at 8:00 a.m., [MEDICATION NAME] Intravenous was plotted and signed as given at 6:00 a.m., and the blood sugar check before breakfast was plotted and signed as done at 7:30 a.m., but the resident was not in the facility at that time. During a meeting with the Administrator and Regional Nurse at 2:30 p.m. the surveyor informed them of these findings. NJAC 8:39-27.1(a)

Based on observation, interview and review of the medical record it was determined that the facility failed to perform proper hand washing techniques during both wound care and medication administration, as well as remove soiled dressings and supplies from the room when wound care was completed. These deficient practices were noted for 2 residents observed for wound care, Residents #5 and #7, as well as 2 of 4 nurses observed during medication administration, as evidenced by the following: 1. During the tour of the unit on 6/13/16 at 6:40 p.m. the surveyor observed Resident #7 in bed, oxygen via nasal cannula in place, indwelling urinary catheter to bedside drainage bag in a privacy bag, and the resident was lying on a low air mattress. The licensed staff nurse informed the surveyor that the resident was alert and oriented, was a new admission, and usually stayed in bed. Review of the medical record on 6/13/16 at 8:05 p.m revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. During wound care observation on 6/14/16 at 11: 22 a.m. the surveyor observed the Registered Nurse (RN) and Certified Nursing Assistant (CNA) position the resident, remove the covers, and prepare to perform wound care treatments to the resident's pressure ulcers of the right hip, sacrum and left hip. At 11:34 a.m. the RN removed her gloves, re-gloved, and removed the sacral wound dressing. The RN removed her gloves, went to the treatment cart, used hand sanitizer only, and re-gloved. The resident was noted to have had a bowel movement and the RN then proceeded to wipe the rectum of the resident with a towel. The RN then removed her gloves, and without any hand washing, re-gloved and proceeded to treat the resident's sacral pressure ulcer. After completion of the wound care dressings at 11:55 a.m. the RN gathered up the garbage and left the garbage in the room garbage pail and stated she would get someone from Housekeeping to remove it. The RN then proceeded to document the treatment and when the surveyor asked her if she was finished, she replied yes, but the RN did not clean the overbed table that was used for the wound care. The RN did not perform hand washing with soap and water at any time during the wound care treatment. She used hand sanitizer approximately 4 times, but did not use soap and water to clean hands. During a meeting with the Administrator and Regional Nurse at 2:30 p.m. the surveyor informed them of these findings. The Administrator confirmed that staff should be hand washing between residents during care. 2. On 6/13/16 at 8:25 p.m. the surveyor observed the Registered Nurse(RN) prepare and administer medications for 2 residents in the same room. The RN prepared the medication to be given by mouth and by injection. The RN applied gloves and administered the pills to the resident and then gave the subcutaneous injection of [MEDICATION NAME] in the resident's abdomen. The RN removed the gloves and used foam hand sanitizer when completed. There was no hand sanitation performed between the oral medication administration and the injection medication. The RN then prepared the medication by mouth and for injection for the next resident. The RN donned gloves and administered the pills to the resident then administered Regular insulin subcutaneously in the right upper arm. Again the RN did not perform any hand sanitation between the oral and injectable medications. The surveyor informed the Regional Nurse and the Administrator. 3. On 6/14/16 at 10:15 a.m. the surveyor observed wound care for Resident #5 who was on isolation precaution. The Registered Nurse (RN) completed the wound care and then signed that the treatment was completed on the electronic medical record. The surveyor informed the RN that a bottle of wound cleanser, a box of gloves and a container of Sani wipes were left on the over bed table. The RN went back into the room, wiped the overbed table, removed the supplies and replaced the supplies back in the treatment cart. The surveyor informed the Regional nurse and the Administrator on 6/14/16. 4. The surveyor observed Registered Nurse (RN) #3 during the 6/14/16 morning medication administration (8:30 a.m. through 9:50 a.m.). During the observation, the RN administered medications to 3 residents. The first resident received an injection in the arm. Alcohol Based Hand Gel (ABHG) was used prior to entering the resident's room and upon exiting the room. The second resident received an oral medication. The RN used ABHG before and after administering the medication. The third resident received 3 oral medications and 1 injection in the abdomen. The RN used ABHG before entering the resident's room and upon exiting the room. The RN re-entered the resident's room and performed hand washing. The surveyor spoke with the Administrator on 6/14/16 at 2:30 p.m. at which time the Administrator stated the RN should have performed hand washing after administering an injection and between residents. NJAC 8:39-19.4(a)1.

Based on observation, interview, and record review it was determined that the facility failed to perform hand hygiene in a manner to prevent the spread of infection. The deficient practice was observed on 7/28/15 during multiple handwashings by 4 staff persons and evidenced by the following: 1. The surveyor observed Certified Nursing Assistant (CNA) #1 on 7/28/15 at 10:30 a.m. at the handwashing sink behind the nursing station (NS). CNA #1 applied soap and lathered for 5 seconds before rinsing under running water. CNA #1 turned off the water faucet. 2. The surveyor observed CNA #1 at 10:43 a.m. at the Nursing Station handwashing sink. CNA #1 soaped and immediately put hands under running water. The water faucet was turned off with bare hands. 3. The surveyor observed CNA #1 at 10:54 a.m. at the NS handwashing sink. CNA #1 applied soap to dry hands and lathered for 5 seconds, turned on the water faucet bare handed, wet hands for 2 seconds, and rinsed off soap under running water. 4. The surveyor observed CNA #2 at 10:57 a.m. at the NS handwashing sink. CNA #2 soaped and lathered hands for 5 seconds and rinsed hands under running water. CNA #2 entered a resident room, applied gloves, picked up a half full urinal and emptied it in the resident's bathroom. The CNA came out with the same gloves and touched the resident's clothing, overbed table, and rolling walker before leaving the room. The CNA removed the gloves and performed hand hygiene with alcohol based hand gel (ABHG). 5. The surveyor observed CNA #2 at 11:23 a.m. handwashing at the NS sink. CNA #2 applied soap and immediately rinsed with water. CNA #2 entered a resident room, gloved, and performed a finger stick to obtain blood for a glucose level. 6. The surveyor observed a Rehabilitation staff person (#1) at 11:32 a.m. at the NS handwashing sink. The staff person applied soap and lathered for 6 seconds and rinsed hands under running water. 7. The surveyor observed a Rehabilitation staff person (#2) at 11:35 a.m. at the NS handwashing sink. The staff person applied soap to hands and immediately rinsed hands under running water for 9 seconds. The water faucet was turned off with bare hands. The surveyor described the 7 handwashing observations to the Administrator on 7/29/15 at 1:30 p.m. The Administrator stated the facility policy for handwashing required staff to lather hands outside of running water for 40 - 60 seconds. The following day (7/30/15) at 10:30 a.m. the Administrator provided the facility's handwashing policy and procedure, and evidence of handwashing inservicing performed on 7/29/15 and 7/30/15 for nursing and rehabilitation staff persons. NJAC 8:39-19.4(a)1

Based on observation, interview and record review it was determined that the facility failed to adequately assess and provide the necessary treatment to promote healing of a sacral pressure ulcer. This deficient practice was identified for 1 of 1 resident reviewed for pressure ulcers, Resident #5, as evidenced by the following: On 7/28/15 at 9:00 a.m. during the initial tour the Director of Nursing (DON) told the surveyor Resident #5 was admitted to the facility following surgery after a fall at home that resulted in a fracture. On 7/29/15 at 9:30 a.m. the surveyor went to Resident #5's room to observe a sacral wound treatment. The resident was in bed and positioned on the left side. The Licensed Practical Nurse (LPN) was already in the room and the dressing from the sacral area had been removed from the resident. After visibly observing the wound the LPN stated that she was going to postpone administering the treatment because the wound had changed since she observed it 3 days earlier. The wound was now larger and had slough (necrotic/dead tissue separating from the viable portions of the body) covering a large portion of the sacral wound. The LPN left the room without measuring the dimensions of the wound and stated she was going to call the physician. On 7/29/15 at 11:30 a.m. the surveyor interviewed the LPN who had postponed the wound treatment on Resident #5. The LPN stated she had received a new physician order [REDACTED]. The LPN stated I haven't done the wound measurements yet. I am going to do them when I do the treatment after the new medication arrives. I don't want to disturb the resident twice. On 7/29/15 at 12:10 p.m. the LPN informed the surveyor that the new medication had arrived and she was ready to measure the sacral wound and perform the treatment. The sacral wound dimensions were 6 centimeter (cm) length x 3.3 cm width. The depth of the wound was undetermined due large area of slough. On 7/29/15 at 12:30 the surveyor reviewed Resident's #5's electronic medical record (EMR) and