Every finding on record at Complete Care at Voorhees, LLC

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a cognitively impaired resident who was at risk for aspiration (accidental breathing in of fluid or food into the lungs) and had a physician's order for a ground (soft, moist, finely minced) texture diet received food that was consistent with their prescribed mechanically altered diet to prevent accidental choking (airway obstruction caused by food or small objects) and aspiration (foreign material inhaled into the airway/lungs). This deficient practice was identified for 1 of 7 residents (Resident #106) reviewed for accidents. On 3/25/26, a Hospice Liaison (HL) brought in pizza for the residents for a scheduled activity event. During this time, Resident #106, who was on a ground diet, was served regular consistency pizza by the HL. Resident #106 was found by staff unable to breathe, cyanotic (a bluish or purplish discoloration of the skin, lips, or nail beds caused by a lack of oxygen in the blood) and required suctioning resulting in the resident being sent to the hospital and admitted with Aspiration Pneumonia. During interviews with the surveyor, the Activity Director (AD) stated she coordinated the event with the HL the day prior and that the protocol was for the activity staff to check the diet list of the residents and for the staff to serve pizza to the residents, however, the HL arrived early and began serving the pizza to the residents. Interviews with the HL and AD revealed that prior to the resident activity, the AD did not educate the HL on the facility's policy for dietary-related activities. Interviews with the Licensed Nursing Home Administrator (LNHA) confirmed that activities and/or nursing staff are to check the resident's diets prior to serving the residents food for resident safety and that the HL should not have served pizza to the residents. The facility's failure to ensure a cognitively impaired resident who was at risk for aspiration received the prescribed mechanically altered diet placed Resident #106 at risk for choking and aspiration. This posed the likelihood of serious harm, impairment, or death which resulted in an Immediate Jeopardy (IJ) situation which ran from 3/25/26 at 1:30 PM, when Resident #106 consumed the pizza, until 4/7/26, when the HL was educated on the role of a vendor and the importance of not providing food directly to residents. This IJ was Past Non-Compliance (PNC). The PNC IJ was identified from 3/25/26 at 1:30 PM, which continued until 4/7/26, when the HL was educated. The facility was back in compliance when the facility addressed the situation by immediately treating the resident for airway obstruction, sending the resident to the hospital for aspiration pneumonia, and educating all staff, including the HL, on the facility's policies for dietary-related activities. The facility's administration was notified of the F689 IJ and was provided with the IJ template on 4/27/26 at 3:35 PM. The facility submitted an acceptable Removal Plan (RP) on 4/28/26 at 10:28 AM, and the survey team verified the implementation of the RP on-site during the continuation of the survey on 4/28/26 at 1:40 PM and determined the IJ was PNC. The evidence is as follows: A review of the facility's Therapeutic Diet Orders policy, dated 9/1/24, included; The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by the physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences, and Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or appropriate nutritive content as prescribed. A review of the facility's Dietary-Related Activities policy, dated 9/1/24, included; Food and beverages provided by the Activities Department shall be within the dietary restrictions of each resident, and Nursing staff shall be available to assist the activities department with providing feeding or emergency assistance during scheduled dietary-related activities. A review of the facility's Use and Storage of Food Brought in by Family or Visitors policy, dated 9/1/24, included; The facility staff will assist residents in accessing and consuming food that is brought in by resident and family or visitors if the resident is not able to do so own their own. The policy did not address checking to ensure food brought in by visitors was appropriate for the residents' diet. A review of the facility's Volunteer/Visiting Vendor Services Policy, implemented 10/10/24 and revised 4/7/26, included; Volunteers/Vendors are not permitted to offer food or drinks to residents unless explicit approval is obtained from a licensed nurse. On 4/23/26 at 10:23 AM, the surveyor observed Resident #106 lying in bed, receiving intravenous fluids to their right upper arm. The surveyor reviewed the medical record for Resident #106. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; vascular dementia, adjustment disorder with depressed mood, transient ischemic attack (temporary blockage of blood flow to the brain), and cerebral infarction (blockage that disrupts blood flow causing brain tissue to die). A review of the quarterly minimum data set (MDS), an assessment tool used to facilitate the management of care dated 2/12/26, included the resident had a Brief Interview for Mental Status score of 7 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was on a mechanically altered diet (requires a change in texture of food or liquids). A review of the Individual Comprehensive Care Plan (ICCP) included a focus area dated 11/9/21, that the resident was on a mechanically altered diet. Interventions included: Provide diet as ordered. A review of the Order Summary Report, as of 3/25/26, included the following physician's order (PO):A PO dated 2/24/25, for Consistent Carbohydrate Diet (CCD) ground texture, thin liquids consistency, no rice. A review of the Speech Language Pathologist (SLP) Discharge summary dated [DATE], revealed the resident had dysphagia (difficulty swallowing) and discharge recommendations included a mechanical soft/ground texture diet. A review of the Facility Reportable Event (FRE) dated 3/28/26, indicated that on 3/25/26 at 1:30 PM, during a resident activity, a Hospice Liaison (HL) brought in pizza for the residents and failed to follow the facility's protocol. The HL provided regular texture pizza to Resident #106 who then had difficulty swallowing and required staff intervention to clear the resident's airway. A review of a Progress Note (PN) dated 3/25/26 at 2:20 PM, and written by the Insurance/Registered Nurse (I/RN), revealed that a nurse requested the I/RN's assistance because Resident #106 was having an active airway obstruction related to food intake. The PN further indicated the resident was pale, had circumoral cyanosis (bluish discoloration around the mouth indicating reduced oxygen), and was not breathing. According to the PN, the resident was suctioned and a large glob of cheese was removed from the resident's airway. Afterwards, the resident's oxygen saturation was 60% (percent) on room air and a non-rebreather oxygen mask was applied, but the resident's oxygen saturation remained in the mid 60%. The resident was then sent to the hospital for evaluation. A review of a PN dated 3/25/26 at 2:45 PM, and written by the Registered Nurse (RN #1), revealed at approximately 1:30 PM, Resident #106 was in the dayroom during a resident activity where pizza was being served. The PN further revealed the resident's lips became cyanotic (bluish discoloration caused by insufficient oxygen levels) and the resident could not speak. The resident was brought to the RN who suctioned the resident's mouth and recovered three large pieces of cheese, but the resident's oxygen saturation was 70% and the resident's breathing was labored. The PN further indicated that Resident #106 was sent to the hospital and admitted with a diagnosis of aspiration pneumonia (a lung infection caused by inhaling foreign material, such as food, into the airway). A review of the hospital's Inpatient Discharge summary dated [DATE], included the resident's primary discharge diagnoses were; choking episode, hypoxia (a life-threatening condition where tissues and organs do not receive enough oxygen), and aspiration pneumonia. On 4/27/26 at 10:09 AM, the surveyor interviewed the Speech Language Pathologist (SLP), who stated Resident #106 had a history of dysphagia and was on a ground texture diet (also called a minced and moist diet), which she described as food that is finely cut up with gravy to make it moist. The SLP further stated that in the past, the resident had been trialed on a chopped diet (soft, moist, and tender foods cut into small, bite-sized pieces), but had trouble chewing and would cough on that diet. The SLP stated regular consistency pizza should not be given to a resident on a ground texture diet, because the consistency of the pizza would have to be altered to a ground texture. The SLP added that residents on a mechanically altered diet should be served the correct consistency food to prevent choking or aspiration. On 4/27/26 at 10:37 AM, the surveyor interviewed the HL via telephone. The HL stated he worked with the Activities Director (AD) to set up the resident activity and notified her that he was bringing pizza for the residents. The HL further stated that he was not informed prior to the activity of any residents with dietary restrictions, so when he arrived 30 minutes early, he began serving pizza to the residents because he assumed that all the residents invited to the activity were allowed to eat the pizza. The HL explained that after Resident #106 started eating the pizza, the HL saw facility staff checking a binder to see who was allowed to have pizza, and once the staff realized that Resident #106 had a dietary restriction, the staff immediately brought the resident to the nurse. The HL stated that after the incident, the facility educated him that he should not offer food to the residents and that facility staff were supposed to serve the residents' food. On 4/27/26 at 10:49 AM, the surveyor conducted a telephone interview with the Activities Aide (AA #1), who stated the HL was supposed to arrive at 2:00 PM that day, but arrived early as the activities staff were transporting the residents to the activity. The AA further stated that the HL started serving pizza to the residents and observed pizza was given to Resident #106, who was on a mechanically altered diet. The AA stated that as soon as she observed that, she informed the HL not to give the pizza to the resident. The AA then confirmed that the HL and the activities staff did not consult with each other prior to the pizza being served. The AA explained that the activities staff were supposed to serve the pizza and provide alternatives to residents with dietary restrictions. The AA stated that this process was important to prevent residents from choking. On 4/27/26 at 11:16 AM, the surveyor interviewed the Activities Director (AD), who stated that the process for dietary-related activities was as follows: the activities department checked with the facility kitchen to ensure there was food that was consistent with each resident's diet, a diet sheet was printed each day to include the residents' allergies, diet textures, and liquid consistencies, a nurse was assigned to be in attendance, and the activities staff, along with nursing staff, assisted in serving the residents' food after verifying the residents' diets to ensure the appropriate food was being served to prevent choking and aspiration. The AD further stated she coordinated the activity with the HL, who notified her of the pizza the day prior and the AD had alternatives available, such as pudding, for residents that were on a ground texture diet. The AD stated she informed the activities staff of the pizza, but did not notify the nursing staff. The AD explained that the HL began serving the pizza as activities staff were transporting residents to the activity and as soon as AA #1 saw Resident #106 was served pizza, she took the resident to the nurse. The AD stated that the activities staff were supposed to check the diet sheet for each resident's diet and serve the residents the appropriate textured food. On 4/27/26 at 11:24 AM, the surveyor attempted to conduct a telephone interview with RN #1 and left a voicemail for the RN to call the surveyor back. On 4/27/26 at 11:51 AM, the surveyor conducted a telephone interview with the Insurance Registered Nurse (I/RN), who stated Resident #106 had consumed pizza that he/she should not have had. The I/RN reiterated what she wrote in her PN on 3/25/26, that the resident was not breathing, was cyanotic, and required suctioning to remove a glob of cheese. The I/RN explained that the resident was then able to cough up more cheese and breathe, but was still cyanotic with an oxygen saturation level of 60% and was sent to the hospital. On 4/27/26 at 11:56 AM, the surveyor attempted to conduct a telephone interview with the Medical Doctor (MD) who declined to speak with the surveyor. On 4/27/26 at 12:17 PM, the surveyor interviewed the Nurse Practitioner (NP) who stated the I/RN notified her of the incident with Resident #106. The NP stated it was important that there were checks and balances in place to ensure residents received the correct diet textures for resident safety, because choking is considered a medical emergency that requires immediate intervention and likely hospitalization for aspiration pneumonia. On 4/27/26 at 12:51 PM, the surveyor interviewed the Director of Nursing (DON), who stated that during dietary-related activities, the activities staff have a binder with all the residents' diets. The DON explained that the activities staff were supposed to check the binder for the residents' diets as they served the residents' food to ensure the correct diet was provided to prevent choking and aspiration. The DON further stated the HL set up the 3/25/26 activity with the AD and notified her that he was going to bring pizza. The DON added that the HL arrived early that day and began serving the residents while the activities staff were still transporting residents to the activity. The DON explained that as soon as AA #1 saw Resident #106 was served pizza, she asked if the resident was okay, but the resident could not speak, so the AA took the resident to the nurse. The DON verified that the food should have been served by the AA, not the HL. On 4/27/26 at 1:08 PM, the surveyor interviewed the LNHA who stated that during dietary-related activities, the activities staff have a binder of the residents diets, and the activities and/or nursing staff checked the resident's diets prior to serving the resident's food for resident safety. The LNHA further stated that on 3/25/26, Resident #106 was served pizza from the HL as activities staff were transporting residents to the activity. The LNHA explained that AA #1 noticed the resident did not seem [him/herself] and took the resident to the nurse to be treated. The LNHA further stated that the HL should not have served pizza to the residents. On 4/27/26 at 1:44 PM, the surveyor conducted a follow-up interview with the AD, who confirmed that when she was notified of the HL's plan to bring pizza to the activity, she did not inform the HL of the facility's policies related to food brought in by visitors or dietary-related activities. The AD further stated she believed there was a policy on vendors bringing food into the facility, but that she did not educate the HL on the policy prior to the activity. On 4/29/26 at 11:53 AM, the surveyor interviewed RN #1, who stated that on 3/25/26, during her afternoon med pass, a swarm of staff approached her with Resident #106 who was not breathing. The RN stated staff told her that the resident had eaten pizza and the RN observed the resident was blue. The RN immediately began suctioning the resident and requested assistance from the I/RN. The RN explained that after she was able to suction out a piece of cheese, the resident began gasping for air and more cheese came out. When asked about Resident #106, the RN stated the resident loves to eat and will eat anything in [his/her] sight, and that Resident #106 was on a mechanically altered diet. The RN explained that it was important that Resident #106 was served their prescribed diet texture to prevent aspiration. The facility submitted an acceptable Removal Plan (RP) on 4/28/26 at 10:28 AM, which indicated the action the facility would take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice which included:The HL was stopped and Resident #106 was immediately assessed, treated, and sent to the hospital on 3/25/26. All residents pending the activity were reviewed to ensure no one received food outside of their prescribed diet on 3/25/26. The pizza party activity was cancelled prior to its start time on 3/25/26. The LNHA spoke with the Hospice Supervisor for notification and education related to the event on 3/27/26.Audits of all altered diets/care plans and food-related activities were completed on 3/27/26. All staff were in-serviced by the DON on therapeutic diet orders, dietary-related activities, foreign body obstruction, incidents and accidents, meal supervision and assistance, and accidents and supervision which was completed on 3/28/26. The HL was re-educated by the DON on diet consistencies, dietary-related activities, the role of a vendor in activities, and the importance of not providing food directly to a resident on 4/7/26. The survey team verified the implementation of the RP on-site during the continuation of the survey on 4/28/26 at 1:40 PM. It was determined that the IJ was PNC as the facility self-corrected the deficient practice on 4/7/26. NJAC 8:39-17.4(a)(2)

Based on interviews, medical record review, and review of other pertinent facility documents on 02/17/2026 and 02/19/2026, it was determined that the facility failed to promptly notify the Physician about a resident's abnormal urine culture result. The facility also failed to follow its policy titled Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notification. This deficient practice was identified for 1 of 6 residents (Resident #6) reviewed for laboratory results.This deficient practice was evidenced by the following: According to the admission Record (AR), Resident #6 was admitted to the facility with diagnoses which included but were not limited to: Acute Kidney Failure (a rapid loss of kidney function), Diabetes (high blood sugar levels), and Urinary Tract Infection (bacteria infection in the bladder, kidneys).A review of Resident #6's most recent Quarterly Minimum Data Set (MDS), an assessment tool dated 11/16/2025, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident's cognition was severely impaired.A review of Resident #6's urine culture report revealed a collection date of 11/12/2025 at 09:08 AM, and a received date of 11/14/2025 at 10:14 AM. The urine culture report further revealed a reported date of 11/14/2025 at 1:49 PM, indicating the facility was notified that Resident #6 had an abnormal urine culture result on 11/14/25. A review of Resident #6's Progress Notes (PNs) revealed that on 11/18/2025 the Nurse Practitioner (NP) came in to see the resident (Resident #6), reviewed the urine culture results and ordered antibiotic therapy.During an interview with the surveyor on 02/19/2026 at 10:52 AM, the Unit Manager/Licensed Practical Nurse (UM/LPN) stated that abnormal urine culture results are usually received from the lab in about two to three days. She further stated that the expectation is for the nurse to notify the provider with the results as soon as possible. The UM/LPN stated, if the provider is not notified of an abnormal lab result until four days later, it would be considered a delay in care and if antibiotic is not started on time, there is a possibility of the infection becoming worse. The UM/LPN acknowledged the facility policy was not followed for R#6.During an interview with the surveyor on 02/19/2026 at 1:05 PM, the Director of Nursing (DON) in the presence of the Regional Nurse (RN), stated that the nurse is responsible for collecting the specimen. The DON further stated that the urine culture result usually came back within three to four days, and that once the results were received, the expectation was for the nurse to communicate the results with the Clinician as soon as possible for further orders. The DON stated that lab results are entered into the Point click Care (PCC) system and that Clinicians have access to review them on the PCC but the expectation is for the nurse to alert the Clinician once the lab results were received. The Regional Nurse (RN) stated, if the Medical Doctor (MD) was not made aware of a lab result and there is no documentation to show the MD was notified, then the facility policy was not followed.During an interview with the surveyor on 02/19/2026 at 1:32PM, the Nurse Practitioner (NP #1) caring for Resident #6 stated, if there is an abnormal lab result and it is after hours, the nurse is expected to call the on-call service for orders. She stated Resident #6 was seen by a different NP (NP #2) on 11/17/2025 and that there was no documentation that NP #2 reviewed the abnormal lab results. NP #1 stated that the lab should have been reviewed by NP #2 on 11/17/2025. NP #1 further stated that when she saw Resident #6 11/18/2025, there was a change in the resident's baseline. She stated that she assessed the resident, reviewed the lab results and noticed the resident had severe UTI based on the lab results; and that she started the resident on antibiotic therapy. The NP #1 further stated that the expectation is for the nurse to call the provider once an abnormal lab result was received and that the provider should had been notified on 11/14/2025 about the abnormal results. When asked if there was a delay in care, the NP #1 stated, yes, that would be considered as a delay in care. Review of the facility policy titled Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notification dated 02/10/2026, under Policy revealed: It is the policy of this facility to timely notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of lab results. Under Policy Explanation and Compliance Guideline, 1. The facility must promptly notify the attending physician, physician assistant, nurse practitioner or clinical nurse specialist of lab results that fall outside of clinical reference ranges in accordance with the facility policies and procedures for notification of a practitioner or per ordering physician orders. Delayed notification may contribute to delays in changing the course of treatment or care plan. NJAC 8:39-13.1 (d)