paper record. Resident #5 was admitted to the unit from the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was also admitted with a Stage II sacral pressure ulcer and right heel suspected Deep Tissue Injury. A Comprehensive Care Plan was in place from admission with multiple interventions that included pressure relieving mattress, pressure relief gel cushion to wheelchair and turn and re-positioning schedule. According to the Initial Wound Report form dated 7/20/15 at 4:00 p.m. Resident #5 had a Stage II pressure ulcer measuring 1 cm length x 0.4 cm width. No depth of the wound was documented and there was no slough or drainage observed on the wound. The resident had a physician order [REDACTED]. Cleanse with wound cleanser then apply exuderm dressing. On 7/25/15 at 4:50 p.m. the EMR Physician Pharmacy Order form documented a telephone order from the physician to discontinue the present wound treatment and begin a new order to change the Exuderm Sacrum 4 treatment from once a day to once every 3 days. According to the Treatment Administration Record the new treatment order was started on 7/26/15. There was no documented explanation for the change in the sacral wound treatment in the EMR Progress Notes dated 7/25/15. The EMR Progress Note dated 7/26/15 at 3:44 p.m. stated, Open draining wound to left lateral ankle/foot. Large amount of thick pink drainage noted. The nurse also documented in the note, Open area of sacrum noted, slough and non-stageable area also noted. Order for wound care consult received and carried out. A physician order [REDACTED]. There was no documented evidence on Resident #5's EMR or paper record that the sacral wound was measured on 7/26/15 when the change in the wound was observed or that a new Wound Report assessment was generated. The Standard Assessment sheet that recorded all assessments on the EMR for Resident #5 documented, Wound Report: 2 days overdue-7/27/15. The only measurement of the sacral wound documented on the EMR and paper record prior to 7/29/15 was completed 9 days earlier on 7/20/15 when the wound measured 1 cm length x 0.4 cm. On 7/30/15 at 10:30 a.m. the surveyor met with the Administrator, Director of Nursing and the Regional Nurse. The Regional Nurse stated that Resident #5's physician had been contacted and that the wound consult was ordered for the heels and not the sacral area. The Corporate Nurse confirmed that Resident #5's wound was not measured after a documented visual change in size and description on 7/26/15 and a treatment order was not received in a timely manner to help promote healing of the sacral ulcer. NJAC 8:39-27.1(e)

Based on observation, interview and record review it was determined that the facility failed to 1) differentiate the administration times between 3 medications to treat constipation for 1 resident (#3) and 2) obtain physician's orders [REDACTED].#7). Nine residents were reviewed for correctness of physician's orders [REDACTED]. 1. On 7/28/15 at 9:00 a.m. during the initial tour, the Director of Nursing (DON) told the surveyor that Resident #3 was admitted to the unit with a [DIAGNOSES REDACTED]. The resident was observed sitting in a wheelchair next to the bed with nasal oxygen on via nasal cannula. On 7/28/15 at 9:45 a.m. the surveyor reviewed Resident #3's electronic and paper record. The resident had a physician order [REDACTED]. The resident also had a physician order [REDACTED]. The physician did not specify in what order these three medications for constipation should be administered. 2. On 7/28/15 at 8:15 a.m. the surveyor observed the Licensed Practical Nurse (LPN) administer medication to Resident #7. The resident's Electronic Medication Record (EMAR) (which is a computerized record that informs the LPN of the medications that need to be administered) documented Pregabalin 75mg (Lyrica) a controlled substance due to be administered to Resident #7 for neuropathic pain. The LPN informed the surveyor that the medication has to be obtained from the back up medication supply because it was not received from the Provider Pharmacy. Resident #7 was admitted into the facility on [DATE] after suffering a fall at home with [DIAGNOSES REDACTED]. Review of the Resident's records on 7/28/15 at 10:00 a.m. showed that although the Resident had been admitted on [DATE], the Physician had not yet reviewed and signed the medication orders. The Resident had 13 medications that were being administered to the Resident daily without a physician's orders [REDACTED].>On 7/28/15 at 10:05 a.m. the surveyor interviewed the Director of Nursing (DON) who stated that the facility and the Provider Pharmacy were trying to get in touch with the Physician with no success. The DON stated the Doctor (Dr.) has to write a physical prescription before Pharmacy can dispense, the Dr. has not been here yet, the medication has been taken from backup. NJAC 8:39-29.1(e)

Based on observation, interview and record review, it was determined that the facility failed to provide appropriate pharmaceutical services with respect to medication documentation, administration and medication order entry. This deficient practice was observed for 9 of 9 residents, Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9 as evident by the following: The facility provided a copy of the contract with the Consultant Pharmacist on 8/14/14. At that time it was determined that the current Consultant Pharmacist has been working with the facility since 9/19/08. The Consultant Pharmacist signed the agreement with the new management of the facility on 6/5/14. This Consultant Pharmacist was working with the facility through the transition in administration, staffing and change from the hospital pharmacy to the outside provider pharmacy which took place on or about 7/15/2014. Prior to this change the Provider Pharmacy was the hospital pharmacy and was located in the hospital as is the facility There were cut off times and delivery times from the new provider pharmacy posted in the facility. The 1st cut off time was 10:00 a.m., with delivery leaving the pharmacy at 12:00 noon. The 2nd cut off time was 9:00 p.m. with the delivery leaving the pharmacy at midnight. There was no evidence of that the Consultant Pharmacist identified and addressing unavailable medications, problems with the medication delivery schedule from the provider pharmacy, blanks on the e-MAR and failure to notify the physicians of omitted or late medications. During the Group Meeting with Residents on 8/13/14 at 11 a.m., residents indicated that some of the medications are not given on a timely basis. Residents indicated that some medications are given 1-2 hours past the scheduled time. One of the residents indicated that the Physician ordered Percocet for pain; however, this resident was given Tylenol instead. This resident also indicated that the sleeping medication was scheduled for 11 p.m. - midnight, however, this resident received the medication at 12:45 a.m. This resident also explained that medication administration that is scheduled at times of shift change is routinely delayed by 1-2.5 hours due to shift report. This is an issue especially during the 3 p.m. shift change. The surveyor was given a copy of the facility and current active pharmacy agreement on 8/13/14 at 9:30 a.m. by the Administrator. The agreement copy was signed but not dated. On page 4 section - 1.2 Delivery schedule, the agreement indicated that the PHARMACY shall maintain a twice per day Monday through Friday delivery schedule and once per day delivery schedule on Saturdays, Sundays and legal holidays. N.J.A.C. 29.2(a) REFER F 281, F309, F333

Based on interview, observation and record review it was determined that the facility failed to adhere to appropriate standards for ordering and administering Physician prescribed medications. It was found that the facility failed to identify medication administration problems upon changing the pharmacy provider, failed to train staff on the use of a back-up supply system, and failed to have a functioning accountability system for the receipt of medications. These deficient practices were noted for 9 out of 9 residents, Resident #1, 2, 3, 4, 5, 6, 7, 8 and 9, reviewed for potential significant medication errors and evidenced by the following: The surveyor interviewed a Registered Nurse (RN) and LPN #1 on 8/13/14 at 11 a.m. regarding how medications were ordered. Both the RN and LPN #1 stated that the physician's orders [REDACTED]. Afterwards, the facility would call the Pharmacy Retailer to verify that they received the orders. Both nurses stated that they did not document who they spoke to or at what time. The surveyor continued the interview and asked about the process when the pharmacy delivered the medications. Both Nurses stated that they would verify the delivery with the invoice and if everything was correct sign the invoice. The signed invoice went with the pharmacy and the facility kept a copy (some signed, some blank) in a binder. On 8/13/14 at 1:55 p.m. the surveyor interviewed the Administrator concerning how the staff document that a medication was not given for any reason or the administration time was other than what was ordered. The Administrator said that once the medication administration time listed on the Electronic Medical record had passed the nurse could not enter any information on that record except the code NN. This code means that the information concerning why a particular dose was not administered could be found in the nursing progress notes. The nurse would have to leave the eMAR and write the corresponding note in the medical record. Information concerning medication administration issues would not be found on the eMAR, but in each individual's medical record. The surveyor interviewed the Administrator on 8/12/14 at 1 p.m. about the delivery of medications to residents. The Administrator stated that the facility changed from the hospital in-house pharmacy to an outside retail pharmacy on 7/15/14. This outside pharmacy made deliveries twice a day around 5 a.m.