Based on interviews, medical record review, as well as review of other pertinent facility documents on 08/27/2025 and 08/29/2025, it was determined that the facility failed to administer medications in accordance with the acceptable standard of nursing practice, and to follow the facility policy on Medication Administration.This deficient practice was identified for 1 of 9 sampled residents (Resident #7) reviewed for medication administration and was evidenced by the following:According to the admission Record, Resident #7 was admitted to the facility with diagnoses that included but were not limited to: Depression (mental health condition characterized by a feeling of sadness), Anxiety (a feeling of worry, nervousness or unease) Critical Illness Myopathy (any disease or disorder that affects the muscles, specifically the skeletal muscles that control voluntary movement), and Constipation. A review of Resident #7's quarterly Minimum Data Set (MDS), an assessment tool dated 07/22/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS also indicated that Resident #7 was dependent on staff for Activities of Daily Living (ADL). A review of Resident #7's Order Summary Report (OSR) dated 08/15/2025, revealed Physician's order for the following medications: Valium Oral Tablet 2mg give 1 tablet by mouth two times a day for muscle spasm was ordered on 11/07/2024. Pepcid Oral tablet 20mg give 1 tablet by mouth two times a day for GERD was ordered on 11/22/2024. Senna Oral tablet 8.6mg give 2 tablets by mouth two times daily for constipation 2 tabs=17.2mg was ordered on 01/22/2025. Bupropion HCL ER 300mg give 1 tablet by mouth one time a day for depression was ordered on 03/11/2025. Guanfacine HCL ER oral Tablet 4mg give 1 tablet by mouth one time a day for ADHD was ordered on 05/13/2025. Sertraline HCl oral Tablet 100mg give 1 tablet by mouth one time a day for depression was ordered on 06/06/2025. Tizanidine HCL Tablet 2mg give 1 tablet by mouth two times a day for muscle relaxant hold for sedation was ordered on 07/08/2025. Glycolax powder give 17 grams by mouth one time a day for constipation (in liquid) was ordered on 06/03/2025. A review of Resident #7's Medication Admin Audit Report (MAAR) from 07/27/2025 to 07/28/2025 confirmed the aforementioned medications were scheduled to be administered as follows: Valium Oral Tablet 2mg give 1 tablet by mouth at 9 AM; administered on 07/27/2025 at 11:33 A.M and on 07/28/2025 at 10:16 A.M. Pepcid Oral Tablet 20mg give 1 tablet by mouth at 9:00 A.M.; administered at 11:32 A.M. on 07/27/2025, and at 10:16 A.M. on 07/28/2025. Senna Oral Tablet 8.6mg give 2 tablets by mouth at 9:00 A.M., administered on 07/27/2025 at 11:32 A.M., and on 07/28/2025 at 10:16 A.M. Bupropion HCL ER 300mg give 1 tablet by mouth at 9:00 A.M., administered on 07/27/2025 at 11:32 A.M., and on 07/28/2025 at 10:16 A.M. Guanfacine HCL ER oral Tablet 4mg give 1 tablet by mouth at 9:00 A.M., administered on 07/27/2025 at 11:32 A.M., and on 07/28/2025 at 10:16 A.M. Sertraline HCl oral Tablet 100mg give 1 tablet by mouth at 9:00 A.M., administered on 07/27/2025 at 11:32 A.M., and on 07/28/2025 at 10:16 A.M. Tizanidine HCL Tablet 2mg give 1 tablet by mouth was scheduled to be administered at 9:00 A.M.; administered on 07/27/2025 at 11:32 A.M., and on 07/28/2025 at 10:16 A.M. Glycolax powder give 17 grams by mouth at 9:00 A.M., administered on 07/27/2025 at 11:39 A.M., and on 07/28/2025 at 10:16 A.M. A review of Resident #7's Progress Notes (PNs) from 07/27/25 to 07/28/25, showed no indication in the PNs that the Resident's Primary Care Physician (PCP) was notified that the aforementioned medications were not administered according to the scheduled time. There was also no documentation regarding why the medications were administered late. The surveyor did not find documented evidence of harm to the Resident #7 from the late administration of their medications. During an interview with the Licensed Practical Nurse/Unit Manager (LPN/UM) on 08/29/25 at 11:42 AM, she stated medications can be administered up to 1 hour before and 1 hour after the time the medication is due. The LPN/UM further stated, it's important to give medications on time to avoid interactions or adverse reaction. Some medications are scheduled with food, some multiple times during the day, so you do not want to cause an overdose. That is why it's important to follow the five rights of medication administration. She also stated that if a medication is not administered on time, the nurse should call the PCP to notify them and receive an order to give the medication after the administration time. LPN/UM stated, the nurse should also document why the medication was not administered on time, and that a PCP approved to give the medication after the allowed time. The LPN/UM stated, the expectation is for all nurses to follow the facility's policy for medication administration, looking at the MAAR for Resident #7, the policy was not followed. During an interview with the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) on 08/29/2025 at 12:06 PM, the DON stated medications should be given an hour before or an hour after, except specified by the provider and that the rights of medication administration should be followed including; right medication, the right dose, the right route, the right patient, and the right time. The DON stated that the nurse should call the provider to inform the provider that the medications she was about to administer were outside the scheduled administration time window, and obtain instructions to make sure it was okay to give the medications outside the scheduled timeframe. DON further stated that nurses should document in the resident's PNs if a medication is not administered on time, and document that provider was notified and that they obtained order for the medications to be administered later than ordered time. The DON further stated the expectation is that the medication should be administered an hour before and an hour later. If a resident is out of the facility, there should be a progress note to say the patient is out of the facility and ok to administer medication later as per the provider. The DON stated, the policy was not followed if none of the above was done for medication administration. A review of the facility's policy titled Medication Administrations, dated 091/2024, revealed .12 .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . NJAC 8:39-29.2 (d)

Complaint # NJ 00185028 and NJ00185373 Based on interviews and record review, as well as a review of pertinent facility documents on 5/2/2025, it was determined that the facility failed to administer the medications in accordance with the acceptable standard of nursing practice and follow the facility policy on Administering Medications for 4 of 7 sampled residents (Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for medication administrations. This deficient practice was evidenced by the following: According to the admission RECORD (AR), Resident #2 was admitted to the facility with diagnoses that included but were not limited to: Multiple Sclerosis (a chronic autoimmune disease that affects the central nervous system (brain and spinal cord)), Neuromuscular Dysfunction of the Bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should), and Calculus of the Kidney (solid masses or crystals that form from substances (like minerals, acids and salts) in the kidneys). A review of Resident #2's Minimum Data Set (MDS), an assessment tool, dated 04/10/25, revealed that the Resident had a Brief Interview for Mental Status (BIMS) score of 06 which indicated severe cognitive impairment and was dependent on staff for Activities of daily living (ADLs). A Review of Resident #2's Order Summary Report (OSR) dated 03/01/2025-03/31/2025, revealed an order for Fosfomycin Tromethamine Oral Packet 3 gram (gm), give 1 packet by mouth one time only for UTI (Urinary Tract Infection), ordered on 3/27/2025 with a start date of 3/28/2025 and end date of 3/29/2025. A review of Resident #2's Medication Administration Record (MAR) confirmed the aforementioned order was to be given one time. The MAR did not indicate the medication was administered. A review of Resident #2's progress notes (PN) from 3/1/25 to 3/31/25, revealed there was no indication that the Resident's Primary Care Physician (PCP) was notified that the aforementioned medication was not administered or if the medication was refused. In addition, there was no documented evidence of harm to the Resident. According to the AR, Resident #3 was admitted to the facility with diagnoses that included but were not limited to: Myopathy (any disease or disorder that affects the muscles, specifically the skeletal muscles that control voluntary movement), Injury of the Cervical Spine, Chronic Pain Syndrome, and Constipation. A review of Resident #3's MDS, dated [DATE], revealed that the resident had a BIMS score of 15 which indicated that the resident was cognitively intact and was dependent on staff for ADLs. A review of Resident #3's OSR, dated 5/2/2025 revealed an order for the following medications: Colace capsule 100mg, give 1 capsule by mouth twice a day for Constipation, was ordered on 11/22/2024. Doxycycline Hyclate Oral Tablet 100mg, give 1 tablet by mouth two times a day for Penile Discharge for 7 days, was ordered on 04/09/2025. Ibuprofen 400mg, give 1 tablet by mouth three times a day for Inflammation and Tendinopathy for 7 days, was ordered on 04/23/2025. Senna oral tablet 8.6 mg, give 2 tablets by mouth two times a day for Constipation, ordered on 11/22/2024. Valium Oral tablet 2mg, give 1 tablet by mouth two times a day for Muscle Spasm, ordered on 11/07/2024. A review of Resident #3's MAR and Medication Admin Audit Report (MAAR) from 4/1/2025 to 4/30/2025 confirmed the aforementioned medications were scheduled and administered as follows: Colace capsule 100 mg was scheduled as follows At 9 AM, however, it was administered on 4/1/25 at 11:41 AM, 4/2/25 at 11:52 AM, 4/3/25 at 12:19 PM, 4/4/25 at 10:01 AM, 4/5/25 at 11:56 AM, 4/6/25 at 11:40 AM, 4/7/25 at 11:51 AM, 4/8/25 at 11:55 AM, 4/9/25 at 12:09 PM, 4/10/25 at 11:10 AM, 4/11/25 at 10:33 AM, 4/12/25 at 12:56 PM, 4/13/25 at 10:23 AM 4/15/25 at 10:10 AM, 4/19/25 at 11:28 AM, 4/21/25 at 11:54 AM, 4/22/25 at 12:02 PM, 4/23/25 at 11:29 AM, 4/24/25 at 11:19 AM, 4/25/25 at 10:12 AM, 4/26/25 at 12:07 PM, 4/27/25 at 12:45 PM, 4/29/25 at 11:16 AM, and 4/30/25 at 11:58 AM At 5 PM, however, it was administered on 4/3/25 at 6:56 PM, 4/7/25 at 6:53 PM, 4/8/25 at 6:10 PM, 4/11/25 at 9:34 PM, 4/18/25 at 7:46 PM, 4/20/25 at 6:11 PM, 4/24/25 at 6:59 PM, 4/25/25 at 6:02 PM, 4/30/25 at 11:58 AM and 6:51 PM. Doxycycline Hyclate was scheduled as follows. At 9 AM, however, it was administered on 4/9/25 at 12:06 PM, 4/10/25 at 11:10 AM, 4/11/25 at 10:33 AM, 4/12/25 at 12:56 PM, 4/13/25 at 10:24 AM, and 4/15/25 at 10:11 AM. At 9 PM, however, it was administered on 4/13/25 at 10:50 PM. Ibuprofen tablet 400mg was scheduled as follows. At 9 AM, however, it was administered on 4/23/25 at 11:30 AM and 4/24/25 at 11:19 AM, 4/26/25 at 12:07 PM,4/27/25 at 12:44 PM, 4/29/25 at 11:16 PM, At 9 PM, however, it was administered on 4/26/25 at 10:52 PM, and 4/27/2025 at 10:54 PM. Valium Oral tablet 2mg was scheduled as follows. AT 9 AM, however, it was administered on 4/1/25 at 11:41 AM, 4/2/25 at 11:52 AM, 4/3/25 at 12:19 PM, 4/5/25 at 11:56 AM, 4/6/25 at 11:49 AM, 4/7/25 at 11:51 AM, 4/8/25 at 11:55 AM, 4/9/25 at 12:09 PM, 4/10/25 at 11:10 AM, 4/11/25 at 11:12 AM, 4/12/25 at 12:56 PM, 4/19/25 at 11:29 AM, 4/21/25 at 11:54 AM, 4/22/25 at 12:02 PM, 4/23/25 at 11:29 AM, 4/24/25 at 12:40 PM, 4/26/25 at 12:07 PM, 4/27/25 at 12:46 PM, 4/29/25 at 11:18 AM, and 4/30/25 at 11:59 AM. At 9 PM, however, it was administered on 4/4/25 at 10:40 PM, 4/13/25 at 11:11 PM, 4/26/25 at 10:52 PM, and 4/27/25 at 10:54 PM. A review of Resident #3's PN from 4/1/25 to 4/30/25, there was no indication in the PN that the Resident's PCP was notified that the aforementioned medications were not administered according to the scheduled time, nor was there documentation on why the medications were administered late. In addition, there was no documented evidence of harm to the Resident from the late administration of medications. According to the AR, Resident #4 was admitted to the facility with diagnoses that included but were not limited to: Hypertension (high blood pressure), Polyneuropathy (a condition when multiple peripheral nerves (the nerves that send messages from the brain and spinal cord to the rest of the body) become damaged), Heart Failure, Left and Right Knee Pain A review of Resident #4's MDS dated [DATE], revealed that the resident had a BIMS score of 15 which indicated that the resident was cognitively intact and was set up and clean-up assist with ADLs. A review of Resident #4's OSR, dated 5/2/2025 revealed an order for the following medications: Guaifenesin Extensive Release tablet 600 mg, give 1 tablet by mouth every 12 hours for Cough, ordered 10/18/2024. Metoprolol Tartrate Tablet 25 mg, give 1 tablet by mouth two times a day for Hypertension, ordered 03/12/2025 Tylenol with Codeine #3 Oral Tablet 300-30 mg, give 1 tablet by mouth every 12 hours for Chronic Pain, ordered 03/27/2025. A review of Resident #4's MAR and MAAR from 4/1/2025 to 4/30/2025 confirmed the aforementioned medications were scheduled and administered as follows: Guaifenesin ER Tablet 600 mg was scheduled as follows AT 8 AM, however, it was administered on 4/2/25 at 10:56 AM, 4/3/25 at 11:13, AM, 4/4/25 at 11:14 AM, 4/5/25 at 10:51 AM, 4/6/25 at 9:39 AM, 4/7/25 at 11:02 AM, 4/8/25 at 11:08 AM, 4/9/25 at 11:22 AM, 4/10/25 at 10:53 AM, 4/11/25 at 9:46 AM, 4/12/25 at 11:15 AM, 4/14/25 at 9:44 AM, 4/15/25 at 9:38 AM, 4/17/25 at 10:08 AM, 4/18/25 at 11:34 AM, 4/19/25 at 12:43 PM, 4/21/25 at 11:25 AM, 4/22/25 at 10:15 AM, 4/23/25 at 11:00 AM, 4/24/25 at 10:17 AM, 4/25/25 at 9:52 AM, 4/26/25 at 11:09 AM, 4/27/25 at 11:09 AM, 4/29/25 at 10:34 AM, 4/30/25 at 11:24 AM AT 8 PM, however, the medication was administered on 4/20/25 at 9:36 PM and 4/23/25 at 9:57 PM Metoprolol Tartrate Tablet 25 mg was scheduled as follows: At 9 AM, however, the medication was administered on 4/2/25 at 10:56 AM, 4/3/25 at 11:13 AM, 4/4/25 at 11:14 AM, 4/5/25 at 10:51 AM, 4/7/25 at 11:02 AM, 4/8/25 at 11:08 AM, 4/9/25 at 11:22 AM, 4/10/25 at 10:50 AM, 4/12/25 at 11:15 AM, 4/18/25 at 11:36 AM, 4/19/25 at 12:43 PM, 4/21/25 at 11:25 AM, 4/23/25 at 11:00 AM, 4/26/25 at 11:09 AM, 4/27/25 at 11:09 AM, 4/29/25 at 10:34 AM, 4/30/25 at 11:24 AM. At 5 PM, however, the medication was administered on 4/7/25 at 6:53 PM, 4/17/25 at 6:37 PM, 4/19/25 at 7:28 PM, 4/23/25 at 9:57 PM, and 4/29/25 at 6:37 PM. Tylenol with Codeine #3 Oral Tablet 300-30 mg was scheduled as follows At 9 AM, however, the medication was administered on 4/2/25 at 10:56 AM, 4/3/25 at 11:13 AM, 4/4/25 at 11:14 AM, 4/5/25 at 10:51 AM, 4/7/25 at 11:01 AM, 4/8/25 at 11:08 AM, 4/9/25 at 11:22 AM, 4/10/25 at 10:53 AM, 4/12/25 at 11:15 AM, 4/18/25 at 11:36 AM, 4/19/25 at 12:43 PM, 4/21/25 at 11:26 AM, 4/23/25 at 11:00 AM, 4/26/25 at 11:09 AM, 4/27/25 at 11:09 AM, and 4/30/25 at 11:24 AM. In a review of Resident #4's PN from 4/1/25 to 4/30/25, there was no indication in the PN that the Resident's PCP was notified that the aforementioned medications were not administered according to the scheduled time, nor was there documentation on why the medications were administered late. In addition, there was no documented evidence of harm to the Resident from the late administration of medications. According to the AR, Resident #5 was admitted to the facility with diagnoses that included but were not limited to: Dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), Chronic Pain, Osteoarthritis (a common joint disease that causes pain, stiffness, and loss of mobility), and Sacral Pressure Ulcer. A review of Resident #5's MDS dated [DATE], revealed that the resident had a BIMS score of 12 which indicated that the resident had mild cognitive impairment, and was dependent on staff for ADLs. A review of Resident #5's care plan (CP), dated 9/28/22, indicated that the Resident was on pain medication therapy related to Arthritis. The CP included interventions included but not limited to Administer Analgesic medications as ordered by Physician. A review of Resident #5's OSR from 04/01/2025 to 04/30/2025 revealed an order for the following medications: Ibuprofen Tablet 200 mg, give 1 tablet by mouth three times a day for inflammation of both hands. Please give with food, ordered 12/14/2023. Restasis Ophthalmic Emulsion, instill 1 drop in both eyes two times a day for Dry Eyes, ordered 10/17/2023. Timolol Maleate Ophthalmic Solution 0.5 %, instill 1 drop in both eyes two times a day for Glaucoma, ordered 10/17/2023. A review of Resident #5's MAR and MAAR from 4/1/2025 to 4/30/2025 confirmed the aforementioned medications were scheduled and to be administered as follows: Ibuprofen Tablet 200 mg was scheduled as follows. At 8 AM, however, the medication was administered on 4/4/25 at 9:46, 4/5/25 at 9:46 AM, 4/7/25 at 9:58 AM, 4/12/25 at 10:08 AM, 4/13/25 at 9:52 AM, and 4/30/25 at 10:10 AM. At 12 PM, however, the medication was administered on 4/2/25 at 1:39 PM, 4/5/25 at 2:34 PM, 4/6/25 at 2:57 PM, 4/7/25 at 1:44 PM, 4/9/25 at 1:41 PM, 4/11/25 at 2:04 PM, 4/22/25 at 2:46 PM, 4/24/25 at 2:46 PM, 4/26/25 at 1:50 PM, 4/29/25 at 1:56 PM, and 4/30/25 at 2:13 PM. At 4 PM, however, the medication was administered on 4/1/25 at 5:43 PM, 4/2/25 at 5:38 PM, 4/3/25 at 6:07 PM, 4/12/25 at 6:34 PM, 4/19/25 at 7:43 PM, 4/23/25 at 5:49 PM, 4/24/25 at 6:48 PM, and 4/25/25 at 5:43 PM. Restasis Ophthalmic Emulsion was scheduled as follows At 8 AM, however, the medication was administered on 4/3/25 at 9:39 AM, 4/4/25 at 9:46 AM, 4/5/25 at 9:47 AM, 4/6/25 at 9:32 AM, 4/7/25 at 9:58 AM, 4/12/25 at 10:09 AM, 4/13/25 at 9:52 AM, 4/17/25 at 11:44 AM, 4/18/25 at 11:12 AM, 4/19/25 at 10:12 AM, 4/20/25 at 11:02 AM, 4/21/25 at 9:38 AM, 4/24/25 at 9:38 AM, 4/26/25 at 9:34 AM, 4/29/25 at 9:39 AM, and 4/30/25 at 10:10 AM. At 8 PM, however, the medication was administered on 4/20/25 at 9:39 PM. Timolol Maleate Ophthalmic was scheduled as follows: At 8:10 AM, however, the medication was administered on 4/4/25 at 9:46 AM, 4/5/25 at 9:47, 4/7/25 at 9:58 AM, 4/12/25 at 10:09 AM, 4/13/25 at 9:52 AM, 4/17/25 at 11:44 AM, 4/18/25 at 11:08 AM, 4/19/25 at 10:12 AM, 4/20/25 at 11:02 AM, and 4/30/25 at 10:10 AM. At 8:10 PM, however, the medication was administered on 4/13/25 at 9:52 AM and 4/20/25 at 9:39 PM. A review of Resident #5's PN from 4/1/25 to 4/30/25, there was no indication in the PN that the Resident's PCP was notified that the aforementioned medications were not administered according to the scheduled time, nor was there documentation on why the medications were administered late. In addition, there was no documented evidence of harm to the Resident from the late administration of medications. During an interview with LPN #1 on 5/2/25 at 10:17 AM, she stated medications can be administered up to 1 hour before and 1 hour after the time the medication is due. The LPN further stated that the nurses were to give crackles or snacks if the medication was to be administered with food. She stated that the nurses were to wait at least 5 minutes when a resident had 2 eye drops and document in the MAR after the eye drops administration. The LPN explained that when the medication was administered, the nurses had to document in the MAR to indicate that the medication was given. She further explained that if a resident refused the medication, the nurses were expected to document it in the resident's MR. LPN #1 also stated that if the medications were late, the nurses were to call the PCP and document in the MR. During an interview with the DON, in the presence of the Administrator and Regional Director of Operations on 5/2/25 at 2:53 PM, the DON stated the rights of medication administration are the right medication, the right dose, the right route, the right patient, and the right time. She further stated that a medication can be administered 1 hour before and 1 hour after a medication is due. The DON explained the Fosfomycin for Resident #2 was brought to theh facility by the family, and the family was informed that the PCP from the facility needed to write an order prior to the medication being given. The DON was unable to explain if the Fosfomycin was given to Resident #2. The DON further explained that blanks on the MAR could possibly mean the medication was not given. A review of the facility's policy titled Medication Administrations, dated 091/2024, revealed .12 .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . NJAC 8:39-29.2 (d)