-6 a.m. and 12 noon-1 p.m. The Administrator also stated that STAT (as soon as possible) medications would be delivered on an as needed basis. The facility just began using a Cubex for back-up medications. A Cubex was a secured machine that housed multiple medications not ordered for a specific resident. This machine did not contain Schedule II narcotics at the time of the survey. According to the Administrator the facility had not made a determination of the most commonly used medications with which to stock the machine. The Administrator stated they would add additional medications once they determined which medications were commonly ordered. The Administration stated the staff had not been trained on the use of the Cubex. While the survey team found medication issues with each resident they reviewed, the Administrator claimed to be unaware of any concerns with medications not given or given at a later time due to non-delivery to the nursing unit. If medication was delivered and placed into the Cubex machine, nursing staff had not been trained on how to obtain the medication from the machine. Nursing staff would document that a medication was not available while the Administrator would tell the surveyors the medication had been delivered, there was no functioning system for accountability of medication. 1. During the morning medication pass on 8/12/14 the surveyor observed 3 residents, Resident #2, #3 and #6 who did not receive all their medications as ordered. Both Licensed Practical Nurses (LPN) stated that the particular medications were unavailable and would be given when pharmacy delivered the medications. 2. During the morning medication pass on 8/12/14 at 9:30 a.m. Resident #2's spouse approached LPN #1 to give the resident [MEDICATION NAME] for pain. The surveyor overheard LPN #1 inform the Administrator that the resident's [MEDICATION NAME] had yet to be delivered. With the surveyor present, LPN #1 went to administer Resident #2's morning medications at 9:40 a.m. LPN #1 stated that the morning medications had not been delivered, but would be given as soon as they were delivered. The missing medications included those used to treat pain, hypertension (high blood pressure) and abnormal heartbeat. LPN #1 did not check the Cubex to see if the medications were onsite. The surveyor and LPN #1, on 8/13/14 at 11:15 a.m., verified that the medications were given at 10:42 a.m. yesterday. The surveyor interviewed Resident #2 on 8/12/14 at 11:30 a.m. Resident #2 stated s/he arrived at the facility last night following hip surgery. The resident stated s/he began to have pain around 6 a.m. and requested [MEDICATION NAME] but was given Tylenol because the [MEDICATION NAME] had not been delivered. Resident #2 stated the Tylenol "took the edge off" but still had some pain. Resident #2 was afraid that s/he would not get the [MEDICATION NAME] prior to physical therapy (PT). The surveyor reviewed Resident #2's eMAR and physician's orders [REDACTED]. According to the admission orders [REDACTED]. The facility entered the order on the eMAR as: Tylenol 650 mg, give 2 tablets for pain; and a separate entry of Tylenol 325 mg, give 2 tablets for temperature. The medication Tylenol did not come in 650 mg tablets. The facility obtained a clarification order from the Physician on 8/12/14 for Tylenol 325 mg, give 2 tablets every 6 hours as needed for pain and added it to the eMAR. The order to give 2, 650 mg tablets of Tylenol was discontinued on 8/14/14 at 12:26 p.m. 3. During the morning medication pass on 8/12/14 at 9:40 a.m. Resident #3 did not receive 3 of their medications, which included those to treat [MEDICAL CONDITION], hypertension and constipation. LPN #1 stated the 3 medications were unavailable and would administer them once they were delivered. LPN #1 did not check the Cubex to see if the medications were onsite. The surveyor and LPN #1, on 8/13/14 at 11:15 a.m., verified that the medications were given at 2:42 p.m. yesterday. The surveyor reviewed Resident #3's medical record on 8/13/14 at 9 a.m. The medical record stated Resident #3 had some confusion and was admitted following foot surgery. The surveyor then reviewed Resident #3's electronic Medication Administration Record (eMAR). The surveyor observed that on 8/9/14 Resident #3's scheduled 9 a.m. medications were not given. The nurses documented in the Progress Notes that the medications had not been delivered by pharmacy. The missed medications were prescribed to treat hypertension, a possible infection, high cholesterol, [MEDICAL CONDITIONS], diabetes mellitus (DM) and pain. The next day the surveyor went back to reviewed Resident #2's electronic Medication Administration Record (eMAR) and Resident #3's Progress Notes on 8/13/14 at 9:30 a.m. LPN #1 documented that the unavailable medications from yesterday were given at 9 a.m. and 10 a.m. respectively. LPN #1 did not document that the Physicians were notified. The surveyor had LPN #1 go on the facility's medication administration computer program on 8/13/14 at 11:15 a.m. to verify the exact time Resident #2 and Resident #3's medications were given on 8/12/14. Resident #2 received his/her medications at 10:40 a.m. and Resident #3 received their medications at 2:42 p.m. LPN #1 stated s/he did not call the Physicians regarding the medications not being available and that they were given later than scheduled. 4. During the morning medication pass on 8/12/14 at 8:50 a.m. Resident #6 did not receive a blood pressure medication and a supplement. LPN #2 stated the medications were not in the medication cart. LPN #2 went to the Cubex machine to get a back-up supply. LPN #2 stated the Cubex arrived yesterday and s/he was not educated on how to use it. LPN #2 had 2 other Nurses attempt to get the back up supply, but none of the Nurses knew how to use the Cubex. LPN #2 stated that the medications would be given as soon as they were delivered. The surveyor and LPN #2, on 8/13/14 at 12 noon., verified that the medications were given at 11 a.m. yesterday. The supplement was taken from the Cubex by the Administrator and the blood pressure medication was delivered by the pharmacy. During the Group Interview on 8/13/14 at 11 a.m., Resident #6 stated that sometimes medications were given 1-2 hours late, especially pain medication. Resident #6 was worried that s/he would not receive [MEDICATION NAME] prior to PT. Resident #6 also stated that at times s/he requested [MEDICATION NAME] but was given Tylenol because [MEDICATION NAME] was unavailable. The surveyor reviewed Resident #6's eMAR on 8/13/14 at 12:45 p.m. On 8/5/14, the 9 a.m. dose of [MEDICATION NAME], a pain medication, was not given. According to the Progress Notes, the medication had not been delivered. 5. On 8/14/14 at 8:45 a.m., the surveyor reviewed the electronic medical record of Resident # 7. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's care plan revealed interventions for the amputation of the 4th and 5th toes on right foot. The care plan indicated that wound care daily as ordered by the Physician. A review of the eTAR revealed the following : 1. Santyl ointment 250 unit / gram apply to right 4th toe wound topically one time a day to be started on 8/9/14 at 10 a.m. was documented as NN (Other /see Nurse Notes) on 8/9/14 and 8/10/14. The nurses' notes on both dates indicated medication not available awaiting pharmacy. 2. [MEDICATION NAME] ointment 250 unit / gram apply to right foot topically every 12 hours for [MEDICAL CONDITION] Santyl to right wound after cleansing with normal saline solution every 12 hours and dry dressing to be started 8/8/14 at 9:00 a.m. Instead NN was documented for dates 8/8/14, 8/9/14 and 8/10. The nurses' notes on these dates indicated the medication was not available, awaiting pharmacy delivery The surveyor interviewed the Administrator on 8/14/14 at 10:40 a.m., who stated that medications were delivered on 8/8/14 at 10 a.m., however she agreed the medications were not administrated as ordered by nursing staff and Physician was not notified. 6. The surveyor reviewed the medical record of Resident #5 who was admitted [DATE]. The surveyor reviewed the eMAR on 8/13/14 at 11:30 a.m. Code NN was documented for the 9:00 a.m. dose of [MEDICATION NAME] 20 mg once a day. The corresponding nursing note said staff was waiting for the pharmacy delivery. On 8/13/14 at 1:20 p.m. the Administrator confirmed the medication was not were not administered on 8/6/14 as ordered and the physician was not notified. 7. The surveyor reviewed the medical record of Resident #1 on 8/12/14 at 11:50 a.m. and again on 8/13/14 at 9:55 a.m. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. On 8/9/14, the Physician ordered [MEDICATION NAME] Sodium Solution 1 gram intravenously (IV) once a day for 5 days to treat Leukocytosis. The start date was 8/10/14. A review of the Electronic Medication Administration Record ( eMAR) for the antibiotic documented that on 8/10/14 at 9:00 a.m. the nurse documented NN indicating the medication was not given at that time. Review of nurses' notes for 8/10/14 contained 3 notes that were timed at 12:18 p.m., 12:19 p.m., and 12:19 p.m. All 3 nurses' notes indicated that the delivery of the IV antibiotic medication was pending. There was no further clarification or explanation. The surveyor interviewed the Administrator on 8/13/14 at 10:15 a.m. who said the medication was ordered at approximately 10:42 p.m. on 8/9/14. This order was received too late for the retail pharmacy to deliver the medication in the morning. The surveyor was told by the Administrator the antibiotic was delivered at approximately 1 p.m. on 8/10/14 but was not administered that day . There was no evidence of any timely notification of the Physician that the medication was unavailable, and there was no evidence of the time of administration being changed when the medication was delivered. The first dose of the antibiotic was not given until 8/11/14. The Physician was notified on 8/13/14 at 1:15 p.m. after the surveyor could not determine whether the IV medication had been administered. Another medication order for Resident #1 revealed the Physician ordered [MEDICATION NAME] tablet 250 micrograms (mcq) by mouth once a day for [MEDICAL CONDITION]. A review of the eMAR revealed the medication was ordered on [DATE] and the start date was 8/10/14. The eMAR indicated NN for the 9 a.m. dose of [MEDICATION NAME] on 8/10/14. On 8/13/14 at 1:15 p.m. the surveyor interviewed the Administrator about the [MEDICATION NAME] order. The Administrator stated that the [MEDICATION NAME] was administered on 8/10/14 at 10:55 a.m. from the back up supply. A a review of the nursing progress notes revealed no evidenced the Physician was notified. The surveyor reviewed the electronic progress notes on 8/14/14. The Nurse who administered the medication wrote two late entries on 8/14/14 about the [MEDICATION NAME] for Resident #1. The first entry was "late entry dig. 0.25 mg given." The surveyor questioned the Administrator about the first late entry which lacked the correct dose, the time and route of administration. The same Nurse documented a 2nd late entry the same day which indicated on 8/10/14 9:50 a.m. late entry. Dig. ( [MEDICATION NAME]) 0.25 mcg given by mouth heart rate 110. 8. The surveyor reviewed Resident #4's record on 8/12/14 at 1:30 p.m. and on 8/13/14 at 9:10 a.m. and noted that a medication was not available for Resident #4 as ordered by the Physician. On 8/4/14 the Physician ordered [MEDICATION NAME] 10 mg tablet, give 1 tablet once a day allergies [REDACTED]. Nurses' Notes on these dates indicated on "8/5/14-pharmacy called to follow up with med will be delivered later today." On 8/6/14-"no med yet from pharmacy." On 8/7/14 the MAR was blank for the [MEDICATION NAME]. On 8/8/14 the nurses' note stated "No med awaiting from pharm", on 8/9/14, the nurses' note stated awaiting pharm to deliver, and again on 8/10/14 the nurses' note indicated "no med again from pharm order fax and called." When the surveyor interviewed the Administrator at 11 a.m. on 8/13/14, the Administrator indicated that this medication was ordered and received on 8/5/14. There was no evidence that nurses were aware that the [MEDICATION NAME] was available for administration and it was documented that the resident did not receive the medication. 9. The surveyor reviewed Resident #8's closed record on 8/14/14 at 10 a.m. The surveyor observed that on the July 2014 eMAR, Resident #8 did not receive a pain medication on 7/22/14 because, according to the Progress Notes, the medication had not been delivered. The same issue occurred on 7/26/14 for a medication to treat [MEDICAL CONDITION] (low sodium). 10. The surveyor reviewed the medical record of Resident # 9 on 8/12/14 at 11:50 a.m. and 8/13/14 at 9:55 a.m. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The record review showed that Resident #9 had issues concerning the administration of the following medications: [REDACTED]. A. On 7/17/14 the Physician ordered [MEDICATION NAME] Solution 3 times a day for ten days to treat oral Thrush, a fungal infection. The start date was 7/17/14. According to the eMAR this medication was scheduled for administration at 9:00 a.m., 1:00 p.m. and 5:00 p.m. The surveyor reviewed the E-MAR and corresponding progress notes for the months of July and August on 8/14/14 at 9 a.m. These records showed that this medication was not available on 7/17/14 at 7:32 p.m., 7/18/14 at 5:29 p.m. Review of the E-MAR showed "NN" for 7/17/14 at 5:00 p.m., on 7/18/14 at 9:00 a.m., 1:00 p.m. and 5:00 p.m., and 7/19/14 at 5:00 p.m.. There were corresponding E-MAR medication administration notes on 7/17/14 at 5:29 p.m. "not available" and on 7/18/14 there were E-MAR medication administration notes indicating (medications) not available at 3:13, 3:14 and at 5:29 p.m., awaiting pharmacy delivery. According to staff interview the [MEDICATION NAME] was never given and the physician reordered it on 8/5/14. According to nursing notes of 8/5/14 timed 2:22 p.m. it was not available, pharmacy will deliver later today. The nursing note of 8/6/14 timed 1:05 p.m. the eMAR indicated no med yet waiting for pharmacy delivery. Review of the August E-MAR only showed "NN" for the 9:00 a.m. dose of this medication. There was no corresponding note explaining the omission of the medication as per facility policy. B. On 7/15/14 the Physician also ordered [MEDICATION NAME] Solu Tablet 30 mg once a day for [MEDICAL CONDITION] reflux disease to start on 7/16/14. The MAR on 8/3/14 at 6:30 a.m. indicated "NN." The eMAR note of 8/3/14 at 6:37 a.m. indicated [MEDICATION NAME] not found, will reorder. The eMAR was blank for the 8/6/14 daily dose of [MEDICATION NAME]. Review of the E-MAR for 8/8/14 and 8/9/14 again indicated "NN" for the [MEDICATION NAME]. The eMAR note of 8/8/14 at 7:07 a.m. indicated the [MEDICATION NAME] will be reordered. There was no documentation that this medication was administered at this time and date. The eMAR medication administration note dated 8/9/14 at 6:50 a.m. indicated the [MEDICATION NAME] was on order. The eMAR was blank for the 8/10/14 dose of [MEDICATION NAME]. C. Resident #9 also had a 7/18/14 physician's orders [REDACTED]. The eMAR indicated "NN" for this medication on 7/30/14 at 9:00 a.m. There was no documentation that the medication was administered as ordered by the physician. The e-MAR note at 3:06 p.m. written by the same nurse indicated medication reordered today; however, it was not clear if this was the missing medication. D. The Physician ordered [MEDICATION NAME] Patch 24 hour 0.4 mg/hour Apply 1 patch trans dermal 1 time a day related to [MEDICAL CONDITION] Hold for Systolic Blood Pressure less than 100 for Resident #9. Remove at 9 p.m. The MAR was blank for the patches scheduled for administration on 8/6/14 and 8/7/14 at 9 a.m. Also, there was no blood pressure recorded for either date. There was no evidence of an explanation for the blanks in the E-MAR notes for the 2 doses of the [MEDICATION NAME]es that were not given to the resident. E. The Physician ordered for Resident #9 [MEDICATION NAME] Tablet Give 20 mg by mouth 1 time a day for [MEDICAL CONDITIONS] hold if systolic blood pressure is below 100 on 7/18/14 to start the same day. This medication was plotted on the E-MAR for administration at 6:30 a.m. . The E-Mar was blank for 3 doses of this medication 8/1/14, 8/6/14 and 8/10/14. There was no evidence of corresponding nursing notes or E-MAR medication administration notes whether the medication was administered, held, refused or unavailable for administration. F. The Physician ordered [MEDICATION NAME] Tablet 50 mg Give 1 tablet every 8 hours related to Acute but ill-defined [MEDICAL CONDITION] Disease on 7/23/14 to start the same day. Instructions indicated hold if heart rate is less than 60 and systolic blood pressure is less than 110. The E-MAR was blank for the blood pressure, pulse nurse ' s initials and whether the medication was administered, held, or unavailable for the 6 00 doses on 8/1/14 and 8/10/14. The Administrator was made aware of the missing medications and lack of documentation on 8/14/14 REFER F309, F 281 N.J.A.C. 8:39-11.2(b); 13.1(d); 29.2(d)

Based on observation, interview, and electronic and paper record review it was determined that the facility failed to provide consistent medication administration, evaluation, assessments and treatments as ordered by physicians so residents could receive care and services in a timely manner. This deficient practice was noted in 9 of 9 residents reviewed, Residents #1, #2, #3, # 4, # 5, #6, #7, #8 and #9 as evidenced by the following: 1. During the morning medication pass on 8/12/14 the surveyor observed 3 residents, Resident #2, #3 and #6. All three residents did not receive all their medications as ordered. Both licensed practical nurses (LPN) stated that the particular medications were unavailable and would be given when the pharmacy delivered the medications. 2. During the morning medication pass on 8/12/14 at 9:30 a.m. Resident #2's spouse approached LPN #1 requesting the resident's pain medication, [MEDICATION NAME]. The surveyor overheard LPN #1 inform the Administrator that the resident's [MEDICATION NAME] had yet to be delivered. With the surveyor present, LPN #1 went to administer Resident #2's morning medications at 9:40 a.m. LPN #1 stated that the morning medications had not been delivered. The missing medications included those used to treat pain, hypertension and abnormal heartbeat. LPN #1 did not check the Cubex to see if the medications were in that drug dispensing/storage machine. On 8/13/14 at 11:15 a.m. the surveyor rechecked with LPN #1 the status of the omitted medications from the previous day, it was verified that the medications were given at 10:42 a.m. yesterday. The surveyor interviewed Resident #2 on 8/12/14 at 11:30 a.m. Resident #2 stated s/he arrived at the facility last night following hip surgery. The resident stated s/he began to have pain around 6 a.m. and requested [MEDICATION NAME] but was given Tylenol because the [MEDICATION NAME] had not been delivered. Resident #2 stated the Tylenol "took the edge off" but still had some pain. Resident #2 expressed the fear that s/he would not get the [MEDICATION NAME] prior to Physical Therapy. The surveyor reviewed Resident #2's eMAR and physician's orders [REDACTED]. According to the admission orders [REDACTED]. The order was entered on the eMAR as: Tylenol 650 mg, give 2 tablets for pain; and a separate entry of Tylenol 325 mg, give 2 tablets for temperature. The medication Tylenol did not come in 650 mg tablets. The facility obtained a clarification order from the Physician on 8/12/14 for Tylenol 325 mg, give 2 tablets every 6 hours as needed for pain and added it to the eMAR. The surveyor informed the Administrator on 8/13/14 at 2:10 p.m. that the order for Tylenol 650 mg, give 2 tablets every 4 hours as needed was still an active order on the eMAR. The order was discontinued on 8/14/14 at 12:26 