Based on observations, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 1/2/25 from 10:00 AM until 10:51 AM, the surveyor observed the following in the presence of the Food Service Director (FSD): 1. There was no trash can at the handwashing sink at the entrance to the galley of the kitchen. The nearest trash can was covered with a lid and failed to contain a foot pedal. The FSD stated that the lid was normally removed during food service. 2. The oven in the galley of the kitchen was heavily soiled. The FSD stated that it was cleaned two weeks ago. 3. The lower double convection oven in the galley of the kitchen was soiled with a thick, black substance. The FSD stated that it was recently cleaned. The FSD failed to provide the surveyor with documented evidence to account for when the ovens were cleaned at that time. 4. Dietary Aide (DA) #1 who operated the dish machine wore a beard guard beneath his chin which left both his mustache and beard exposed. The FSD stated that the beard guard should have fully covered his beard. The FSD then instructed DA #1 to donn (put on) an alternative facial covering that covered both his beard and mustache. On 1/6/25 from 11:53 AM until 12:39 PM, the surveyor observed the following in the Nursing Unit Pantries: 1. In the 100 Unit Pantry in the presence of Licensed Practical Nurse (LPN) #4, the surveyor observed that there was no temperature log on the refrigerator and freezer. LPN #4 stated that we are supposed to have a temperature log and staff were required to check the temperatures and sign the log on every shift. 2. A forty-six (46) ounce carton of thickened water was opened and was not dated. LPN #4 stated that it was supposed to be dated when opened. 3. There was no thermometer in the freezer. A container of ice cream that was stored in the freezer was hard to the touch. LPN #4 stated that a thermometer was required to be in the freezer to ensure that food items were maintained at the proper temperature. 4. In the 200 Unit Pantry in the presence of Certified Nursing Assistant (CNA) #1, the refrigerator temperature was 30 degrees Fahrenheit (F). The temperature log indicated that the refrigerator minimum/maximum range was 34 F to 40 F. Further review of the temperature log revealed that the last recorded refrigerator temperature on 1/6/25 was 42 F. CNA #1 stated that she would notify maintenance. 5. A forty-six (46) ounce carton of orange juice was opened and was not dated. CNA #1 stated that she would throw it out because it could only be in the refrigerator for 48 to 72 hours. 6. In the freezer, there was a clear plastic cup with a convenience store logo that contained ice and was not labeled or dated. CNA #1 stated that the cup belonged to an unsampled resident and was usually stored in the resident's room. CNA #4 stated that it was an infection control issue if the cup was brought to the freezer from the resident's room. During a follow-up visit to the kitchen on 1/7/25 from 11:17 AM until 12:02 PM, the surveyor observed the following in the presence of the FSD: 1. The District Food Service Manager (DFSM) washed his hands for eleven seconds outside of the stream of running water and then proceeded to rub his hands together under the stream of running water before he dried his hands and donned gloves. The DFSM then proceeded to obtain food temperatures from the steam table. 2. The DFSM then doffed (removed) his gloves and failed to perform hand hygiene before he opened the chef's refrigerator and removed a bag of cheese and placed it on a cutting board. The DFSM then proceeded to assemble and prepare grilled cheese sandwiches. On 1/7/25 at 12:45 PM, in a later interview with the DFSM, he stated that he stated that the whole process of handwashing was twenty seconds and included the time that it took to rinse the hands in water. The DFSM further stated that there was no policy that directed a specific amount of time to lather the hands outside of the stream of running water. The DFSM stated that hand washing was required after gloves were doffed (removed) only if touching ready to eat food. On 1/8/25 at 10:39 AM, during an interview with the Regional Director of Operations (RDO) #2, in the presence of the FSD and the survey team, RDO #2 stated that it was a top priority to maintain a temperature log for the refrigerator and freezer because we want to know what the temperatures were to ensure that the refrigerator and freezer were working properly. RDO #2 stated that a thermometer was required in both the refrigerator and freezer to ensure that the temperature was maintained below 41 F in the refrigerator and close to zero for the freezer. RDO #2 stated that staff should notify maintenance to adjust it. RDO #2 further stated that once opened, thickened liquids should be refrigerated and used within seven days so that nursing would know when to discard it. On 1/8/25 at 11:25 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that the process for hand washing was to turn on the water, wet the hands, apply soap, lather the hands scrubbing vigorously under the nails and the tops of the hands for twenty seconds or more, rinse the hands under water with the hands pointed downward, then dry the hands with a paper towel and discard it and use additional paper towels to turn off the faucet and discard them. The IP stated that you were supposed to scrub with soap for twenty seconds out of the stream of running water to loosen up the dirt and germs and then rinse the hands under the stream of water. The IP further stated that her expectation was for everyone to sanitize their hands before donning and doffing gloves. On 1/8/24 at 12:13 PM, the surveyor interviewed the Director of Nursing (DON) who stated that all facial hair should be covered, and beard guards should not be worn beneath the chin in order to keep hair from getting into the dishes. On 1/8/25 at 2:21 PM, the Licensed Nursing Home Administrator (LNHA) stated that hands should be washed for twenty seconds with friction prior to rinsing them. A review of a facility Staff Attire policy dated September 2017, revealed the following: All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. A review of a facility Food Preparation policy dated September 2017, revealed the following: All staff will practice proper hand washing techniques and glove use. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. A review of a facility, Food Storage: Cold Foods policy dated April 2018, revealed the following: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated will be appropriately stored in accordance with the FDA (Food and Drug Administration) Food Code. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A review of a facility, Hand Hygiene policy dated 9/1/24, revealed the following: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene technique when using soap and water: Wet hands with water . Apply to hands the amount of soap recommended by the manufacturer. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Rinse hands with water. Dry thoroughly with a single-use towel. Use a clean towel to turn off the faucet. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. NJAC 8:39-17.2 (g); 19.4

Based on observation and interview, it was determined that the facility failed to ensure that the residents' dining experience was provided in a manner to promote dignity and respect of the residents. This deficient practice was identified in 1 of 5 units observed (the 100 unit) and was evidenced by the following: 1.) On 1/9/25 at 10:00 AM, during the surveyor-conducted resident council meeting, 4 of 4 residents (Resident #6, #60, #71 and #98) who attended the meeting stated that roommates did not get served their meal trays at the same time. 2.) On 1/7/25 at 9:27 AM, the surveyor observed the breakfast meal on the high end of the 100 unit and Resident #71 was delivered his/her breakfast tray. Resident #71 stated we don't get our meal trays delivered at the same time. At that time, the surveyor observed Resident #117 (Resident #71's roommate) standing at his/her doorway of their room and stated, I'm waiting for my breakfast tray. At 9:38 AM, the surveyor observed several residents on the unit had not received their breakfast trays. The Certified Nursing Assistant (CNA #4) confirmed with the surveyor that the following residents had not received their breakfast trays and that she had called the kitchen for the following seven (7) breakfast trays: Resident #20, #56, #80, #88, #112, #113, and #117. At 9:57 AM, the surveyor observed a food truck delivered to the 100 unit with the missing breakfast trays. The nursing staff delivered the breakfast trays to the residents. At that time, the surveyor observed that Resident #20's tray contained only oatmeal and not toast, which was listed on the meal ticket. At 10:02 AM, CNA #4 called the kitchen to obtain a new tray for Resident #20 that included the toast. At that time, CNA #4 stated that Resident #11 had not recieved a breakfast tray yet and then called the kitchen to obtain Resident #111's breakfast tray. The CNA did not give Resident #20 his/her tray with the missing item. At 10:14 AM, the surveyor observed the Food Service Director (FSD) deliver a breakfast tray to Resident #111. At 10:15 AM, the surveyor showed the FSD Residents #20's breakfast tray, that was still in the food truck, was missing the toast. The FSD stated she will get the resident a new breakfast tray. The FSD stated she was trying to find out what happened that all the breakfast trays were not delivered at the same time. At 10:25 AM, the surveyor observed Resident #20's breakfast tray delivered to the unit. On 1/8/25 at 1:19 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), in the presence of the Regional Director of Nursing (RDON), the Regional Director of Operations, the Regional Nurse Quality Assurance Nurse Specialist, and the survey team, who stated that her expectation would be that meal trays would not be missing from the food trucks. The LNHA further stated that unit 100 was the last unit to be served breakfast, usually around 9:15 AM, and that residents in the same room should be served their trays at the same time. The LNHA further stated that it was important that residents are served meals at the same time because it was their resident's right. A review of the facility's Promoting/Maintaining Resident Dignity policy, dated 9/1/24, included that all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident's rights. A review of the facility's Meal Distribution policy, revised September 2017, included that the nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents. NJAC 8:39-4.1(a)12

Complaint #: NJ180809 Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident environment, equipment and living areas in a safe, sanitary, and homelike manner for 3 of 35 residents (Resident #106, #107, and #126) and air temperature log for 5 of 5 units observed during environmental rounds. This deficient practice was evidenced by the following: 1.) On 1/3/2025 at 12:13 PM, the surveyor toured the 500 Unit, which was noted to be chilly in the hallway near room [ROOM NUMBER]. The hatch door leading to the attic was observed to be partially open. The Director of Maintenance (DM) took the air temperature, which registered at 65 degrees. A review of the Air Temperature audit logs from 12/1 2024 to 1/8/25 revealed the following: On 12/3/2024: The 100 Unit shower room was documented as 70 degrees. The 300 Unit shower room was documented as 70 degrees. The 400 Unit shower room was documented as 69 degrees. On 12/18/2024: The 100 Unit, resident's room [ROOM NUMBER] was documented as 69 degrees. The 200 Unit resident's room [ROOM NUMBER] was documented as 69 degrees. On 12/31/2024: The 200 Unit shower room was documented as 70 degrees. The 500 Unit shower room was documented as 69 degrees. On 1/7/2025: The 100 Unit shower room was documented as 69 degrees. The 200 Unit shower room was documented as 67 degrees. The 300 Unit shower room was documented as 68 degrees. On 1/8/2025 at 11:47 AM, the Account Manager of Environmental Services ([NAME]) stated in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, that the temperature should be comfortable and should not go below 65 degrees. He further stated the residents usually like it warmer. At that time, the LNHA stated she was unaware that the air temperature should be maintained between 71 to 81 degrees. 41260 2.) On 1/2/25 at 10:07 AM, the surveyor observed Resident #126 sitting on the edge of the bed. The resident stated their main concern with the facility was the cleanliness of the bathroom. The resident stated their roommate would often leave feces on the toilet and floor, and that the housekeeping staff did not come to clean the bathroom until hours later. The resident then asked the surveyor to look at their bathroom because there had been feces on the toilet since approximately 2:00 AM that morning. When the surveyor opened the resident's bathroom door, there was a strong, foul odor noted and feces on the toilet seat. The surveyor reviewed the medical record for Resident #126. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 10/7/24, included the resident had a Brief Interview for Mental Status (BIMS)score of 15 out of 15, which indicated the resident's cognition was intact. 41072 3.) On 1/2/25 10:25 AM, during the initial tour of the 200 Unit, the surveyor observed Resident # 106's bathroom and the toilet had a black substance dripping down the outside of the white toilet bowl. The white toilet seat was in a up position with yellow stains that were visible to the resident. The surveyor observed yellow liquid and black substance on the floor at the base of the toilet. At that time, the surveyor interviewed Resident #106 who stated that they uses the bathroom and was not sure when it was last cleaned. On 1/3/25 at 8:16 AM, the surveyor observed Resident #106's bathroom and observed the white toilet seat was in the up position with yellow stains, and yellow stains were also on the floor at the base of the toilet. A review of Resident #106's Admission record, an admission summary, revealed the resident had diagnoses which included, dementia, retention of urine, and constipation. A review of the resident's quarterly MDS, dated [DATE], included the resident had a BIMS score of 11 out of 15, which indicated that the resident's cognition was moderately impaired. Further review of the MDS revealed the resident was continent of both bowel and bladder. On 1/3/25 at 12:40 PM, the surveyor interviewed the [NAME] who stated the housekeepers cleaned the residents' rooms three times during their 7:00 AM to 3:00 PM shift. The [NAME] further explained that the housekeepers were expected to make morning rounds at 7:00 AM to empty resident room trash cans and inspect the room for any immediate need for cleaning. The [NAME] stated after the housekeepers' first break, they cleaned resident rooms until the end of their shift when they made their final rounds in each resident room. The [NAME] also stated there was a porter from 2:00 PM to 10:00 PM, but no housekeeping staff from 10:00 PM to 7:00 AM. At that time, the surveyor informed the [NAME] of Resident #126's dirty toilet that had been soiled at 2:00 AM and not yet cleaned by 10:00 AM during the surveyor's observation. The [NAME] stated the housekeeper should have seen the dirty toilet during their 7:00 AM rounds and cleaned the toilet for infection control reasons. The [NAME] further stated that Resident #106s bathroom should have been addressed on the 7:00 AM rounds. 37547 4.) On 1/3/25 at 11:47 AM, during a tour of the 200 Unit, the surveyor interviewed Resident #107 who stated that they had spoken the Licensed Nursing Home Administrator (LNHA) and the Director of Maintenance (DM) about their toilet seat being discolored with yellow on top of the seat and the inner side of the toilet seat. The resident stated that the LNHA indicated that at the very least they would replace the toilet seat. Resident #107 further stated that the bathroom was cleaned on Wednesday 1/1/25. A review of Resident #107's Admission Record revealed that the resident had diagnosis which included, Achalasia of cardia (a swallowing disorder), dementia, unspecified severity, with other behavioral disturbance, and dysphagia (difficulty swallowing). A review of Resident #107's quarterly MDS, dated [DATE], included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was fully intact. On 1/3/25 at 12:06 PM, the surveyor interviewed Housekeeper (HK) #1 who stated that resident rooms were cleaned daily. HK #1 stated that she did not know when Resident #107's room was cleaned last because she worked on a different unit. At that time, HK #1 accompanied the surveyor into Resident #107's bathroom. The surveyor showed HK #1 two areas of yellow staining and HK #1 stated these could come off. HK #1 then proceeded to spray the toilet seat and the surrounding area of the toilet with disinfectant cleaner and wiped it with a rag and both the yellow and black debris was removed. HK #1 stated, that was not discoloration. Resident #107 was present at that time and stated that we thought the yellow substance was staining, but it was urine. Resident #107 stated that the toilet was so much cleaner now. On 1/3/25 at 12:32 PM, the surveyor interviewed the [NAME] who stated that he had spoken with Resident #107 and the toilet seat should have been replaced after 12/5/24, and he referred the task to a Maintenance Aide verbally but had not documented it. The [NAME] stated that it was an infection control situation, and it should have been done. On 1/3/25 at 1:04 PM, the surveyor interviewed the DM who stated that he spoke with Resident #107 in the hall a couple of weeks ago and told the resident that he would get him/her a new toilet seat but then the resident requested a new toilet instead. The DM stated that he could have replaced the toilet seat right away. On 1/3/25 at 1:12 PM, the surveyor observed the DM outside of Resident #107's room with a new toilet seat after surveyor inquiry. On 1/8/25 at 1:22 PM, the surveyor interviewed the LNHA who stated that any staff member who sees a dirty toilet could notify housekeeping to clean the bathroom. The LNHA further stated it was important to ensure a resident's toilet was cleaned promptly for infection control reasons and because it was the resident's environment. A review of the facility's Routine Cleaning and Disinfection policy, dated 9/1/24, included that the facility is to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Routine cleaning and disinfection of frequently touched or visible soiled surfaces will be performed in common area, residents' rooms and at time of discharge. NJAC 8:39-31.4(a)

Complaint NJ #'s:168726, 168827, and 175632 Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure medications were administered within the physician's order scheduled time in accordance with professional standards of practice for 2 of 35 residents (Resident #86 and #160) reviewed for professional standards of practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) On 1/2/25 at 10:27 AM, during the initial tour, the surveyor observed Resident #86 lying in bed sleeping. On 1/3/25 at 10:22 AM, the surveyor reviewed the medical record for Resident #86. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, Diabetes Mellitus (DM- high blood glucose), high blood pressure, pain in the right hip, and Alzheimer's disease. A review of the Medication Administration (Admin) Audit Report from 6/1/24 to 8/31/24 revealed the following: Metoprolol extended release (ER) 25 milligrams (mg), give one (1) tablet (tab) by mouth: scheduled for 8:00 AM. Ferrous Sulfate (iron) 325mg, give 1 tab by mouth: scheduled for 9:00 AM. Fluticasone (nasal spray) 50 micrograms (mcg) 1 spray in each nostril: scheduled for 9:00 AM. Aspirin 81 mg, give 1 tab by mouth: scheduled for 9:00 AM. Buspirone (for anxiety) 7.5mg, give 1 tab by mouth: scheduled for 9:00 AM. Lactobacillius (probiotic) 1 capsule by mouth: scheduled for 9:00 AM. Breo Ellipta (inhaler) 200/25 mcg, 1 puff: scheduled for 9:00 AM. Cholecalciferol (for calcium) 1000 unit, give 1 tab by mouth: scheduled for 9:00 AM. Hydralazine (for blood pressure) 50 mg, give 1 tab by mouth: scheduled for 9:00 AM. Amlodipine 10 mg, give 1 tab by mouth: scheduled for 9:00 AM, Oxycodone 5 mg, give 1 tab by mouth: scheduled for 8:00 AM was changed to Oxycontin 10 mg, give 1 tab by mouth: scheduled for 8:00 AM. In June 2024, medications were documented as administered late (not within the 60 minutes prior to or after the scheduled timeframe) a total of 47 times. In July 2024, medications were documented as administered late a total of 58 times. In August 2024, medications were documented as administered late a total of 34 times. A review of the Progress Notes (PN) from June 2024 to August 2024 did not reveal the physician was notified of the late administration of the medications. On 1/7/25 at 10:51 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #3) who stated that medications should be administered one (1) hour before or 1 hour after the scheduled time. LPN/UM #3 stated that it was important for medications (meds) to be administered within the timeframe because some medications needed to be taken with food, or pain meds taken before wound care. She further stated that if not administered within the timeframe the medications could interfere with one another. LPN/UM #3 stated that it was a medication error if the meds were not administered as scheduled and it should be reported to the supervisor. On 1/7/25 at 10:58 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that medications should be administered 1 hour before or 1 hour after the scheduled time. She stated that it was important to administer within those timeframes because the resident's blood pressure or blood glucose could be affected. She then stated it was also important to administer meds during the scheduled time to prevent the resident from being double dosed. LPN #1 stated that it was considered a medication error, and the physician should be notified to see if they still wanted the medication to be administered. On 1/7/25 at 12:20 PM, the Regional Director of Nursing (RDON) stated that nurses had an hour window which was one hour before or one hour after to administer the medications. She further stated that meds should be administered within the one-hour window as it may interfere with the next dosage. The RDON stated if the meds are not administered within the one-hour window the expectation would be that the nurse notify the physician. At that time, the surveyor and the RDON reviewed the Medication Audit report which revealed there were 13 nurses that did not administer medications within the one-hour window. On 1/8/25 at 8:43 AM, the surveyor interviewed the Regional Director of Nursing (RDON) who stated she spoke with some of the nurses regarding the times and they indicated that the medications were not administered late but that they documented late because the unit was busy. On 1/9/25 at 9:55 AM, the RDON stated in the presence of the Licensed Nursing Home Administrator (LNHA), the Regional Director of Operations (RDO), and the survey team that she attempted to contact the 13 nurses and six (6) nurses responded they administered the medications on time but documented late. The RDON acknowledged the nurses should document once the medications were administered. 41072 2.) On 1/3/25 at 10:22 AM, during medication pass observation, the surveyor observed a Licensed Practical Nurse (LPN #3) administer medications to Resident #160. At that time, Resident #160 stated he/she had pain patches to both his/her knees. LPN #3 and the surveyor observed Resident #160 pull up his/her pant legs and observed undated and unidentified white patches to both knees. LPN #3 removed the white patches from both knees. Resident #160 stated he/she had pain to both knees and it has been worse since the weather has changed. At that time, LPN #3 and the surveyor reviewed the active physician's orders (PO) which revealed there was not a physician order for patches to both knees. LPN # stated she will call the doctor to inform them of the patches to the knees. On 1/3/25 at 9:18 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated that she was made aware of the patches that were on Resident #160's knees without a PO and would start an investigation. On 1/3/24 at 9:23 AM, the surveyor reviewed the medical record for Resident #160. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, primary osteoarthritis of the left hip, muscle weakness, unspecified osteoarthritis, and unspecified dementia. A review of the admission Minimum Data Set (MDS), an assessment tool, dated 10/29/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident ' s cognition was severely impaired. Further review of the MDS revealed that the resident had occasional pain at a moderate pain level. A review of the individual comprehensive care plan (ICCP) included focus area, dated 10/22/24, that the resident had chronic pain related to arthritis. Interventions included: monitor/record/report to nurse resident complaints of pain or requests for pain treatment. A review with Order Summary Report (OSR), dated as of 1/8/25, included the following PO: A PO, dated 1/3/25, for Lidocaine External Patch 4% apply to B/L(bilateral) knee topically one time a day for chronic pain and remove per scheduled with a start date of 1/4/25. The OSR did not reveal a PO for pain patches to both knees prior to surveyor inquiry. A review of the January 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reveal a PO for pain patches to bilateral knees prior to 1/3/25 at 11:21 AM. A review of the December 2024 and January 2025 progress notes did not reveal any documentation of pain patches being applied to Resident #160's bilateral knees prior to the observation on 1/3/25. On 1/6/24 at 1:43 PM, the surveyor conducted a follow up interview with LPN/UM #1 who stated that the Nurse Practitioner was notified and a PO for Lidocaine pain patches to both knees was obtained. LPN/UM#1 stated that patches to both knees should not have been applied without a PO. On 1/7/25 at 8:47 AM, the Regional Director of Nursing (RDON) provided the surveyor an incident report for a medication error regarding applying pain patches without a PO. On 1/8/25 at 9:50 AM, the surveyor interviewed the RDON who stated that the patches should not have been applied to Resident #160's knees without a physician's order. The RDON stated that she would have expected the nurses to call the physician to obtain a PO before applying the patches. A review of the facility's Medication Administration policy, dated 9/1/24, included the following: 10. Ensure the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, and right documentation. 11. Review the MAR to identify medication to be administered. 12. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. A review of the facility's Medication Orders policy, dated 9/1/24, included that medication should be administered only upon a signed order of a person lawfully authorized to prescribe. The policy further revealed that the facility shall ensure medications will be administered as follows: a) according to physician's orders, b) per manufactures specifications and c), in accordance with accepted standards and principles which apply to professional providing services. A review of the facility's Medication Errors policy, dated 9/1/24, included, Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber 's order . a. Medications administration not in accordance with the prescriber's order. Examples include, but not limited to: i. incorrect dose, route of administration, dosage form, time of administration . c. Medications administered not in accordance with professional standards and principles . 7. If a medication error occurs . c. Document actions taken in the medical record. NJAC 8:39-29.2(d)

Complaint #: NJ175632 Based on observation, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to provide foot care and services for 1 of 1 resident (Resident #86) reviewed for foot care. This deficient practice was evidenced by the following: On 1/2/25 at 10:27 AM, during the initial tour the surveyor observed Resident #86 lying in bed sleeping. On 1/3/25 at 10:22 AM, the surveyor reviewed the medical record for Resident #86. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, Diabetes Mellitus (DM- high blood glucose), abnormalities of gait (a person's manner in walking) and mobility, and Alzheimer's disease. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 11/10/23, that the resident had DM. Interventions included: inspect feet daily, wash feet daily, dry thoroughly, and may use a light dusting powder or lotion. On 1/7/25 at 10:32 AM, the surveyor observed the resident lying in bed, dressed and their fingernails were trimmed. At that time, the surveyor was unable to observe the resident's feet. On 1/7/25 at 10:34 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that she was an agency nurse but that the Hospice Aide (HA) came and performed morning (AM) care. At that time, the surveyor and LPN #1 entered Resident #86's room. LPN #1 removed the resident's socks and their feet appeared dry and the toenails appeared they needed to be trimmed and groomed. She stated that she was unsure when the last time the resident's toenails were trimmed by the Podiatrist. LPN #1 stated that the HA and the Certified Nursing Assistant (CNA) should have applied lotion to the resident's feet during care and as needed. On 1/7/25 at 10:40 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #3) who stated that the Podiatrist came every other month. She further stated that the Podiatrist trimmed the residents' toenails, and the CNAs performed daily foot care. LPN/UM #3 stated that the resident was very feisty during care especially if he/she did not know the person. On 1/8/25 at 8:43 AM, the surveyor interviewed the Regional Director of Nursing (RDON) who stated that the resident was last seen by the Podiatrist in May of 2024. She further stated that since the resident was combative three (3) times the Podiatrist's office put the resident on the do not return list unless the facility called for the resident to be seen. The RDON stated that the facility was unaware that the resident was on that list. When asked who was responsible for performing daily foot care to the resident, the RDON stated the CNAs. On 1/8/25 at 8:58 AM, the surveyor interviewed LPN #2 who stated she was an agency nurse but that the CNAs should perform foot care and the nurse should assess the resident's feet during the skin assessment. On 1/8/25 at 9:02 AM, the surveyor interviewed the HA who stated that she came Monday to Friday and was with her residents for one (1) to two (2) hours. She stated that she performed AM care by washing the resident from head to toe. The HA stated that she performed fingernail care once but was then advised that the nurses trimmed the fingernails. The HA then stated that during AM care, she also provided foot care. When asked did she perform foot care yesterday (1/7/25), the HA replied yes around 8:30 AM. At that time, the surveyor informed the HA of the appearance of the resident's feet yesterday around 10:30 AM. When asked did she perform foot care today (1/8/25), the HA stated no, someone else applied lotion to the resident's feet. On 1/8/25 at 9:10 AM, the Resident's Representative (RR) was present in the room and stated the resident's feet were dry, so she asked a CNA to lotion them. The RR stated that the resident's feet were dry and flaky, and she always had to tell an aide to provide foot care for the resident. On 1/8/25 at 1:09 PM, the RDON provided an email confirming the resident was last seen by the Podiatrist on 5/16/24 and would not be placed back on the list to be seen unless requested by the facility. On 1/8/25 at 2:30 PM, the RDON stated in the presence of the Licensed Nursing Home Administrator (LNHA), the Regional Director of Operations (RDO), the Regional Nurse Quality Assurance Nurse Specialist and the survey team that the CNAs were responsible for performing foot care and that the HA and the CNAs should be looking at the resident's feet and inform the nurse if the resident's nails needed to be trimmed. On 1/9/25 at 9:55 AM, the RDON stated in the presence of the LNHA, the RDO, and the survey team that the resident was scheduled to be seen by the Podiatrist after surveyor inquiry. The RDON acknowledged that foot care should be performed daily during care. A review of the facility's Activities of Daily Living (ADLs) policy dated 9/1/24, included, Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. A review of the facility's Skin Integrity - Foot Care policy dated 9/1/24, included, 1. The facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from the resident's medical conditions. 2. Assessment Risk c. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. NJAC 8:39-27.1(a);27.2 (g)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to adjust medication administration times to accommodate for scheduled dialysis times. This deficient practice was identified for 1 of 1 resident (Resident # 33) reviewed for dialysis and was evidenced by the following: On 1/2/24 at 10:15 AM, the surveyor observed that Resident #33 was not in his/her room. Per the staff, Resident #33 was at dialysis. On 1/7/24 at 10:18 AM, the surveyor interviewed Resident #33 who stated that his/her Midodrine medication (used to treat low blood pressure) was ordered three (3) times a day and he/she did not receive the medication at noon on his/her dialysis days. The resident stated the midodrine medication was scheduled for 6 am, 12 noon and 6pm, and the nurses were supposed to send the medication with him/her to dialysis for the noon dose. Resident #33 further stated that he/she had low blood pressure and was dizzy at dialysis the day before. Resident #33 stated that the medication was not adjusted around her dialysis times or sent with her to dialysis to be taken on her dialysis days at noon. On 1/3/25 at 11:32 AM, the surveyor reviewed the medical record for Resident #33. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to end stage renal (kidney) disease, chronic kidney diseases and dependence on other enabling machines and devices. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/14/24, included the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident received dialysis while a resident at the facility. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 2/9/24, that the resident needed dialysis related to renal failure and that the resident went to dialysis on Mondays, Wednesdays, and Fridays with a 10:00 AM pick up time. The ICCP did not include any interventions to schedule medications around the resident's scheduled dialysis times. A review of the Order Summary Report (OSR), dated as of 1/8/25, included the following physician orders (PO): A PO, dated 12/30/24, for dialysis on Mondays, Wednesdays, and Fridays with a chair time of 10:00 AM and a pickup time of 9:00 AM. A PO, dated 11/30/24, for Midodrine HCL oral tablet 10 mg (milligrams) one tablet by mouth three times a day for hypotension (low blood pressure). Hold for SBP (systolic blood pressure) greater than 140. A review of the November and December 2024 Medication Administration Record (MAR) included the following PO: A PO, dated 11/22/24, for Midodrine HCL oral tablet 10 mg one tablet by mouth three times a day for hypotension. Hold for SBP greater than 140. The medication was scheduled to be administered at 6:00 AM, 12:00 PM, and 6:00 PM. A review of the January 2025 MAR included the following PO: A PO, dated 11/22/24, for Midodrine HCL oral tablet 10 mg one tablet by mouth three times a day for hypotension. Hold for SBP greater than 140. The medication was scheduled to be administered at 6:00 AM, 1:00 PM and 5:00 PM. On 1/8/25 at 9:23 AM, the surveyor interviewed Licensed Practical Nurse (LPN #5) who stated that if a medication was scheduled during the time the resident was at dialysis, then the nurse would not administer that medication. On 1/8/25 at 9:40 PM, the surveyor interviewed the LPN # 4 who stated dialysis residents' medication administration times were scheduled around their dialysis times and that the medication was scheduled during the dialysis time, the nurse should reach out to the physician to adjust the medication times. LPN#4 further stated that medication could not be sent with the resident to dialysis because we are not a pharmacy and cannot dispense medication. On 1/8/25 at 9:40 AM, the surveyor interviewed LPN/Unit Manager (LPN/UM #1) who stated that dialysis residents' medications should not be scheduled during dialysis times and that the nurse should have called the doctor to get the medication times changed. The LPN/UM #1 further stated that medication could not be sent with the resident to dialysis. On 1/8/24 at 9:44 AM, the surveyor interviewed the Regional Director of Nursing (RDON) who stated that medication should not be scheduled during dialysis times when the residents is not at the facility and nurses should have called the doctor to get the medication times changed on dialysis days. The RDON further stated that medication could not be sent with the resident to dialysis. The RDON stated that she had spoken with Resident #33 prior, and that the resident wanted to take the medication at 12 noon and for the facility to send the medication with her for the 12-noon dose on dialysis days. The RDON stated that she had informed the resident that the facility could not send medication to dialysis. On 01/08/25 at 1:19 PM, the Licensed Nursing Home Administrator (LNHA) in the presence of the RDON, the Regional Director of Operations, the Regional Nurse QA Specialist and survey team was made aware that the PO for midodrine medication was scheduled at noon on dialysis days. A review of the facility's Medication Administration policy, dated 9/1/2024, included that the six rights of medications were administered as followed: right resident, right drug, right dosage, right route, right time, and right documentation. A review of the facility's Hemodialysis policy, dated 9/1/2024, included the licensed nurse will communicate to the dialysis facility via telephonic communication or written communication, to include timely medication administration (initiated, held, or discontinued) by the nursing home. NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