p.m. 3. During the morning medication pass on 8/12/14 at 9:40 a.m. Resident #3 did not receive 3 of his/her medications, which included those to treat [MEDICAL CONDITION] (low red cell blood count), hypertension and constipation. LPN #1 stated the 3 medications were unavailable and would administer them once they were delivered. LPN #1 did not check the Cubex. The surveyor and LPN #1, on 8/13/14 at 11:15 a.m., verified that the medications were given at 2:42 p.m. yesterday, 8/12/14. The surveyor reviewed Resident #3's medical record on 8/13/14 at 9 a.m. The medical record stated Resident #3 had some confusion and was admitted following foot surgery. The surveyor then reviewed Resident #3's eMAR. The surveyor observed that Resident #3's 8/9/14 scheduled 9 a.m. medications were not given. The nurses documented in the Progress Notes that the medications had not been delivered by pharmacy. The missed medications were prescribed to treat hypertension, a possible infection, high cholesterol, [MEDICAL CONDITIONS], diabetes mellitus (DM) and pain. On 8/13/14 at 9:30 a.m., the surveyor went back and reviewed Resident #2's eMAR and Resident #3's Progress Notes. LPN #1 documented that the unavailable medications from yesterday were given at 9 a.m. and 10 a.m. respectively. LPN #1 did not document that the physicians were notified of the delay. The surveyor requested that LPN #1 go on the facility's medication administration computer program on 8/13/14 at 11:15 a.m. to verify the exact time Resident #2 and Resident #3's medications were given on 8/12/14. Resident #2 received their medications at 10:40 a.m. and Resident #3 received their medications at 2:42 p.m. LPN #1 stated s/he did not call the physicians regarding the medications not being available and that they were given later than scheduled. 4. During the morning medication pass on 8/12/14 at 8:50 a.m. Resident #6 did not receive a blood pressure medication and a supplement. LPN #2 stated the medications were not in the medication cart. LPN #2 went to the Cubex machine to get a back-up supply. LPN #2 stated the Cubex arrived yesterday and s/he was not educated on how to use it. LPN #2 had 2 other nurses attempt to get the back up supply, but none of the nurses knew how to use the Cubex. LPN #2 stated that the medications would be given as soon as they were delivered. On 8/13/14 at 12 noon., the surveyor and LPN #2 verified that the medications were given at 11 a.m. yesterday. The supplement was taken from the Cubex by the Administrator and the blood pressure medication was delivered by the pharmacy. During the Group Interview on 8/13/14 at 11 a.m., Resident #6 stated that sometimes medications were given 1-2 hours late, especially pain medication. Resident #6 was worried that s/he would not receive [MEDICATION NAME] prior to PT. Resident #6 also stated that at times s/he requested [MEDICATION NAME] but was given Tylenol because [MEDICATION NAME] was unavailable. The surveyor reviewed Resident #6's eMAR on 8/13/14 at 12:45 p.m. On 8/5/14, the 9 a.m. dose of [MEDICATION NAME], a pain medication, was not given. According to the Progress Notes, the medication had not been delivered. 5. On 8/14/14 at 8:45 a.m., the surveyor reviewed the electronic medical record of Resident # 7 that revealed the following The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's care plan revealed interventions for the amputation of the 4th and 5th toes on right foot. The care plan indicated, wound care daily as ordered by the Physician. A review of the eTAR revealed the following : 1. Santyl ointment 250 unit / gram apply to right 4th toe wound topically one time a day to be started on 8/9/14 at 10 a.m. was documented as NN (Other /see Nurse Notes) on 8/9/14 and 8/10/14. The nurses' notes on both dates indicated medication not available awaiting pharmacy. 2. [MEDICATION NAME] ointment 250 unit / gram apply to right foot topically every 12 hours for [MEDICAL CONDITION] Santyl to right wound after cleansing with normal saline solution every 12 hours and dry dressing to be started 8/8/14 at 9:00 a.m. Instead NN was documented for dates 8/8/14, 8/9/14 and 8/10. The nurses' notes on these dates indicated medication not available; awaiting pharmacy. The surveyor interviewed the Administrator on 8/14/14 at 10:40 a.m. who stated that medications were delivered on 8/8/14 at 10 a.m., however she agreed the medications were not administrated as ordered by nursing staff and that the Physician was not notified. 6. The surveyor reviewed the medical record of Resident #5 who was admitted [DATE] with [DIAGNOSES REDACTED]. A review of the e-MAR on 8/13/14 at 11:30 a.m. revealed "NN" documented for 9 a.m. medication Olmesartan Medoxonil ([MEDICATION NAME]) 20 milligrams ( mg) 1 po daily. A review of the nurse progress notes revealed: on 8/6/14 awaiting pharmacy delivery. On 8/13/14 at 1:20 p.m. the Administrator confirmed the medication was not administered on 8/6/14 as ordered and the Physician was not notified. 7. The surveyor reviewed the medical record of Resident #1 on 8/12/14 at 11:50 a.m. and again on 8/13/14 at 9:55 a.m., which revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. On 8/9/14, the Physician ordered [MEDICATION NAME] Sodium Solution 1 Gram intravenously (IV) once a day for 5 days to treat Leukocytosis. The start date was 8/10/14. A review of the Electronic Medication Administration Record ( eMAR) for IV medicated at 9:00 a.m. had the notation "NN" on the start date. According to the Chart Codes/ Follow Up Codes, "NN" meant "Other/ See Nurse Notes." Review of nurses' notes for 8/10/14 were documented 3 notes that were timed at 12:18 p.m., 12:19 p.m., and 12:19 p.m. All 3 nurses' notes indicated delivery of this IV antibiotic medication was pending. There was no further clarification or explanation. On 8/13/14 at 10:15 a.m., the surveyor interviewed the Administrator who said the medication was ordered at approximately 10:42 p.m. on 8/9/14 which was not in time for the 9:00 a.m. delivery. The Administrator told the surveyor that the IV antibiotic was delivered at approximately 1 p.m. on 8/10/14 but was not administered that day . There was no evidence of any timely notification of the Physician that the medication was unavailable, and there was no evidence of the time of administration being changed when the medication was delivered. The Physician was not notified until 8/13/14 at 1:15 p.m. after the surveyor had spoken with the Administrator that the antibiotic was not administered as ordered. The Physician also ordered [MEDICATION NAME] tablet 250 micrograms (mcq) once a day for the treatment of [REDACTED]. A review of th eMAR revealed the medication was ordered on [DATE] and the start date was 8/10/14. The eMAR indicated "NN" for the 8/10/14 9:00 a.m. dose of [MEDICATION NAME]. On 8/13/14 at 1:15 p.m. the surveyor interviewed the Administrator about the [MEDICATION NAME] order. The Administrator stated that the [MEDICATION NAME] was administered at 10:55 a.m. from the back up supply on 8/10/14. The Administrator also told the surveyor that nurses were not able to go back into the eMAR to make a late entry concerning the actual time a medication had been administered. Instead the nurse must document the time of administration in the nursing progress notes. A a review of the nursing progress notes revealed no documentation and no evidenced the Physician was notified concerning the [MEDICATION NAME]. The surveyor reviewed the electronic progress notes on 8/14/14 that revealed the nurse who administered the medication wrote two late entries on 8/14/14 about the [MEDICATION NAME] for Resident #1. The first entry stated " late entry dig. 0.25 mg given. " The surveyor questioned Administrator about the first late entry which lacked the correct dose, the time and route of administration. The same nurse then documented a 2nd late entry which noted that on 8/10/14 at 9:50 a.m. late entry. "Dig. ( [MEDICATION NAME]) 0.25 mg given by mouth heart rate 110." 8. Surveyor review of Resident #4's record on 8/12/14 at 1:30 p.m. and on 8/13/14 at 9:10 a.m. showed that medication was not available for Resident #4 as ordered by the Physician. On 8/4/14 the Physician ordered [MEDICATION NAME] 10 mg tablet once a day. The eMAR indicated "NN" on 8/5/14, 8/6/14, 8/8/14, 8/9/14, and 8/10/14 for the [MEDICATION NAME]. Nurses' Notes on these dates documented the following: on "8/5/14-pharmacy called to follow up with med will be delivered later today." On "8/6/14-no med yet from pharmacy." On On 8/7/14 the MAR was blank for the [MEDICATION NAME]. On 8/8/14 the nurses' note stated "No med awaiting from pharm", on 8/9/14, the nurses' note stated awaiting pharm to deliver, and again on 8/10/14 the nurses' note indicated "no med again from pharm order fax and called." When the surveyor interviewed the Administrator at 11 a.m. on 8/13/14, the Administrator indicated that this medication was ordered and received on 8/5/14. There was no evidence that nurses were aware that the [MEDICATION NAME] was available for administration. 9. The surveyor reviewed Resident #8's closed record on 8/14/14 at 10 a.m. The surveyor observed that on the July 2014 eMAR, Resident #8 did not receive a pain medication on 7/22/14 because, according to the Progress Notes, the medication had not been delivered. The same issue occurred on 7/26/14 for a medication to treat low sodium. 10. The surveyor reviewed the medical record of Resident # 9 on 8/12/14 at 11:50 a.m. and 8/13/14 at 9:55 a.m. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The record review showed that Resident #9 had isssues concerning the administration of the following medications: [REDACTED]. A. On 7/17/14 the Physician ordered [MEDICATION NAME] Solution 3 times a day for ten days to treat oral Thrush, a fungal infection. The start date was 7/17/14. According to the eMAR this medication was scheduled for administration at 9:00 a.m., 1:00 p.m. and 5:00 p.m. The surveyor reviewed the E-MAR and corresponding progress notes for the months of July and August on 8/14/14 at 9 a.m. These records showed that this medication was not available on 7/17/14 at 7:32 p.m., 7/18/14 at 5:29 p.m. Review of the E-MAR showed "NN" for 7/17/14 at 5:00 p.m., on 7/18/14 at 9:00 a.m., 1:00 p.m. and 5:00 p.m., and 7/19/14 at 5:00 p.m.. There were corresponding E-MAR medication administration notes on 7/17/14 at 5:29 p.m. "not available" and on 7/18/14 there were E-MAR medication administration notes indicating (medications) not available at 3:13, 3:14 and at 5:29 p.m., awaiting pharmacy delivery. According to staff interview, the [MEDICATION NAME] was never given and the Physician reordered it on 8/5/14. According to nursing notes of 8/5/14 timed 2:22 p.m. it was not available, pharmacy will deliver later today. The nursing note of 8/6/14 timed 1:05 p.m. the eMAR indicated no med yet waiting for pharmacy delivery. Review of the August E-MAR only showed "NN" for the 9:00 a.m. dose of this medication. There was no corresponding note explaining the omission of the medication as per facility policy. B. On 7/15/14 the Physician also ordered [MEDICATION NAME] Solu Tablet 30 mg once a day for [MEDICAL CONDITION] reflux disease to start on 7/16/14. The MAR on 8/3/14 at 6:30 a.m. indicated "NN." The eMAR note of 8/3/14 at 6:37 a.m. indicated [MEDICATION NAME] not found, will reorder. The eMAR was blank for the 8/6/14 daily dose of [MEDICATION NAME]. Review of the E-MAR for 8/8/14 and 8/9/14 again indicated "NN" for the [MEDICATION NAME]. The eMAR note of 8/8/14 at 7:07 a.m. indicated the [MEDICATION NAME] will be reordered. There was no documentation that this medication was administered at this time and date. The eMAR medication administration note dated 8/9/14 at 6:50 a.m. indicated the [MEDICATION NAME] was on order. The eMAR was blank for the 8/10/14 dose of [MEDICATION NAME]. C. Resident #9 also had a7/18/14 physician's orders [REDACTED]. The eMAR indicated "NN" for this medication on 7/30/14 at 9:00 a.m. There was no documentation that the medication was administered as ordered by the Physician. The e-MAR note at 3:06 p.m. written by the same Nurse indicated medication reordered today; however, it was not clear if this was the missing medication. D. The Physician ordered [MEDICATION NAME] Patch 24 hour 0.4 mg/hour Apply 1 patch trans dermal 1 time a day related to [MEDICAL CONDITION] Hold for Systolic Blood Pressure less than 100 for Resident #9. Remove at 9 p.m. The MAR was blank for the patches scheduled for administration on 8/6/14 and 8/7/14 at 9 a.m. Also, there was no blood pressure recorded for either date. There was no evidence of an explanation for the blanks in the E-MAR notes for the 2 doses of the [MEDICATION NAME]es that were not given to the resident. E. The Physician ordered for Resident #9 [MEDICATION NAME] Tablet Give 20 mg by mouth 1 time a day for [MEDICAL CONDITIONS] hold if systolic blood pressure is below 100 on 7/18/14 to start the same day. This medication was plotted on the E-MAR for administration at 6:30 a.m. . The E-Mar was blank for 3 doses of this medication 8/1/14, 8/6/14 and 8/10/14. There was no evidence of corresponding nursing notes or E-MAR medication administration notes whether the medication was administered, held, refused or unavailable for administration. F. The Physician ordered [MEDICATION NAME] Tablet 50 mg Give 1 tablet every 8 hours related to Acute but ill-defined [MEDICAL CONDITION] Disease on 7/23/14 to start the same day. Instructions indicated hold if heart rate is less than 60 and systolic blood pressure is less than 110. The E-MAR was blank for the blood pressure, pulse nurse ' s initials and whether the medication was administered, held, or unavailable for the 6 00 doses on 8/1/14 and 8/10/14. The Administrator was made aware of the missing medications and lack of documentation on 8/14/14. The surveyor interviewed the Administrator on 8/12/14 at 1 p.m. about the delivery of medications to residents. The Administraor stated that the facility changed to a non -hospital based pharmacy on 7/15/14 and the pharmacy made deliveries twice a day around 5 a.m.-6 a.m. and 12 noon-1 p.m. The Administrator also stated that STAT (as soon as possible) medications would be delivered on an as needed basis. Also, the facility just began using a Cubex for back-up medications. The Administrator stated that the Cubex was a secured machine that housed multiple medications not ordered for a specific resident) but not Schedule II narcotics at this time. The Administrator stated they would add additional medications once they determined which medications were commonly ordered. The Administrator stated the staff was not in-serviced on the use of the Cubex. The Administrator provided the surveyor with the facility's Pain Management and Protocols Policy and Procedures, dated 7/15/14, on 8/13/13 at 9:30 a.m. The facility's policy stated that residents would be assessed and managed "accordingly to improve quality of life" and to "ensure appropriate intervention and effectiveness for comfort." NJAC 8:39-27.1 (a)

Based on observation, interview and review of the electronic and paper medical records, it was determined that the facility failed to administered medications in accordance with Physicians' orders. This resulted in both inaccurate transcription of orders and failure to notify the Physician of medication and treatment errors. This deficient practice was noted for 9 of 9 residents ( #1, #2, #3, #4, #5, #6, #7, #8, #9) reviewed for adherence to professional standards of care as evidenced by the following: All the residents reviewed had the notation "NN" on the electronic Medication Administration Record (eMAR) and/or electronic Treatment Administration Record (eTAR) in varying amounts. According to the Chart Codes/ Follow Up Codes, "NN" was the code for "Other/ See Nurse Notes." This code indicates that further information about the medication or treatment would be found in the nursing progress notes. On 8/13/14 at 10:15 a.m. the Administrator told the surveyor that the computer system would not allow the nurses to go back into the eMAR and make a late entry after the administration time had passed. The only way to document the actual administration time or lack of administration of a medication due to unavailability or resident refusal once the administration time listed on the eMAR has passed is for the nurse to document in the nursing progress notes. 1. The surveyor reviewed the medical record of Resident #1 on 8/12/14 at 11:50 a.m. and on 8/13/14 at 9:55 a.m. The resident was admitted on [DATE]. On admission the Physician ordered the antibiotic [MEDICATION NAME] 1 gram intravenously (IV) once a day for 5 days for the treatment of [REDACTED]. The start time set for 9:00 a.m. The resident was also ordered the cardiac medication [MEDICATION NAME] 250 micrograms by mouth once a day for [MEDICAL CONDITION] with the start date of 8/10/14. A review eMAR for the 8/10 start of the antibiotic showed the notation "NN" on the start date. The surveyor reviewed the nursing note in the medical record concerning the antibiotic and found 3 corresponding nursing notes written on 8/10 that indicated the IV antibiotic delivery was pending. The surveyor interviewed the Administrator about the IV antibiotic on 8/13/14 at 10:15 a.m. and was told that the medication was ordered on [DATE] at 10:42 p.m., but did not arrive until 1 p.m. on 8/10/14 as per the usual delivery schedule. This antibiotic was scheduled to be administered at 9 a.m. on 8/10/14. There was no evidence that the Physician was notified that the medication was not available for administration as scheduled. Although according the Administrator the antibiotic was received in the facility on 8/10/14, which was the ordered start date, it was not administered to Resident #1 until 8/11/14 at 9 a.m. The first dose of the antibiotic was delayed by one day. The Physician was not notified about the missing dose of the IV antibiotic until 8/13/14 at 1:15 p.m. At this time the Administrator agreed that the Physician should have been notified, and the medication time should have been adjusted in order that the antibiotic be started as close as possible to the intended start date. The surveyor then reviewed Resident #1's eMAR concerning the [MEDICATION NAME] medication. The eMAR indicated " NN " for the 9 a.m. dose of [MEDICATION NAME] on 8/10/14. On 8/13/14 at 1:15 p.m., the surveyor interviewed the Administrator about the [MEDICATION NAME] order and was told that the [MEDICATION NAME] was administered at 10:55 a.m. on 8/10/14 from the back up supply. A review of the nursing progress notes revealed no documentation/evidence that the Physician was notified. The surveyor reviewed the electronic progress notes on 8/14/14 which showed that the nurse who administered the [MEDICATION NAME] did not write the two late entries until 4 days later on 8/14/14. The first noted "late entry dig. 0.25 mg given." The surveyor questioned the Administrator about this note which lacked the correct dosage, time and route of administration. The same nurse documented a 2nd late entry on 8/14 which reflected [MEDICATION NAME] 0.25 mcg was given on 8/10 at 9:50 a.m. by mouth and the resident's heart rate was 110. 