Complaint #: NJ175632, 176860 Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to ensure appetizing and palatable temperature of food for 1 of 1 lunch meal on 1 of 5 nursing units (300 Unit). This deficient practice was evidenced by the following: 1. On 1/3/25 at 9:21 AM, the surveyor conducted a Resident Council meeting which included four residents (Resident #6, #60, #71 and #98). All four residents informed the surveyor that the food was served cold and was not appetizing or recognizable. On 1/7/25 at 11:17 AM, the surveyor informed the Food Service Director (FSD) and the District Food Service Manager (DFSM) that they wanted to observe a lunch meal service for the day including food temperatures. The DFSM stated that all hot foods should be above 135 F on the food service line. The surveyor asked the FSD to calibrate a thin probe thermometer in their presence, which the FSD completed using an ice bath, and the thermometer reached 32 F (degrees Fahrenheit). On 1/7/25 at 11:46 AM, the surveyor observed the DFSM who took the following food temperatures from the steam table: Swedish meatballs 184 F Rice 191 F Green beans 178 F Beets 163 Mashed potatoes 159 F Ground meatballs 171 F Puree green beans 148 F Turkey patties 178 F Turkey patty puree 145 F Gravy 193 F Sauce 189 F Meatballs without sauce 158 F Pasta 170 F. On 1/7/25 at 11:56 AM, the [NAME] began serving the lunch meal on the tray line. The [NAME] utilized plastic insulated domes and bases, heated plate liners, and heated plates to maintain temperature. On 1/7/25 at 12:02 PM, the Dietary Aide (DA) #2 left the kitchen with meal cart for the 300 Unit Day Room. At this time, the surveyor, the FSD and the District Food Service Manager In Training (DFSMIT) accompanied DA #2 with a thin probed thermometer that was calibrated to 32 F. On 1/7/25 at 12:04 PM, DA #2 arrived at the 300 Unit with the meal cart and left the meal cart on the nursing unit. On 1/7/25 at 12:05 PM, Nursing signed receipt for the meal cart delivery and began to distribute the meal trays to the residents in the day room and to those residents who dined in their rooms. On 1/7/25 at 12:22 PM, the FSD informed the surveyor that all the residents' meal trays had been served. At that time, the FSD stated that hot items should be 135 F and cold items should be less than 40 F. The FSD then served the surveyor the puree test tray and poured coffee into the mug located on the tray. On 1/7/25 at 12:22 PM, the surveyor observed the FSD obtain the following temperatures from the puree sample tray: Puree green beans 116 F Puree meat balls 112 F Puree mashed potatoes 118 F Puree apple sauce 68 F At that time, the FSD stated that the hot food items should be maintained at 135 F to ensure that they do not fall into the danger zone. The FSD stated that the canned apple sauce was not refrigerated and should have been chilled first and served below 40 F or below to remain out of the food temperature danger zone. The FSD explained that if food temperatures were in the danger zone it meant that they were not at the proper temperature. On 1/7/25 at 12:28 PM, the surveyor observed the FSD obtain the following temperatures from the regular sample tray: Green beans 120 F Rice 128 F Meatballs 126 F Mandarin oranges 64 F Coffee 128 F Hot water 140 F At that time, the FSD stated that hot beverages were served from carafes on the unit and should be served between 170 F and 180 F. The FSD further stated that the Mandarin oranges were canned fruit and were not refrigerated prior to the meal service and should be served at less than 40 F. 2. On 1/8/25 at 08:55 AM, The surveyor requested and was served both a regular and puree breakfast test tray for palatability. Both of the meal trays were provided without a meal ticket to indicate what food items were served. The surveyors sampled scrambled eggs with red and green peppers, wheat toast, and a slice of ham that were of regular consistency. The scrambled eggs with red and green peppers on both the regular and puree tray lacked both seasoning and taste. On the pureed tray, there was a brown pureed substance that had a brown liquid around it that was not identifiable and had a pasty taste and texture. A review of the facility's Meal Distribution policy dated September 2017, revealed the following: .Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining. A review of the facility's Food Preparation policy dated September 2017, revealed the following: .The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time food items are exposed to temperatures greater than 41 F and/or less than 135 F, or per state regulations . On 1/9/25 at 10:19 AM, in the presence of the Regional Director of Nursing (RDON) the Licensed Nursing Home Administrator (LNHA) stated that she was surprised that the food temperatures were a Resident Council concern because they had improved. NJAC 8:39-17.4(a)(2)

Complaint #: NJ00174162 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) provide nail care to a resident who required assistance with the activities of daily living (ADL) and b.) implement the comprehensive care plan. This deficient practice was identified for 1 of 8 residents (Resident #118) reviewed for activities of daily living. This deficient practice was evidenced as follows: 1.) On 1/7/25 at 11:07 AM, during an incontinence tour, while accompanied by Licensed Practical Nurse/Unit Manager (LPN) #1 and Certified Nurse Assistant (CNA) #2, the surveyor observed Resident #118 bilateral (b/l) lower legs with multiple blister-like areas containing some dried blood. The LPN/UM#1 stated that the resident scratches themselves. Resident #118's fingernails were observed to be medium in length and contained reddish-brown blood-like residue under multiple fingernails and thick brown fecal-like matter under their right thumb. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, hemiplegia and hemiparesis (partial paralysis on one side if the body) following cerebral infarction (a stroke) affecting the left non dominant side, dysarthria (weakness in the muscles used for speech) following cerebral infarction, chronic kidney disease and depression. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 9/11/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident had an upper extremity impairment on one side, required moderate assistance with personal hygiene, toileting hygiene, oral hygiene, and required substantial assistance with showers and lower body dressing. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 12/8/23, that the resident has a potential impairment to skin integrity. The interventions included: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Assist resident with general hygiene, skin will be assessed on a weekly basis and findings documented, monitor/document location, size and treatment of skin injury. On 1/8/2025 at 8:43 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1, who stated that the Certified Nursing Assistant (CNA) was responsible for cleaning the resident's fingernails as needed and trimming them to prevent scratching. The surveyor and LPN/UM#1 made a follow-up visit with the resident. At that time, Resident #118's fingernails still contained residue and were still the same length as the previous day (1/7/25). LPN/UM #1 confirmed that the resident's nails were medium in length and needed to be trimmed and cleaned. On 1/8/2025 at 9:56 AM, the surveyor interviewed the Regional Director of Nursing (RDON), who stated that the CNAs should check the residents' fingernails when they are performing care and clean them when they are soiled. She further stated that the resident's fingernails should be kept short and clean to prevent an infection. The RDON stated that the care plan should be followed. A review of the facility's Activities of Daily Living (ADLs) policy, dated 9/1/2024, included Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. A review of the facility's Comprehensive Care Plans policy, date 9/1/2024, included The policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. NJAC 8:39-27.2 (g)

Complaint #: NJ172440 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that resident dietary preferences were accurately identified and implemented for 4 of 21 residents (Resident #20, #39, #107, and #275) reviewed for dining and was evidenced by the following: On 1/3/25 at 10:00 AM, during a surveyor-conducted resident council meeting, 4 out of 4 residents (Residents #6, #60, #71 and #98) stated that condiments such as cream, sugar, mustard, and mayonnaise would not be on the meal trays and that the facility did not honor food preferences on their meal tickets. The residents also stated that when they ask for a substitute food item than what was on their meal ticket, it can take a long time for another meal tray, or they don't get it at all. 1. On 1/3/25 at 11:36 AM, the surveyor observed Resident #107 seated in a wheelchair in his/her room. The resident stated that his/her meal ticket listed no bread, no citrus, and no tomato, but received bread on his/her meal tray. On 1/3/25 at 1:02 PM, the surveyor reviewed the medical record for Resident #107. A review of the Admission Record revealed that the resident had diagnosis which included but were not limited to: Achalasia of cardia (a swallowing disorder), dementia, unspecified severity, with other behavioral disturbance, and dysphagia (difficulty swallowing). A review of the resident's quarterly Minimum Data Set (MDS), and assessment tool used to facilitate the management of care, dated 12/14/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was fully intact. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 3/8/24, that the resident had a need for a mechanically altered diet. Interventions included: Provide diet as ordered-Encourage diet compliance and educate family members on maintaining correct diet texture when eating outside facility or bringing in snacks. A review of the Order Summary Report revealed an order dated 5/20/24 for a Regular diet ground texture, thin liquids. On 1/6/25 at 1:02 PM, the surveyor received a Grievance Form that was completed by the facility's Director of Social Services (DSS) on 6/26/24 and indicated that the resident's family member reported a problem with tray accuracy and alleged that the resident received a biscuit on his/her tray. The DSS documented that the meal ticket was verified and indicated no bread. A review of the progress notes included a Health Status Note (HSN), dated 06/27/24 at 11:14 AM, which indicated that the resident had a cinnamon bun [trade name redacted] in a napkin and was educated that he/she was not allowed to have bread, and he/she responded, I only ate half. Further review of the progress notes revealed that there was no documentation that detailed that the resident was served a biscuit on 6/26/24 as indicated on the grievance form. On 1/6/25 at 1:37 PM, the surveyor observed the resident's meal tray and confirmed tray accuracy. The surveyor confirmed that the resident had no bread, no citrus, and no tomato listed on their meal ticket as preferences. On 1/7/25 at 11:00 AM, the surveyor interviewed the DSS who stated that on 6/26/24 the resident's family member called her to the resident's room and showed her the resident's meal tray with a meal ticket that indicated no bread products, and the resident was given a biscuit. The DSS stated that she went to the kitchen and verified that going forward no other bread products would be on the tray. On 1/7/25 at 12:21 PM, the surveyor interviewed Regional Director of Nursing (RDON) who stated that the meal ticket should match what is on the tray. The RDON further stated that a dry biscuit should not have been served to the resident and should match what was on the meal ticket. On 1/8/25 at 10:09 AM, the surveyor interviewed the Registered Dietician (RD) who stated that the resident's current diet was a ground consistency. The RD stated that there was a concern for aspiration (when food or liquid enter the airway) if the resident was served a biscuit. The Regional Registered Dietician (RRD) was present and stated that if bread were served it should have had gravy on it to ensure that it was moistened and soft. On 1/8/25 at 2:02 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) in the presence of the surveyor team who stated that it was her expectation for staff to follow the resident's dietary preferences and diet orders. 2.) On 1/3/25 at 11:56 AM, the surveyor observed Resident #275 seated alone at a table in the dining room. The resident stated that he/she had not yet received his/her meal tray. On 1/3/25 at 11:58 AM, the surveyor observed Licensed Practical Nurse/Unit Manager (LPN/UM) #4 serve Resident #275 his/her meal tray. The resident stated that he/she had not received margarine that was listed as meal preference on his/her meal ticket, or salt and pepper. LPN/UM #4 provided the surveyor with margarine, salt and pepper when requested. When the surveyor asked LPN/UM #4 why the resident had not received margarine or salt and pepper on his/her tray, he stated that he was unsure why the resident had not received margarine as indicated on his/her meal ticket, or salt and pepper. 41072 3.) On 01/06/25 at 01:38 PM, the surveyor observed Resident #39's lunch meal tray ticket that included a chicken pot pie, dinner roll, ham and cheese sandwich with lettuce, tomato, and mayonnaise, tossed salad with dressing, deluxe fruit salad, hot coffee, and apple juice. The surveyor observed that Resident #39's lunch tray did not include the ham and cheese sandwich with lettuce, tomato, and mayonnaise. At that time, Certified Nursing Assistant (CNA # 4) stated that there was a ham and cheese sandwich on top of the meal cart and gave the sandwich to the resident. Resident #39 stated, my meal ticket has that I'm supposed to get lettuce and tomato on my sandwich. The sandwich did not have lettuce and tomato. On 1/6/25 at 1:41 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #6) who stated that it was every day that items were missing from residents' meal trays. LPN #6 stated that she would call the kitchen and let them know when items would be missing from the meal trays. On 1/8/25 at 11:14 AM, the surveyor interviewed the Registered Dietician (RD) in the presence of the Regional Registered Dietitian, who confirmed that Resident #39 had a food preference of a ham and cheese sandwich with lettuce, tomato, and mayonnaise on his/her meal ticket. 4.) On 1/7/25 at 9:35 AM, the surveyor observed breakfast meal delivery on the 100 Unit. The surveyor observed CNA #3 stated she had called the kitchen and requested a new breakfast tray for Resident # 20 because the tray was missing toast. On 1/7/25 at 9:57 AM, Resident #20's breakfast tray was delivered to the 100 unit. The surveyor observed Resident # 20's meal ticket on the tray that included oatmeal, toast, diet jelly, margarine, hot tea, and orange juice. The surveyor observed the meal tray did not include the toast, the diet jelly, or the margarine. At 10:15 AM, the surveyor and the Food Service Director (FSD) confirmed that the toast, diet jelly, and margarine were missing from the tray. The FSD stated I will get the resident a new tray. I am trying to find out what happened to the breakfast trays this morning. At 10:25 AM, Resident # 20 received the breakfast tray that included the toast, diet jelly, and margarine. On 1/8/25 at 1:19 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), in the presence of the Regional Director of Nursing, the Regional Director of Operations, the Regional Nurse QA Nurse Specialist, and the survey team, who stated that she would expect the kitchen would have someone checking that everything on the meal tray matches the meal ticket. The LNHA further stated that it was important that the facility followed the meal ticket, the diet order, and the residents' preferences because it is the residents right. A review of the facility Meal Distribution policy, dated September 2017, revealed that the nursing staff will be responsible for verifying meal accuracy and timely delivery of meals to residents/patients. The policy further included: All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences . NJAC 8:39-17.4(a)1, e

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure the proper sanitization of a glucometer used to obtain blood glucose results for two (Residents (R) R61 and R81) of seven residents reviewed during medication administration observations. This failure had the potential to lead to serious illness and death for R61 and R81 related to the transmission of blood borne pathogens from resident to resident via the un-sanitized glucometer. In addition, the facility failed to ensure all areas in the laundry room were cleaned. The facility's Administrator was informed on 09/27/23 at 5:10 PM, that Immediate Jeopardy existed related to the failure to ensure that two of seven residents identified as receiving blood glucose checks received glucometers properly sanitized in between resident use. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 09/28/23 at 2:33 PM. The survey team validated the implementation of the removal plan through interviews, and record review. Immediate Jeopardy was removed on 09/29/23 at 3:40 PM. After removal of the Immediate Jeopardy, the deficiency remained at a D scope and severity for an isolated potential for more than minimal harm and in addition to the findings in the laundry room. Findings include: 1. During an observation on 09/27/23 at 11:19 AM Licensed Practical Nurse (LPN1) was observed obtaining a blood glucose check for Resident (R81). LPN1 obtained a glucometer (one of two stored in her medication cart) and then obtained an alcohol pad which she used to wipe the glucometers result display window for approximately one to two seconds. LPN1 was then observed taking the glucometer and other supplies to R81's room, where she obtained the resident's blood glucose from one of the resident's fingers. After obtaining the result of R81's blood glucose check, LPN1 placed the blood glucose monitor just used to obtain R81's blood glucose back on the top of the medication cart. LPN1 was not observed to clean the glucometer machine with a facility approved cleaning agent/sanitizer. On 09/27/23 at 11:41 AM, immediately after obtaining R81's blood glucose and administering her insulin, LPN1 was observed obtaining a blood glucose check for R61 with the same glucometer. The glucometer's result display window was, again, observed to be wiped with an alcohol wipe for approximately one to two seconds and then LPN1 went to R61's room and obtained her blood glucose with the monitor. After obtaining R61's blood glucose, LPN replaced the monitor back into the medication cart without cleaning it. a. R61's Admission Record dated 09/29/23 and found in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes and HIV positive status. R61's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/23 indicated a Brief Interview for Mental Status (BIMS) score of one out of 15 (severely cognitively impaired). R61's physician's orders located in the EMR under the Orders tab included an order for blood glucose checks to be obtained four times daily before meals and at bedtime. Review of R61's Medication Administration Record (MAR) located in the EMR under the Orders tab confirmed the resident was receiving her blood glucose checks routinely as ordered. b. R81's Admission Record dated 09/29/23 and found in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with type 2 diabetes and moderate dementia. R81's quarterly MDS with an ARD of 08/31/23 indicated a BIMS that could not be done due to the resident's poor cognition. The assessment indicated R81 had both short and long-term memory deficits. R81's physician's orders located in the EMR under the Orders tab included an order for blood glucose checks to be obtained four times daily before meals and at bedtime. Review of R81's MAR located in the EMR under the Orders tab confirmed the resident was receiving her blood glucose checks routinely as ordered. During an interview on 09/27/23 at 11:56 AM, LPN1 stated the facility process for cleaning blood glucose monitors was that the night shift normally cleaned the monitors at night. She stated, I clean (the glucometer) with an alcohol pad before and after I use it because I have been a nurse for [AGE] years and that is just what I have always done, but generally it (cleaning and sanitizing the glucometer) is done at night. LPN1 stated it was facility procedure for the glucometers to be cleaned each night with an alcohol pad. LPN1 stated she was not familiar with the concept of kill or wet time, but stated she let the alcohol dry before using the glucometer to obtain blood glucose. LPN1 stated she thought someone from the pharmacy had been in the facility to watch her do medication administration, but she was not sure if she had been taught about obtaining glucometer checks at any time by the facility. During an interview on 09/27/23 at 12:16 PM, the Director of Nursing (DON) stated the facility process and her expectation related to the cleaning of glucometers was Clorox bleach wipes, available in all nursing cart in the bottom drawer, were to be used to clean glucometers before and after each use and indicated wet/kill time instructions were to be followed based on manufacturer's directions on the container of bleach wipes used. During a follow-up interview with the DON on 09/27/23 at 12:49 PM, she confirmed the only two residents receiving blood glucose checks on that medication cart were R81 and R61 and confirmed LPN1 worked only on the unit and medication cart observed by the surveyor. She stated, [LPN1] only works on that cart. That is her cart. The DON confirmed that although R81's blood glucose had been obtained prior to R61's blood glucose at the time of the surveyor's observation of LPN1 administering blood glucose checks to both residents; there was no way to predict which order the two residents would have their blood glucose monitored, placing R81 at risk for exposure to the HIV virus when glucometers were not appropriately sanitized between resident use. The DON confirmed LPN1 had received previous training. The facility's policy titled Blood Glucose Sampling-Capillary (Finger Sticks) Policy, dated 03/23 was reviewed and indicated, The purpose of this procedure is to guide safe handling of the capillary blood sampling devices to prevent transmission of bloodborne diseases to residents and employees;' and General Guidelines: 1. Always ensure that blood glucose meters intended for reuse are leaned and disinfected between resident uses; and Steps in the Procedure: 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devises after each use. The Assure Platinum Blood Glucose Monitoring User Instruction Manual (the manufacturer's instructions for use of the blood glucose monitor used by the facility) indicated, Page 47 Maintenance: Cleaning and Disinfecting Guidelines: .Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe; .Option 2: To disinfect the meter, dilute 1 ml (milliliter) of household bleach (5 - 6% sodium hypochlorite solution) in 9 ml of water to achieve a 1:10 dilution (final concentration of 0.5 - 0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). The use the damped paper towel to thoroughly wipe down the meter; and With all the recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time. Review of the product label instructions for Clorox Healthcare Bleach Germicidal Wipes (the facility's indicated glucometer disinfecting product) revealed the wet/dry time to be used for the product to ensure all potential pathogens were eliminated from the surface of the glucometer machines/other facility equipment was three minutes (this indicated the cleaned/disinfected surface was to remain wet for at least three minutes to ensure disinfection of the surface). 29162 2. Observations on 09/28/23 from 11:00 AM through 11:30 AM of the facility laundry room revealed the door was open and remained open throughout the entire observation. There were plastic strips hung up on each side of the washer room and the folding room. Those strips remained hanging beside the doorway throughout the observation. They had scattered water-like stains on them and served as a barrier between the washers and clean folding area when they were down and in their place. An unpainted, cracked and broken wooden palette with torn and worn cardboard on top of it sat between two washing machines. On the floor there were many rust-like and white flake particles around the bottom and edges of the palette. Continued observations revealed Housekeeper (HK)1 loaded soiled laundry into a washing machine without protection covering her uniform then went directly to fold clean laundry. She did not complete hand hygiene or spray and clean the gray dirty laundry tub. Four gray dirty empty laundry tubs sat in the sorting area and had unknown debris in them. One of the tubs had a brown sticky substance that was four centimeters (cm) long and two cm wide on the longest side of the tub. None of them had been lined. The washing machines all had multiple rust like and white flakes around the entire bottoms and sides. There was water on the floor around the machines in front of the window. The wrap on the elbow joint area of two pipes, hanging from the ceiling, was frayed, and hanging down. There was debris of an unknown substance on the windowsill, and a spider web in the corner. The backsplash area, faucets, bases, soap holder and paper towel dispenser of both sinks were dirty. The laundry room floor had scattered loose debris on it. During an interview on 09/28/23 from 11:00 AM through 11:45 AM, the Housekeeping Supervisor (HKS) and the Housekeeping District Manager (HDM) revealed they agreed with all the above. The HDM stated he was surprised by the findings. The HKS remarked she intended to get the staff cleaning the laundry room immediately and denied having any documentation or cleaning schedules in place. Review of the facility's policy titled Laundry Room Cleaning and Upkeep, dated 01/10/10, revealed the washers, dryers, bins, sinks fans, tables, floors, walls, pipes, and windowsills were to have been cleaned daily. When soiled linen was sorted; eye protection, gowns, and gloves were to be worn. All bins and washers should have been sanitized between sorting each wash load and at the end of each day using approved disinfectant. All washers should have been dusted and cleaned: top, sides, and front at the end of each shift. Floors, walls, sinks, pipes, windowsills should have been dusted/cleaned at the end of each shift and as needed if visually soiled. The laundry room should have been scheduled monthly for deep cleaning to include machines, scrubbing of floor, corners/edges behind and around bins, chemical buffets, chemical dispensers, and dusting behind dryers, and racks. Laundry employees cleaned, dusted, and disinfected daily. NJAC 8:39-19.4(a) NJAC 8:39-19.4(n) NJAC 8:39-21.1(d)(e)(g)

Based on record review and interview, the facility failed to provide a fully completed Form CMS-10055 (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to include the cost of continued services for three of three residents (Resident (R) 388, R389, and R57) reviewed for liability notices out of a total sample of 41 residents. This failure prevents the resident or responsible party the ability to make an informed decision related to the cost of continued services. Findings include: 1. Review of the beneficiary notice provided by the facility revealed R389 was admitted to Medicare Part A Skilled Services on 02/15/23. The last covered day of Part A Skilled Services was 04/12/23. The SNFABN was issued on 04/04/23 by the Social Services Director (SSD) to the responsible party. In the section labeled . F. Estimated Cost . the SSD did not put a cost. This failure to include the estimated cost prevented the resident representative from making an informed decision about continuing to receive physical and occupational services. 2. Review of the beneficiary notice provided by the facility revealed R388 was admitted to Medicare Part A Skilled Services on 01/18/23. The last covered day of Part A Skilled Services was 04/10/23. The SNFABN was issued on 04/04/23 by the SSD to the responsible party. In the section labeled . F. Estimated Cost . the SSD did not put a cost. This failure to include the estimated cost prevented the resident representative from making an informed decision about continuing to receive speech therapy. 3. Review of the beneficiary notice provided by the facility revealed R57 was admitted to Medicare Part A Skilled Services on 04/03/23. The last covered day of Part A Skilled Services was 06/14/23. The SNFABN was issued on 04/04/23 by the SSD to the responsible party. In the section labeled . F. Estimated Cost . the SSD did not put a cost. This failure to include the estimated cost prevented the resident representative from making an informed decision about continuing to receive physical and occupational services. During an interview on 09/27/23 at 2:33 PM the SSD revealed When I started working at this facility, the regional director who trained me, told me not to put down the costs because they change daily. I have never put the cost down on the form. During an interview on 09/27/23 at 4:14 PM the Administrator revealed The costs are covered and reviewed with the resident on the admission paperwork. We do not put the actual cost on the Beneficiary Notices because they are constantly changing. NJAC 8:39-5.1(a)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure food was palatable for nine out of 41 sampled residents (Residents (R)28, R102, R40, R60, R119, R189, R89, R188, R97), for 27 residents residing on the 200 unit, and for six residents who attended the resident council interview out of 146 total residents who resided in the facility. Findings include: 1. Interviews with seven residents revealed concerns with food palatability: a. During an interview on 09/26/23 at 11:08 AM, R28 stated she had been served a moldy peanut butter and jelly sandwich. R28 stated the food was not good and the food was cold (when it should be hot). Review of R28's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/30/23 in the electronic medical record (EMR) under the MDS tab revealed R28 had intact cognition with a Brief Interview for Mental Status Score (BIMS) of 15 out of 15 (score of 13 - 15 indicates intact cognition). b. During an interview on 09/25/23 at 9:50 AM, R189 stated the food was terrible and the coffee and food was not hot when she received it. Review of R189's admission MDS with an ARD of 09/27/23 in the EMR under the MDS tab revealed R189 had intact cognition with a BIMS of 15 out of 15. c. During an interview on 09/25/23 at 10:25 AM, R119 stated the food was terrible. Review of R119's quarterly MDS with an ARD of 06/22/23 in the EMR under the MDS tab revealed R119 had moderately impaired cognition with a BIMS of 12 out of 15 (score of 8 - 12 indicates moderate impairment). d. During an interview on 09/25/23 at 11:50 AM, R89 stated the food was rotten. Review of R89's quarterly MDS with an ARD of 08/28/23 in the EMR under the MDS tab revealed R89 had intact cognition with a BIMS of 15 out of 15. e. During an interview on 09/25/23 at 11:03 AM, R102 stated the food was cold when he was served and stated it lacked seasoning. Review of R102's admission MDS with an ARD of 06/18/23 in the EMR under the MDS tab revealed R102 had moderately impaired cognition with a BIMS of 11 out of 15. f. During an interview on 09/25/23 at 3:31 PM, R40 stated he did not like the food and was tired of the same things being served repeatedly. R40 stated the food was not always hot when he received it. Review of R40's significant change MDS with an ARD of 06/30/23 in the EMR under the MDS tab revealed R40 had intact cognition with a BIMS of 15 out of 15. g. During an interview on 09/25/23 at 3:36 PM R60 stated he had only one complaint and it was the food, stating it was not good. Review of R60's significant change MDS with an ARD of 06/28/23 in the EMR under the MDS tab revealed R60 had intact cognition with a BIMS of 14 out of 15. h. During interviews on 09/28/23 at 4:48 PM, R97 and R188 were interviewed together. Both residents stated the food was not good. R188 stated she did not like how the salads were put together and they did not taste good. Both residents stated the food was not hot. R188 had a grilled cheese sandwich with a slice of tomato and showed the surveyor the sandwich by removing one of the slices of bread. The cheese was not melted; the resident stated it was cold and unappetizing. Review of R97's quarterly MDS with an ARD of 07/16/23 in the EMR under the MDS tab revealed R97 had intact cognition with a BIMS of 15 out of 15 (score of 13 - 15 indicates intact cognition). Review of R188's quarterly MDS with an ARD of 08/28/23 in the EMR under the MDS tab revealed R188 had intact cognition with a BIMS of 15 out of 15. 2. During the resident council interview on 09/27/23 at 1:00 PM, six of eight residents attending the meeting stated the food was terrible. 3. During a kitchen observation on 09/27/23 at 3:50 PM, the foods on the tray line for the dinner meal included sliced sausage in tomato-based sauce, egg souffle (quiche), pasta, string beans, cooked carrots, and canned fruit. The quiche was the alternative to the sausage entree, and it consisted of baked eggs cut into square pieces with a slice of American cheese on top. The Dietary Director (DD) verified the quiche was not actually quiche because it did not have a pie crust. Tray line meal service to residents eating on the first six carts (out of nine total carts) was observed from 4:05 PM - 4:43 PM. On 09/27/23 at 4:43 PM the cart to the 200 unit left the kitchen and was pushed down to the 200 unit. At 5:01 PM, all the residents on the 200 unit had received their trays and the test tray of a regular diet consisting of sausage, quiche, green beans, and pasta was evaluated for flavor and temperature. The DD was present and took the temperatures of the foods. The temperatures were as follows: quiche 114 degrees F, green beans 114.7 degrees F, sausage 123 degrees F, and pasta 119 degrees F. All the foods that should have been hot were lukewarm which was verified by the DD. The DD stated his goal was for residents to receive their trays at a minimum temperature of 135 degrees F. The flavor was acceptable; although the quiche was not appetizing in appearance (spongy egg with a slice of American cheese on top, and no pie crust). 4. During an interview on 09/27/23 at 4:44 PM, the DD stated he did not receive many food complaints and residents were complimentary of the food. The DD stated they had a food committee meeting monthly; however, one resident dominated the meeting, and it was difficult for other residents to provide input. The DD stated they did not record how many residents attended the meetings, who attended the meetings, or what individual residents said. The DD stated he was informed of specific preferences during the meeting, and he updated residents' tray cards from the information in the meeting. The DD stated the meetings were short and typically lasted less than ten minutes. During an interview on 09/29/23 at 9:18 AM, the Dietary District Manager and the DD stated they would try new approaches to solicit residents' feedback about the food since the residents rarely provided any negative feedback. During an interview on 09/29/23 at 10:00 AM, the Registered Dietitian (RD) stated she had been employed in this capacity for nine months. The RD stated she met with newly admitted residents and obtained their food preferences; she met with residents periodically and as needed after that. The RD stated she received food complaints and passed on specific complaints from residents to the DD so their tray cards could be updated. The RD stated she had given the DD some ideas regarding the food, but there was not much leeway. The RD stated she would like to have input into the menu and tray card system, but she did not have access because she did not work for the same company that the DD worked for (DD and menus were contracted with a specific company). The DD stated the food should be at least 130 degrees F when residents received their meals. Review of the facility's policy titled Food: Quality and Palatability, dated 09/17 and provided by the facility, revealed Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature . NJAC 8:39-17.4(a)2