2. During the morning medication pass on 8/12/14 at 9:35 a.m. the surveyor observed the Licensed Practical Nurse #1 (LPN) attempt to administer Resident #2's scheduled morning medications which included the pain medication [MEDICATION NAME]. LPN #1 stated the pharmacy had not delivered the medications. The surveyor reviewed Resident #2's eMAR and physician's orders [REDACTED]. The facility entered the order on the eMAR as: Tylenol 650 mg, give 2 tablets for pain; and a separate entry of Tylenol 325 mg, give 2 tablets for temperature. The medication Tylenol does not come in 650 mg tablets. The facility obtained a clarification order from the Physician on 8/12/14 for Tylenol 325 mg, give 2 tablets every 6 hours as needed for pain and added it to the eMAR. The surveyor informed the Administrator on 8/13/14 at 2:10 p.m. that the order for Tylenol 650 mg, give 2 tablets every 4 hours as needed was still an active order on the eMAR. The order was discontinued on 8/14/14 at 12:26 p.m. 3. On 8/12/14 at 9:40 a.m. LPN #1 attempted to administer morning medications to Resident #3. Three of the ordered medications for this resident were not available. On 8/13/14 at 9:30 a.m. the surveyor went back to review Resident #2's eMAR and Resident #3's Progress Notes. LPN #1 documented that the medications that were unavailable at 9:00 a.m. unavailable medications were given at 9 a.m. and 10 a.m. on 8/12 respectively. LPN #1 did not document that the Physicians were notified of the delay in administration for either resident. The surveyor had LPN #1 log on the facility's medication administration computer program on 8/13/14 at 11:15 a.m. to verify the exact time Resident #2 and Resident #3's medications were given on 8/12/14. It revealed that Resident #2 received medications at 10:40 a.m. and Resident #3 received medications at 2:42 p.m. The LPN #1 stated to the surveyor that s/he did not call the Physicians regarding the medications not being available and that they had been given later than scheduled. The survey team informed the Administrator concerning the issue of medications not being available on 8/12/14 during medication pass for Residents #2 and #3 at 1 p.m. The Administration stated that if a medication was not available the nurse should call the Physician and get permission to give the medication when delivered and document in the resident's progress notes. 3. The surveyor reviewed the eMARs for Residents #3, #5, #6, and #8 on 8/12 through 8/14. Each eMAR had some boxes documented as NN. The surveyor then reviewed the corresponding Residents #3, #5, #6 and #8's Progress Notes (Nurse Notes). The Nurses documented that the medication was not given because it was not available. There was no documentation that the Physicians were notified of the delay. 4. On 8/12 through 8/14/14 the surveyor reviewed the eMAR and eTAR for Resident #2,# 3, #6 and #8 and noted multiple blank spaces concerning both medications and treatments. These areas are listed below: Resident #2: 8/11/14 for [MEDICATION NAME], a laxative. The eMAR lists the order as give 5 mg STAT(immediately) for constipation with a start date of 8/12/14. There was an X for each day in Aug, except for 8/11 which was blank. Resident #3: 8/8/14 the eMAR has a blank space for both Atorvastatin for high cholesterol and Insulin. The eTAR has a blank in the 7 a.m. slot concerning staff check of the bed and chair alarms and the urinary drainage catheter. Resident #6: The eMAR slot of 8/7/14 time 6:30 a.m. for the antihypertensive [MEDICATION NAME] for hypertension is blank. The slot of 8/10/14 time 6:30 a.m. for [MEDICATION NAME] is blank. The slot of 8/6/14-8/10/14 time 7 a.m. concerning assess for pain is blank. The 8/5/14-8/10/14 (all 3 shifts) to check the bed and chair alarms are blank. The 8/11/14-8/12/14 slots for evening and night shifts to check the bed and chair alarms are blank. Resident #8: On the eMAR the slot for 7/24/14 at 5: p.m. for Sodium Chloride tabs is blank. The 7/30/14 slot for skin assessment is blank. The slots for 7/29/14 (night shift)-7/30/14 (day and evening shift) and 7/31/14 (day and night shift) to check the bed and chair alarms are blank. The surveyor made the Administrator aware of the multiple blank spaces throughout the survey. The Administrator stated the Nurses "forgot" to document. The Administrator stated the nurses documented elsewhere in the medical record regarding the pain assessment for Resident #6. 5. The surveyor reviewed the medical record of Resident #5 who was admitted [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the e-MAR on 8/13/14 at 11:30 a.m. which documented "NN" for the 8/6/14 9 a.m. dose of [MEDICATION NAME]. The corresponding progress note showed that the dose was not given because the facility was awaiting pharmacy delivery. On 8/13/14 at 1:20 p.m. the Administrator confirmed the medication was not given on 8/6/14 as ordered and the Physician was not notified. 6. According to the Admission physician's orders [REDACTED].#6's skin was to be assessed every Wednesday. The facility incorrectly entered the order on the eTAR as assess the skin once a day. 7. The surveyor reviewed Resident #4's medical record on 8/12/14. The resident was admitted on [DATE] for therapy and care of a right ankle fracture. The surveyor interviewed Resident #4 on 8/12/14 at 12:22 p.m., on 8/13 at 11:00 a.m. during the group interview, and again on 8/14/14 at 12:15 p.m. The resident stated during the interviews that a protective patch was placed on her back in the hospital and had never been removed until the resident did so on 8/11/14, one week after admission, and presented the patch to the Nurse. The surveyor reviewed Resident #4's medical record on 8/12/14 at 1:30 p.m., and again on 8/13/14 at 10 a.m. Resident #4's was first assessed by staff on 8/11/14 as having a facility acquired coccyx wound that staff identified as a Stage II pressure sore measuring 0.5 x 0.3 x 0 cm, with no drainage. The Initial Five Day Charting Assessment that was completed on the day of admission, 8/4, only documented a problem with skin integrity as it related to the surgical repair of the ankle. Resident #4 had an 8/4/14 physician's orders [REDACTED]. Surveyor review of Resident #4's medical record on 8/12/14 at 1:30 p.m. and 8/13/14 at 9:10 a.m. identified that the medication was not available. The Electronic Medication Administration Record (eMAR) indicated "NN" for 8/5/14, 8/6/14, 8/8/14, 8/9/14, and 8/10/14 for the [MEDICATION NAME]. The Nurses' Notes on these dates indicated the following: On 8/5/14-pharmacy called to follow up with medication will be delivered later today. On 8/6/14-no medication yet from pharmacy. On On 8/7/14 the eMAR was blank for the [MEDICATION NAME]. On 8/8/14 the nurses' note indicated no med, still awaiting from pharmacy On 8/9/14, the nurses' note indicated awaiting pharmacy to deliver, and again on 8/10/14 the nurses' note again indicated that the medication had still not been received from the pharmacy, the order was faxed and called. The surveyor interviewed the Administrator at 11 a.m. on 8/13/14 who told the surveyor that this medication was ordered and received on 8/5/14. There was no evidence that nurses were aware that the [MEDICATION NAME] was available on that date for administration as evidenced by the multiple notes from the nursing staff regarding their inability to administer the medication. 8. On 8/14/14 at 8:45 a.m. the surveyor reviewed the medical record of Resident # 7. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan revealed interventions for care of toe amputations and that wound care was ordered daily by the Physician. A review of the eTAR revealed the following : Santyl ointment 250 unit / gram was to be applied to right 4th toe wound once a day to be started on 8/9/14 at 10 a.m. This treatment was documented as NN on 8/9/14 and 8/10/14. The nurses's notes on both dates indicated the Santyl ointment was not available, awaiting pharmacy delivery. [MEDICATION NAME] ointment was also ordered to be applied to the right foot every 12 hours for [MEDICAL CONDITION] and Santyl ointment to be applied to right foot wound after cleansing with normal saline solution and cover with a dry dressing. This was to be done every 12 hours starting 8/8/14 at 9:00 a.m. NN was documented for dates 8/8, 9 and 10/14. The nursing notes on these dates indicated the medication was not available and staff was awaiting delivery from the pharmacy. There was no documented evidence that the Physician was notified that the treatments were not provided as ordered. The surveyor interviewed the Administrator on 8/14/14 at 10:40 a.m. concerning Resident #7. The Administrator told the surveyor the medications were delivered on 8/8/14 at 10 a.m., however she agreed that the medications were not administered as ordered by nursing staff and the physician was not notified. There was no explanation of why the nursing staff did not know the ointments had been delivered or where they were being kept. 9. The surveyor reviewed the medical record of Resident # 9 on 8/12/14 at 11:50 a.m. and on 8/13/14 at 9:55 a.m. The resident was admitted on [DATE]. The Physician ordered [MEDICATION NAME] Solution, an oral rinse to treat Thrush, 3 times a day at 9:00 a.m., 1:00 p.m. and 5:00, for 10 days to treat oral thrush. The start date was 7/17/14. On 8/14/14 at 9:00 a.m. the surveyor reviewed Resident #9's eMAR and corresponding progress notes for the months of July and August. According to these documents the [MEDICATION NAME] was not available on 7/17/14 at 6:32 p.m. and 7/18/14 at 5:29 p.m. Review of the eMAR showed "NN" for 7/17/14 at 5 p.m., 7/18/14 at 9 a.m., 1 p.m. and 5 p.m., and 7/19/14 at 5 p.m. There were corresponding notes on 7/17/14 timed 5:29 p.m. and on 7/18/14 timed 3:13 p.m., 3:14 p.m. and 5:29 p.m. that note the [MEDICATION NAME] was not available. The staff noted they were awaiting pharmacy delivery. The Physician re-ordered [MEDICATION NAME] on 8/5/14. According to nursing notes on 8/5/14 timed 2:22 p.m. the medication was not available and that the pharmacy would deliver later today. A nursing note on 8/6/14 timed 1:05 p.m. and the eMAR notes indicated that the medication was still not available and the staff was waiting for the pharmacy delivery. Review of the August eMAR only noted "NN" for the 9:00 a.m. dose of this medication. There was no corresponding nursing note for this omitted dose as per facility policy. On 7/15/12 the Physician ordered [MEDICATION NAME] Solu Tab Tablet 30 mg, give 1 tablet by mouth once a day for Resident #9. This medication was to start on 7/16/14. An eMAR note on 8/3/14 at 6:30 a.m. indicated "NN" which reflected that the [MEDICATION NAME] was not found and it would be reordered. The eMAR was blank for the 8/6/14 dose of [MEDICATION NAME]. Review of the eMAR