Based on observation, interview, record review and facility policy review, the facility failed to ensure meals were served at regular times comparable to those in the community, failed to ensure there was not more than a 14-hour lapse between dinner and breakfast the next morning, and failed to ensure a substantial evening snack was offered to residents. In addition, the greater than 14-hour timeframe between dinner and breakfast the next day, had not been approved by the resident group. These failures had the potential to affect 142 out of 146 residents (four residents received nutrition via tube feeding.) Findings include: 1. Review of the undated Truck Delivery Log provided by the facility revealed there were nine carts (trucks) that delivered food to residents. The first meal cart was delivered to Unit Five at 7:36 AM, lunch was delivered at 11:36 AM, and dinner was delivered at 4:24 PM. The time span from dinner to breakfast was greater than 15 hours. The last meal cart was delivered to Unit Four dayroom two at 8:24 AM, lunch was delivered at 12:30 PM, and dinner was delivered at 5:18 PM. The time span from dinner to breakfast was greater than 15 hours. The time span for all nine carts from dinner to breakfast the next day was greater than 15 hours. 2. During an interview on 09/25/23 at 10:13 AM, the Dietary Director (DD) stated mealtimes for breakfast, lunch, and dinner were 7:30 AM, 11:30 AM, and 4:15 PM. 3. During an interview on 09/28/23 at 4:48 PM, Resident (R)97 and R188 were interviewed together. R188 stated the dinner meal was served early and she had not eaten dinner this early while in the community. R97 agreed, stating the meal was served early and said, This is the way it is. Both residents had received their dinner meals and were eating at the time of the interview. R188 stated she was not offered a bedtime snack and R97 stated she was occasionally, but not routinely, offered a bedtime snack. Review of R97's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/16/23 in the electronic medical record (EMR) under the MDS tab revealed R97 had intact cognition with a Brief Interview for Mental Status Score (BIMS) of 15 out of 15 (score of 13 - 15 indicates intact cognition). Review of R188's quarterly MDS with an ARD of 08/28/23 in the EMR under the MDS tab revealed R188 had intact cognition with a BIMS of 15 out of 15. During an interview on 09/28/23 at 4:43 PM, R27 was eating her dinner and stated dinner was served early tonight. R27 stated she usually received dinner around 5:00 PM and breakfast at 8:00 AM, but today dinner came around 4:30 PM. Review of the undated Truck Delivery Log provided by the facility revealed the dinner cart should be delivered to R27's unit at 4:54 PM. Review of R27's quarterly MDS with an ARD of 08/01/23 in the EMR under the MDS tab revealed R27 had intact cognition with a BIMS of 14 out of 15. During an interview on 09/25/23 at 11:03 AM, R102 stated he only got snacks if he asked for them and reported he was served dinner around 4:30 PM and received breakfast at about 8:15 AM. Review of R102's admission MDS with an ARD of 06/18/23 in the EMR under the MDS tab revealed R102 had moderately impaired cognition with a BIMS of 11 out of 15. 4. Observations of dinner meal service preparation and service revealed: a. During observations in the kitchen on 09/27/23 from 3:44 PM through 4:43 PM revealed the tray line meal service began at 4:10 PM. By 4:43 PM, six of nine total meal carts had been loaded and taken to the units for delivery. b. During observation on 09/28/23 at 4:35 PM, the 100-unit meal cart (lower numbered rooms) was empty; all meals had been served and residents were eating. During observation on 09/28/23 at 4:36 PM, the 100-Unit meal cart (higher numbered rooms) was completely served, and residents were eating in their rooms. During an observation on 09/28/23 at 4:40 PM, the 200-Unit meal cart (lower number rooms) was mostly served with residents from 200 up through 210 eating their meals in their rooms. During an observation on 09/28/23 at 4:45 PM, the remaining trays for the higher number rooms on the 200-Unit were being passed. During an observation in the kitchen on 09/27/23 at 4:22 PM, it was revealed that each cart had a tray with labeled snacks on top of it. The trays had approximately 12 individually labeled snacks for specific residents. Snacks included crackers, sandwiches, yogurt, and pudding cups. No general snacks (without labels with residents' names) were observed. The DD confirmed these were the trays of bedtime snacks for the units. 5. During observations of the pantries on the units with the DD on 09/29/23 from 9:48 AM through 9:58 AM, it was revealed only one of the four pantries had an adequate supply of snacks available. The DD stated the dietary department delivered general snacks (without residents' names and available to all residents) once a week to the pantries on Tuesdays, adding, We could do better with snacks. The DD stated the pantries were not due to be restocked until Tuesday (the day of the observation was Friday). Observations revealed: a. The pantry across from Unit One had a few individual sized packages of crackers, approximately five individual sized packages of cheese flavored crackers, and a few packages of individual sized packages of fudge cookies. There was a refrigerator in the pantry; however, there was no food or beverages for residents in the refrigerator. Review of the Resident List Report dated 09/25/23 and provided by the facility revealed there were 57 total residents residing on Unit One. b. Unit Two pantry had a total of two packages of individual sized puddings. There were no additional snacks in the room. There was a refrigerator in the pantry; however, there was no food or beverages for residents in the refrigerator. Review of the Resident List Report dated 09/25/23 and provided by the facility revealed there were 27 total residents residing on Unit Two. c. Unit Four pantry had a total of ten packages of individual sized snacks, a combination of chips, cheese flavored crackers, and Cheetos. There was a refrigerator in the pantry; however, there was no food or beverages for residents in the refrigerator. Review of the Resident List Report dated 09/25/23 and provided by the facility revealed there were 51 total residents residing on Unit Four. d. Unit Five pantry was adequately stocked with numerous (more than 50 individual sized packages) chips, pretzels, pudding, and cookies. Review of the Resident List Report dated 09/25/23 and provided by the facility revealed there were 11 total residents residing on Unit Five. 6. During an interview on 09/28/23 at 4:59 PM, Licensed Practical Nurse (LPN)5 stated bedtime snacks came to the 100-Unit with the dinner meal cart and they were labeled with specific residents' names. LPN5 stated there were about 10-12 snacks on the cart. During an interview on 09/28/23 at 4:47 PM, LPN Unit Manager (UM)2 stated snacks were delivered to the 200 Unit after dinner. LPNUM2 stated dietary sent a tray with snacks with residents' names on them. LPNUM2 stated if other residents wanted snacks, they called the kitchen. During an interview on 09/28/23 at 5:00 PM, Registered Nurse (RN)UM1 stated bedtime snacks came on a tray from the kitchen with residents' names on them and the nursing staff passed them out. RNUM1 stated if someone wanted a snack that did not have a labeled one, nursing staff could call the kitchen. During an interview on 09/29/23 at 9:18 AM the Dietary District Manager and the DD stated labeled bedtime snacks were sent to each unit on a tray daily at 7:00 PM as the last thing dietary staff did before leaving the building. The DD stated the Registered Dietitian (RD) prescribed the snacks for these residents. The DD confirmed the time span between dinner and breakfast the next morning was more than 14 hours and confirmed this had not been reviewed or approved by the resident group. The DD stated he had been employed for five years and the mealtimes had not changed during this period. During an interview on 09/29/23 at 10:00 AM, the RD stated the normal time for dinner in nursing homes was around 5:00 PM. The RD stated she was not aware the time span between dinner and breakfast the next day exceeded 14 hours. The RD stated she had been employed by the facility for nine months. Review of the facility's policy titled Frequency of Meals, dated 09/17 and provided by the facility, revealed At least three daily meals will be provided, at regular times comparable to normal mealtimes in the community. The time between a substantial evening meal and breakfast the following day will not exceed 14 hours, except when a nourishing snack is served at bedtime. Up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span and a nourishing snack is provided. NJAC 8:39-17.2(f) NJAC 8:39-17.4(b)(d)

Based on observations, interview, record review, and facility policy review, the facility failed to ensure the kitchen dish room, floor, countertops, and wall behind the dish machine was maintained in a sanitary condition creating the potential for the spread of foodborne illness for 142 out of 146 residents who resided in the facility (four received nutrition via tube feeding). In addition, the facility failed to adhere to proper hand hygiene when serving meals to residents on the secured unit during food delivery to the adjoining dining rooms and the resident's individual rooms. Findings include: 1. During the initial tour of the kitchen with the Dietary Director (DD) on 09/25/23 from 10:14 AM to 10:43 AM, the following concerns were noted: a. The garbage can in the handwashing area had a foot operated pedal which opened the garbage can. After the surveyor washed her hands and operated the foot pedal, the top interior surface of the garbage can lid was observed to be covered (approximately a third of the lid) with a green/black fuzzy substance. This would have been visible every time the garbage can was used. b. The dishwashing room was observed. The floor was concrete with a grey smooth finish. Approximately a quarter of the floor had deteriorated with the finish either partially or completely absent, exposing a rough, jumbled surface of multiple small rocks below. Water was pooled in areas where the concrete had disintegrated. There was black residue streaked down the wall of the dirty side of the dish machine covering an area of approximately two by three feet, above the counter where dirty dishes entered the machine. 2. During a second observation of the kitchen on 09/27/23 from 3:44 PM to 4:33 PM, the following concerns were noted: a. The garbage can in the handwashing area was used by the surveyor at 3:44 PM. After the surveyor washed her hands and operated the foot pedal, the top interior surface of the garbage can lid continued to be covered (approximately a third of the lid) with a green/black fuzzy substance. The DD was asked what was on the top interior surface of the lid and he stated it was dirt. The DD removed the garbage can and cleaned the lid. b. An observation of the dish room was made at 4:33 PM. The floor continued to be in a deteriorated condition, with a lack of finish adhered to the floor. There was pooled water in the areas where the concrete was missing. Underneath the stainless counter of the dish machine where the racks for the dishes were stored, was an area of black slime (residue of approximately 1/4 inch in depth) of approximately four feet by one foot in size. The concrete around the floor drain had several areas of a couple inches in depth where the concrete was missing. The areas of missing concrete near the drain were full of brackish water. There were several areas where there was water dripping from the counter onto the floor and onto the area of black slime. The wall behind the dish machine was buckling and coming away from the wall. The area of black residue streaked down the wall of the dirty side of the dish machine covering an area of approximately two by three feet and there was an area with black residue, also approximately two by three feet, on the wall underneath the counter. 3. During an interview on 09/27/23 at 4:44 PM the DD stated the floor in the dish room had been repainted since he had been working at the facility but verified it needed additional repair. The DD stated he had been employed by the facility for about five years. The DD stated he did not know what the black slimy substance was on the floor under the dish machine area, or how long it had been there. However, he stated it needed to be power washed. There were several areas of dripping water onto the floor verified by the DD. The DD stated the dietary staff was responsible for cleaning the floor in the dish room. The DD stated the floor was not a cleanable surface. The DD stated he was not aware of any plans to replace the floor in the dish room. There was black residue on the wall above the dish machine and on the wall under the counter of the dish machine verified by the DD. The DD verified the wall under the dish machine was buckling. During an interview on 09/28/23 at 9:49 AM, the Maintenance Director and surveyor entered the kitchen and walked into the dish room. The Maintenance Director stated he had no work orders in the electronic maintenance system for the dish room floor. He stated he had been employed for a year and two months. The Maintenance Director stated the floor was not cleanable due to the deteriorated state. He further stated to repair the floor he would close the dish room and he would have to reseal the concrete and then paint the floor, which would take a couple days. The Maintenance Director stated he did not know how long the floor had been in its present condition. The Maintenance Director verified the presence of the black slime on the floor under the counter of the dish machine and stated it would have to be power washed. The Maintenance Director stated he did not know what it (black slime) was. The Maintenance Director stated he did not know if the floor had been power washed on any ongoing basis, adding that maintenance kept the power washer. There were several continuous drips from the counter and the area of the disposal onto the floor and area of black slime. The Maintenance Director showed the surveyor there were holes in the stainless-steel countertop and along the welded area of the disposal and that was where the water was dripping. The Maintenance Director stated a pipe burst the previous winter and that might be the reason the wall was buckling under the dish machine. The Maintenance Director stated there was nothing planned or in place to repair the floor in the dish room. During an interview on 09/29/23 at 10:00 AM the Registered Dietitian (RD) stated she completed monthly sanitation reviews in the kitchen. The RD stated she had identified a sanitation concern with the dish room floor on one of her previous sanitation audits. Review of the RD's Kitchen/Sanitation Audit Form dated 04/28/23 revealed, Floors need improvement, staff to clean after lunch prep. Review of the facility's policy titled Environment, dated 09/17 and provided by the facility, revealed All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition . The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 26006 4. During lunch observation on the secure dementia care unit in the left and right dining rooms on 09/25/23 beginning at 12:42 PM, Certified Nurse Aide (CNA)5, CNA3, and Licensed Practical Nurse (LPN)3 were observed serving meal trays to residents in the left and right dining rooms and their own rooms. Neither staff member performed hand hygiene after serving a tray, prior to serving another resident's tray. -CNA5 served a resident a meal tray, touching the resident, the table, and the resident's wheelchair. She then began to assist the resident to eat without first performing hand hygiene. -CNA5 was assisting a resident to eat. The CNA touched another resident who was seated on her right side using her right hand. She then began assisting the resident on her left, using her right hand, without performing hand hygiene. During lunch observation on the secure dementia care unit on 09/27/23 beginning at 12:15 PM in the left and right dining rooms, CNA9, CNA2, and LPN3 were observed serving meal trays without performing hand hygiene between residents. -CNA9 served a meal tray to R16 and opened or unwrapped her meal items. She then returned to the meal cart and retrieved another tray without performing hand hygiene. CNA9 then served the tray to R48, set up her meal items, adjusted her bedside table, and moved her legs, then opened her straw completely and placed it in her drink by holding the top. CNA9 then unlocked R288's wheelchair, moved the chair, and locked it again. CNA9 then served another tray from the meal cart to R115 without first sanitizing her hands. CNA9 then returned to the meal cart and retrieved another tray without performing hand hygiene. She served R92 the meal, opened a straw completely and held the top as she placed it in a drink, and picked up the cups holding them at the drinking surface. -CNA2 served R130 of her meal and opened or unwrapped her meal items. She then returned to the meal cart and without performing hand hygiene, retrieved another meal tray to serve. -LPN3 unlocked R140's wheelchair and assisted him to reposition in the chair. She locked the brakes and without first performing hand hygiene, retrieved another meal tray from the cart and served R8. LPN3 then began assisting R121 to eat without first performing hand hygiene. In an interview on 09/29/23 at 10:38 AM, the Infection Preventionist (IP) stated she expected staff to sanitize or wash their hands between every tray while serving meals. She stated if a staff member was assisting two residents to eat at the same time, they should have sanitized their hands between residents. The IP stated staff was taught to leave the paper on top of a straw when opening to avoid touching the drinking surface, and to avoid touching the drinking surface when holding cups. The IP stated she had not done a formal audit of handwashing during meal service, but she would go around and remind them about hand hygiene. She stated the staff educator had done an audit and provided education on hand hygiene. Review of a QA [Quality Assurance] Audit Tool provided on paper, dated 09/18/23, revealed 30 observations of hand hygiene were completed. The audit did not document the names of staff observed but only their positions (CNA or LPN). The audit tool did not document the location or timing of the observations to determine whether any observations were made during meal service. In an interview on 09/29/23 at 1:34 PM, the Director of Nursing (DON) stated she expected the staff to sanitize their hands between every resident as they served meals. Review of the facility's policy titled Handwashing/Hand Hygiene, dated 01/22, revealed Use an alcohol-based hand rub containing at least 70% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:.before and after direct contact with residents,. after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident,.before and after eating or handling food,.[and] before and after assisting a resident with meals. NJAC 8:39-17.2(g) NJAC 8:39-19.7(d)

Based on interview, record review, and facility policy review, the facility failed to ensure the antibiotic screening documentation was completed for the use of antibiotics including identifying trends and implementing protocols to monitor the antibiotic use, measure the effectiveness of the antibiotics, and create an action plan to lower the use of antibiotics that did not meet the screening criteria for R91 and all residents receiving antibiotics with the potential to affect any residents who have taken antibiotics. Findings include: 1. Review of August 2023 Infection Log revealed there were five residents who received antibiotics for urinary tract infections. All five residents received a complete course of antibiotics as ordered. All five of them did not meet the antibiotic criteria. Review of the Order Listing Report, provided on paper and dated 09/29/23, revealed 17 residents had antibiotics in the month of September. There was no documentation in the electronic medical record (EMR) or in the Infection Preventionist's (IP) paper documents for any of the 17 residents who received antibiotics. During an interview on 09/29/23 at 10:45 AM the IP revealed she was responsible for the Antibiotic Stewardship program. She confirmed she had not completed screening tools for the 17 residents who had an infection in September 2023. She stated sometimes the screening was not completed until after the course of antibiotics had already been completed because she did not always have time to do it immediately upon initiation of an antibiotic. She confirmed sometimes those residents had antibiotic treatment when it had not been indicated by the screening tool. The IP stated she had not completed any reviews of facility antibiotic use and the effectiveness or lack of, for the antibiotics used by the 17 residents. During an interview on 09/29/23 at 1:35 PM the Director of Nursing (DON) revealed she had been aware the IP had completed some antibiotic screening tools and thought those tools should have been completed in the mornings by the IP. She also stated it had been discussed at their morning meetings. She agreed that the lack of screening with not utilizing the correct documents until several days after antibiotics had been started was not correct use of their screening tools. 43050 2. Review of R91's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included Parkinson's disease, depression, and chronic pain. Review of R91's Skin/Wound Note located in the EMR under the Progress Notes tab, dated 08/02/23 revealed a skin assessment on R91 following her report of pain in the sacrum area. Reopening of previous stage III sacral wound noted measuring 3x3x0cm (centimeters) with red wound bed. Scarring and non-blanchable erythema to surrounding skin. Review of R91's Health Status Note located in the EMR under the Progress Notes tab, dated 09/11/23, revealed that the case was reviewed with the collaborating physician. Discussed plan of care for pressure ulcer that was now a stage IV to the sacrum and foul smelling. No need for wound cultures. Wound culture was likely to delay treatment, grow multiple organisms and offer no additional information toward treatment plan. Would continue with empiric treatment of Vancomycin (a broad-spectrum antibiotic) via a peripherally inserted central catheter (PICC) line with a stop order of 09/27/23. During an interview on 09/27/23 at 4:10 PM the Infection Preventionist (IP) revealed I knew [R91] had a PICC line and was on an antibiotic, but I did not have time to look into it. I do not know if the pressure ulcer was cultured or what type of infection the resident had. When asked how the nursing staff would know what type of precautions to use, she stated That is a good question. During an interview on 09/28/23 at 9:50 AM the Nurse Practitioner (NP)1 revealed I discussed [R91] with the Medical Director, and he felt the resident needed to start on the antibiotic immediately. The wound was foul smelling and getting worse. I ordered the antibiotic and PICC line. R91's pain has improved, and the wound no longer smells. The IP never came to me for not obtaining a culture. During an interview on 09/29/23 at 1:35 PM the Director of Nursing (DON) revealed I do not know why the IP missed this antibiotic. At morning meetings, all antibiotics are discussed. If the antibiotic does not meet the McGreers Criteria, then the doctor is called for their rationale. NJAC 8:39-19.1(a) NJAC 8:39-19.4(d)