for 8/8/14 and 8/9/14 again contained the notation "NN" for this medication. The eMAR note of 8/8/14 timed 7:07 a.m. indicated the [MEDICATION NAME] will be reordered. There was no documentation that this medication was administered at this time and date. The eMAR note dated 8/9/14 timed 6:50 a.m. again reflected that the [MEDICATION NAME] was still not available for administration. The eMAR was blank for the 8/10/14 daily dose of [MEDICATION NAME]. Review of Resident #9's eMAR and physician's orders [REDACTED]. The start date was 7/19/14. The eMAR indicated "NN" for [MEDICATION NAME] on 7/30/14 at 9:00 a.m. There was no documentation that the medication was administered as ordered and there was no corresponding eMAR note documented on 7/30/14 at 9 a.m. The eMAR note timed 3:06 p.m. written by the same nurse indicated medication was reordered today; however, it was not clear if this was the missing medication. The Physician also ordered Resident #9 to have a [MEDICATION NAME] Patch to be applied once a day for [MEDICAL CONDITION] with the cautionary warning for staff to hold the patch if the Systolic Blood Pressure was less than 100. The patch was to be removed at 9:00 p.m. The eMAR was blank for the patches scheduled to be applied on 8/6/14 and 8/7/14 at 9 a.m. Also, there was no blood pressure recorded for either date. There was no evidence relating to the 2 missing doses of [MEDICATION NAME]es as whether the medication was administered late, held, refused or unavailable for administration an explanation for the blanks in the eMAR notes for the 2 doses of the [MEDICATION NAME]es. On 7/18/14 the Physician also ordered Resident #9 the diuretic [MEDICATION NAME] 20 mg once a day for [MEDICAL CONDITION] with the cautionary warning to hold if systolic blood pressure is below 100. The [MEDICATION NAME] was to be started the same day. This medication was documented on the eMAR for administration at 6:30 a.m. The E-Mar was blank for 3 doses of this medication 8/1/14, 8/6/14 and 8/10/14. There was no evidence of corresponding nursing notes or eMAR notes whether the medication was administered, held, refused or unavailable for administration. Resident #9 also had a physician's orders [REDACTED]. The medication was ordered on [DATE] and was to start that day. The order contained the cautionary warning to hold if the heart rate is less than 60 and the systolic blood pressure is less than 110. The eMAR was blank for the blood pressure, pulse, nurse's initials and whether the medication was administered, held, or unavailable for the 6 a.m. doses on 8/1/14 and 8/10/14. The Administrator was made aware of the missing medications and lack of documentation on 8/14/14. N.J.A.C. 8:39-11.1; 11.2(b); 23.2(a)(b); 29.2(d) REFER F309 F333

Based on observation, interview and record review it was determined that the facility failed to protect the skin of a resident with a knee immobilizer, which led to the development of facility acquired unstageable pressure ulcers which required debridement. This deficient practice was identified in 1 of 4 residents, Resident #4 as evidenced by the following: During the initial tour of the facility on 9/10/13 at 9:45 a.m. the tour nurse identified that Resident #4 had right leg pressure ulcers "most likely caused by the immobilizer." The nurse also stated that the resident was alert and oriented with some forgetfulness. On 9/10/13 at 11:15 a.m. the surveyor reviewed the medical record of Resident #4 which revealed the following: The resident was admitted to the facility on [DATE] following a hospitalization for a surgical repair to the right knee. The resident was admitted to the facility with a right knee immobilizer applied. A physician's orders [REDACTED]. A review of an "Outcome Summary" of 8/31/13 revealed that the resident was admitted to the facility with a "right calf area tape blister and a right heel DTI." A physician's orders [REDACTED]. A review of the initial 9/5/13 "Wound Assessment Details" by the hospital wound care team revealed the following pressure ulcers: A stage II right proximal, posterior lower leg which measured 3.6 centimeters(cm) x 3.5cm x 0.1cm.; An unstageable right , posterior lower middle leg which measured 2.1cm x 3.5cm x 0.1cm.; An unstageable right, distal posterior lower leg which measured 2.5cm. x 2.3cm x 0.1cm. and a Deep Tissue Injury (DTI) to the right heel which measured 1.5cm x 1.5cm. All right posterior leg pressure ulcers were debrided and santyl ointment was ordered daily for the leg ulcers. A review of the September 2013 Treatment Administration Record (TAR) revealed that treatment was being administered (initialed by staff) to the resident's right proximal posterior leg pressure ulcer only. There were no additional right leg pressure ulcer treatments identified on the TAR. A review of the 8/31/13 care plan did not address the knee immobilizer and there were no identified interventions related to skin assessments and pressure ulcer prevention. A review of an "Outcome Summary" note of 9/3/13 by the Physical Therapist revealed the following: "Pt's immobilizer does not fit her well and continually slides down her leg." On 9/10/13 at 12:15 p.m. the nurse stated to the surveyor that the resident wore the right knee immobilizer at all times. The nurse further stated that on 9/4/13 she removed the immobilizer and discovered unstageable posterior leg pressure ulcers which were most likely from the immobilizer. The nurse further stated that the physician had not been notified regarding the pressure ulcer development. The nurse stated that the facility did not have a policy or protocol for skin assessments and circulation checks with regards to immobilizers. On 9/11/13 at 10:45 a.m. Resident #4 stated to the surveyor that the right knee immobilizer was applied at all times. On 9/11/13 at 11:00 a.m. 2 surveyors along with 2 facility nurses observed the resident's skin and the following was noted: A necrotic right heel which measured 1.3cm x 1.5cm; an unstageable right upper posterior leg pressure ulcer which measured .5cm x .5cm; a stage II right middle posterior leg pressure ulcer which measured 1.2cm x 1.5cm and an unstageable lower posterior leg pressure ulcer which measured 2.5cm x 1cm. The surveyors identified a stage II right bunion area pressure ulcer which measured .3cm x .4cm. The nurse stated that this was most likely caused by a shoe (worn at home) and that treatment was not being applied or wound documentation being done. On 9/11/13 at 1:00 p.m. the Director of Nursing stated that the care plan should address the knee immobilizer with interventions identified related to skin and circulation checks. The DON was not aware that this had not been done. The DON stated that the TAR should identify each pressure ulcer and treatment which should be initialed by staff as completed. The DON was not aware that this had not been done. The DON stated that the physician had not been notified regarding the pressure ulcer development with regards to the immobilizer. The DON further stated that the facility did not have a protocol or policy which directed the care provided by the staff with regards to skin assessments and circulation checks when an immobilizer was applied. On 9/12/13 at 10:30 a.m. the hospital wound care nurse stated to the surveyor that the pressure ulcers were most likely caused by the knee immobilizer. The wound care nurse stated that the physician had not been notified regarding ulcer development and that the resident continued to wear the immobilizer. On 9/12/13 at 11:00 a.m. the Physical Therapist and Occupational Therapist stated to the surveyor that the resident was currently receiving therapy. They stated that the resident wore the immobilizer during therapy and that it was never removed during therapy. The PT stated that the resident's immobilizer often needed to be adjusted in therapy since it slid down her leg. On 9/12/13 at 11:30 a.m. the DON stated to the surveyor that the physician had been notified regarding the pressure ulcer development and that the knee immobilizer had been discontinued. NJAC 8:39-27.1(e)

Based on observation, interview and record review it was determined that the facility failed to develop a plan of care based on individual assessment for a resident with a knee immobilizer in order to protect the resident's skin. This deficient practice led to the development of facility acquired pressure ulcers and was identified in 1 of 4 residents, Resident #4 as evidenced by the following: On 9/10/13 at 11:15 a.m. the surveyor reviewed the medical record of Resident #4 which revealed the following: The resident was admitted to the facility on [DATE] following a hospitalization for a surgical repair to the right knee. The resident was admitted with a right knee immobilizer applied which was to be worn at all times. A review of an "Outcome Summary" of 8/31/13 revealed that the resident was admitted to the facility with a "right calf area tape blister and a right heel DTI." A physician's orders [REDACTED]. A review of the initial 9/5/13 "Wound Assessment Details" by the hospital wound care team revealed the following pressure ulcers: A stage II right proximal, posterior lower leg which measured 3.6 centimeters(cm) x 3.5cm x 0.1cm.; An unstageable right , posterior lower middle leg which measured 2.1cm x 3.5cm x 0.1cm.; An unstageable right, distal posterior lower leg which measured 2.5cm. x 2.3cm x 0.1cm. and a Deep Tissue Injury (DTI) to the right heel which measured 1.5cm x 1.5cm. A review of the 8/31/13 care plan did not address the knee immobilizer and there were no identified interventions related to skin assessments/circulation checks for pressure ulcer prevention. On 9/11/13 at 1:00 p.m. the Director of Nursing (DON) stated that the care plan should address the knee immobilizer with interventions identified related to skin and circulation checks in order to prevent pressure ulcer development. The DON was not aware that this had not been done for the resident. Refer to F 314 NJAC 8:39 -11.2(e)(2)