Based on observations, record review, staff interview, and facility policy review, the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four (Resident (R) 288, R41, R72, and R240) of seven residents reviewed for bed rail use of 41 sample residents. These failures had the potential to cause risk of entrapment or injury due to use of bed rails for these four residents. Findings include: 1. Review of R288's Admission Record, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: ataxia (poor balance), Alzheimer's disease with agitation, muscle weakness, abnormal posture, and delirium. Review of R288's significant change Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 08/01/23, revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and was assessed by staff with memory problems and had moderately impaired cognition with symptoms of inattention. She was rarely/never able to make herself understood or understand others. R288 required extensive physical assistance with bed mobility and total assistance with transfers. She had a history of falls prior to admission and one fall without injury in the facility. During an observation on 09/28/23 at 2:42 PM in R288's room, bilateral 1/4 bed rails were observed on her bed in the up position. Review of R288's Orders tab of the EMR revealed an order, which originated on 07/26/23, for bilateral 1/4 bed rails for mobility. Review of R288's activities of daily living (ADL) Care Plan under the Care Plan tab of the EMR, dated 06/20/23, revealed, [R288] has an ADL self-care performance deficit r/t [related to] Alzheimer's, impaired balance. The approaches included: SIDE RAILS: half rails up as per Dr.'s [doctor's] order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition (FREQ) and as necessary to avoid injury. Review of the Assessments tab of R288's EMR revealed there was no Side Rail Assessment. Cross-reference F700: Bed Rails - the facility failed to assess R288's need for the rails, safety with the rails, fit of the rails on the bed, or risks of using the rails. During an interview on 09/29/23 11:36 AM, the Maintenance Director (MD) stated he had assessed all the beds with side rails on 06/20/23; however, he had not done any assessments of newly installed side rails after 06/20/23, so R288's bed had not been assessed for proper fit and entrapment risk. During an interview on 09/28/23 at 4:46 PM, the Director of Nursing (DON) stated the maintenance bed assessment should have been completed on initiation of the rails and quarterly thereafter. 2. Review of R41's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses including: arthritis, abnormal gait, muscle weakness, cognitive communication deficit, obesity, repeated falls, and seizures. Review of R41's admission MDS assessment, with an ARD of 07/04/23, revealed she scored eight out of 15 on the BIMS indicating moderately impaired cognition. She required extensive assistance with bed mobility and transfers. R41 had a history of falls prior to admission. During an observation and interview with R41 in her room on 09/28/23 at 4:10 PM, bilateral 1/8 bed rails were observed at the head of R41's bed. The resident stated she used them to assist with getting into bed. Review of R41's Orders tab revealed an order for bilateral 1/4 bed rails for mobility, dated 07/03/23. Review of R41's ADL Care Plan, dated 07/14/23, revealed, SIDE RAILS: half rails up as per Dr.'s order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition (FREQ) and as necessary to avoid injury. Review of R41's Side Rail Assessment, dated 07/03/23, revealed, Based upon above assessment findings, the side-rail(s) is not a restraint and will be utilized to enable resident to attain or maintain his/her highest practicable level. Type: Bilateral 1/4 enablers. In an interview on 09/29/23 11:36 AM, the MD stated he had assessed all the beds with side rails on 06/20/23; however, he had not done any assessments of newly installed side rails after 06/20/23, so R288's bed had not been assessed for proper fit and entrapment risk. In an interview on 09/28/23 at 4:46 PM, the DON stated the maintenance bed assessment should have been completed on initiation of the rails and quarterly thereafter. 18947 3. R72's Admission Record, dated 09/29/23 and found in the EMR under the Profile Tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, type 2 diabetes, and hemiplegia and hemiparesis following a stroke. R72's admission Minimum Data Set assessment, dated 07/05/23 and found in the EMR under the MDS Tab, revealed a BIMS assessment score of seven out of 15 (severely cognitively impaired). The assessment indicated the resident required extensive assistance from staff to complete all his activities of daily living (ADLs), including transfers in and out of bed, and indicated bed rails were not in use for the resident. R72's Order Summary Report, dated 09/29/23 and found in the EMR under the Orders Tab, indicated orders for the resident to have bilateral left and right 1/4 side rails as needed for mobility. Review of R72's Comprehensive Care Plan, dated 07/06/23, and found in the EMR under the Care Plan tab indicated an Activities of Daily Living Care Plan related to the resident's limited mobility and hemiplegia. Interventions on the care plan included, in pertinent part, SIDE RAILS: half rails up as per Dr.'s (doctor's) order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition as necessary to avoid injury. Nothing could be found in facility or resident records to indicate a bed check had been done by maintenance or any other department to ensure the physical safety of R72's side rails. R72 was observed in his room laying in his bed on 09/28/23 at 2:51 PM and 4:24 PM and again on 09/29/23 at 9:14 AM. The resident's 1/4 side rails were in the raised position during all the observations. 4. R240's Admission Record, dated 09/29/23 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including breast cancer and obesity. R240's MDS assessment was not available due to the resident's recent admission to the facility. R240's Order Summary Report, dated 09/29/23 and found in the EMR under the Orders Tab, indicated orders for the resident to have bilateral left and right 1/4 side rails as needed for mobility. Review of R240's Comprehensive Care Plan, dated 09/10/23 and found in the EMR under the Care Plan tab, indicated no care plan related to the resident's use of side rails. R240's most recent Nursing Comprehensive Assessment, dated 09/08/23 and found in the EMR under the Evaluation Tab, indicated the resident did not have side rails on her bed because they were not indicated at this time. Nothing could be found in facility or resident records to indicate a bed check had been done by maintenance or any other department to ensure the physical safety of R72's side rails. During an interview on 09/29/23 at 11:36 AM, the MD indicated he had completed physical bed checks on the beds of residents who had side rails most recently on 06/22/23. He stated the facility process was the physical therapy department would send him a request to check a bed for side rail safety through the facility's TELS system and then he would check the bed, however he had not done any additional physical bed checks since 06/22/23 when he did his annual bed safety checks. The MD confirmed he was unable to locate physical bed safety checks for either R72 or R240. During an interview on 09/29/23 at 1:46 PM, the DON indicated her expectation was a physical bed/rail safety check was to be done for every resident with side rails on their bed when side rails were initiated and then at least annually after that. Review of facility's policy titled Proper Use of Side Rails Policy; most recently revised in 05/23, read, in pertinent part The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; and 10. Inspection by maintenance department annually for bed safety and entrapment risk. NJAC 8:39-27.5(b) NJAC 8:39-31.2(d)(e)

COMPLAINT # NJ 4 Based on interviews, review of Medical Records (MR), and review of other pertinent Facility documents on 2/19/21 and 2/24/21, it was determined that the Facility staff failed to ensure a resident with severe cognitive impairment was appropriately protected to prevent the resident from actual abuse by a staff member. The facility staff also failed to follow their policy titled: Abuse Prohibition, to notify the Police and the New Jersey Department of Health (NJDOH) timely, for 1 of 3 residents (Resident #1) reviewed for abuse. On 2/10/21, during the 11:00 p.m. to 7:00 a.m. shift a Certified Nursing Assistant (CNA #1) used a floor mat and furniture to barricade a Resident in the bed. Several staff members on the 7:00 a.m. to 3:00 p.m. shift observed the furniture in place and failed to remove the barricade or report it to the Supervisor or Administration until approximately 7 hours later when the Speech Therapist (ST) observed the furniture blocking the bed and alerted her Director. This placed Resident #1, as well as all residents with cognitive impairment in an Immediate Jeopardy (IJ) situation. The IJ was identified on 2/24/21 at 2:40 p.m., when the Administrator (Admin) and the Director of Nursing (DON) were notified of the IJ situation and were provided the IJ template. The IJ ran from approximately 6:40 a.m. on 2/10/21, until 2/10/21 at approximately 2:30 p.m., when the Unit Manager (UM) reported the incident to the Director of Nursing (DON) and the Administrator and removed the CNAs and the Nurse from their assignment and suspended them pending the investigation. The Facility provided an acceptable Removal Plan which included in-servicing of the staff involved on Abuse, Reporting of Abuse and Prohibition Restraints Policy which removed the Immediacy. The IJ was Past Non-Compliance (PNC). This is deficient practice is further evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), an assessment tool dated 1/30/21, indicated Resident #1 was unable to ambulate and required extensive assistance for Activities of Daily Living (ADLs). Review of Resident #1's Care Plan (CP) revealed a Focus of Impaired/Decline in cognitive function or impaired thought processes related to a condition other than [MEDICAL CONDITION]: Dementia (other than [MEDICAL CONDITION]) evidenced by a Brief Interview for Mental Status (BIMS) score of 3/15 on 1/27/21. According to the Progress Notes dated 2/8/21, the Registered Nurse (RN) documented Resident #1's mental status as alert and oriented to person with severely impaired decision-making skills for daily routine. According to the documentation on the Facility's Reportable Event Record/Report (FRE), reported to the New Jersey Department of Health (NJDOH) by the Director of Nursing (DON) on 2/12/21, with an event date and time of 2/10/21 at 1:30 p.m., the DON reported the type of incident as Staff-to-Resident Abuse. The FRE Narrative, described the event as follows: At approximately 1:30 p.m. on 2/10/21, the staff went into Resident #1's room and upon entering the room the staff observed the residents left side of the bed against the wall and on the right side of the bed was a floor mat up against the side of the bed with dressers at the head and foot of the bed. The staff immediately removed the furniture away from the bed and removed the bed away from the wall. The resident was assessed, and no injuries were found. Staff involved and caring for the resident at the time were suspended pending the investigation and sent home. According to the Individual Statement Form, obtained by Administration during the investigation: The 11:00 p.m. to 7:00 a.m., CNA (CNA #1) documented that when she entered Resident #1's room on 2/10/21, she observed the resident hanging on the bed, she put the resident back in bed and sat there to keep an eye on him/her. When CNA#1 looked out the door she noticed another resident coming out of their room who needed assistance. When she looked back at Resident #1, he/she was again trying to get out of bed (OOB), so she put the dresser in front of the bed before leaving the room. CNA #1 then attended to several other residents before seeing the oncoming CNA (CNA #2). CNA #1 stated that during rounds with CNA #2 she reported to her that she had put the dresser next to the bed because she had to attend to another resident and asked if CNA #2 would remove it for her. According to the Individual Statement Form, the 11:00 p.m. to 7:00 a.m., Licensed Practical Nurse (LPN) documented that she checked the vital signs and blood sugar on Resident #1 around 6:10 a.m. on 2/10/21, and had observed the bed in the lowest position, the floor mat was next to the bed, and the bed was against the wall. The furniture was not against the bed preventing the resident from getting up. According to the Individual Statement Form, the 7:00 a.m. to 3:00 p.m., CNA (CNA #2) documented that upon arriving on her shift on 2/10/21, Resident #1's bed was against the wall and furniture was against the bed. The resident gets out of bed. So, the table drawer is by his/her bed. The bed is all the way down and we checked on him/her often. When she worked on 2/9/21, the bed was against the wall, but no furniture was against the bed. When she worked on 2/7/21, upon leaving for the night the furniture was not against the bed. The bed was against the wall because he/she attempts to get out of the bed. According to the Individual Statement Form, the 7:00 a.m. to 3:00 p.m., CNA (CNA #3) documented that she noticed the furniture was against the wall in the morning on 2/10/21, but prior to that date there was no furniture against the bed. The resident's bed was placed alongside of the wall to create space to use the Hoyer lift for transferring. According to the Individual Statement Form, the 7:00 a.m. to 3:00 p.m., Registered Nurse (RN) documented that when she arrived to the unit on 2/10/21 in the a.m., she had noticed that the bed was against the wall with furniture on the right side, and the fall mat was on the floor. The furniture was not next to the bed when she worked on 2/9/21, however, the bed had been against the wall since last week and even with the bed against the wall the resident was still trying to get up independently. The RN also documented that Resident #1 was a fall risk and had fallen a week prior after attempts of getting up unassisted. According to the Individual Statement Form, the Occupational Therapy Assistant (OTA) documented that upon entering Resident #1's room on 2/10/21, she observed the resident sleeping in bed with the bed pushed against the wall and a floor mat on its side with 2 dressers blocking the side of the bed. According to the Individual Statement Form, the Unit Manager (UM) documented that when she went onto the unit on 2/10/21, to get report around 8:30 a.m., the nurse did not report any issues regarding Resident #1. Around 1:30 p.m., she received a call from the Director of Rehabilitation (Rehab) with concerns about safety of a resident. She immediately went to Resident #1's room and observed the resident resting comfortably in bed. The left side of the bed was against the wall, on the right side there was a fall mat on its side against the bed, there was 2 dressers next to the fall mat. After assuring the resident was safe, I reported my finding to the DON. Review of the Investigation Summary, dated 2/10/21, under Nature of Incident, was Inappropriate fall intervention, the documentation included: At approximately 6:40 a.m., the CNA was sitting with Resident #1 because he/she was agitated, when another resident urgently required the attention of the CNA. The CNA propped the floor mat against the bed next to the furniture before leaving the room. At 7:00 a.m., the next shift came in and completed rounds. Resident #1 received morning ADLs and was assisted with both meals. The therapist identified that the floor mat was being used inappropriately and reported the concern. The assigned care staff were placed on administrative leave pending an investigation. Further review of the Investigation Summary, dated 2/10/21, revealed documentation that interviews completed revealed that the staff member who put the mat against the bed and those who cared for Resident #1 on the following shift were conflicted on how best to keep the resident safe since he/she was unaware of his/her own limitations making the resident a fall risk. Each staff member was motivated by their responsibility and desire to keep the resident safe although the intervention chosen was not appropriate. The staff members will be brought back on 2/16/21, or their next scheduled shift thereafter with re-education on appropriate fall interventions, restraint protocols, and abuse prohibition. Each staff member will be monitored weekly for a period of one month. Review of the FRE showed documentation that the following interventions were put in place: The staff caring for Resident #1 were sent home and suspended pending the investigation. Resident #1 was assessed for injuries and none were found. The furniture and the bed were readjusted and positioned properly. During an interview on 2/19/21 at 11:45 a.m., the DON stated that the UM and the DR came to her office around 2:00 or 2:30 p.m. on 2/10/21 and reported that the furniture in Resident #1's room was positioned next to the bed. They said the staff had it like that to prevent him/her from getting OOB so he/she would not fall. The DON reported the incident to the Administrator (Admin) prior to going to the unit. When the DON arrived on the unit, she asked the 2 CNAs and the LPN to go to the nursing station and wait there until she came back to interview them and get their statements. Upon entering the room she observed the right side of the bed against the wall and the dressers were on the side of the bed, one near the head of the bed, and the other dresser was near the bottom of the bed. The floor mat was positioned between the bed and the dresser. The staff then removed the barricade from around the bed and put the floor mat back in place next to the bed on the floor. The DON also stated that despite the dressers and floor mat up against the bed the resident could still get OOB but was likely to have a more severe injury because he/she could get caught between the dressers. During an interview on 2/19/21 at 1:04 p.m., the OTA stated the Speech Therapist (ST) reported to her that the furniture was around the bed and Resident #1 was barricaded in the bed with the dressers. The ST said she would call the Director of Rehab, so the OTA went to the unit. The OTA observed the bed against the wall with the floor mat tilted on its side vertically and the dressers were pushed up against the mat holding the mat up. The mat was between the dressers and the bed. The resident at that time was sleeping. The OTA was not sure if she moved the floor mat or the dressers away from the bed prior to leaving the room. During an interview on 2/24/21 at 9:51 a.m., the Speech Therapist (ST) reported that on 2/10/21 a CNA reported to her that Resident #1 was agitated that day, so she waited and did not see him until around 1:30 p.m. When she walked into Resident #1's room she observed the blue mat and 2 dressers next to the bed. The bed was against the wall on the left side, the mat was standing up and it was kind of holding him/her in the bed. It was a barrier to keep him/her in bed. The ST stated that Resident #1 had good days and bad days. Some days he/she was confused, sleepy, unable to focus and easily distracted, other days he/she was alert and focused. The nurse told the ST they were looking into Resident #3's medications because of the behaviors and fatigue. The ST also stated she left everything as is because it was like a crime scene. The ST returned to the Rehab department and notified a co-worker of the barricade. The co-worker went right over there to see him/her while the ST called the Director of Rehabilitation (DR). The ST also stated, that she did not report the incident to anyone since she did not see any nurse on the unit and since the resident was calm, but she did not move any furniture away from the bed prior to leaving the room. Because he/she was calm I did not move anything because I wanted nursing to see it. I preferred nursing to see the side of it, so I did not move it. The ST agreed that Resident #1 could have been in danger because the furniture was left in place. Yes, if he got agitated and tried to climb over the dresser yes, he could have gotten hurt. Because he was calm, I left everything as is. The ST returned to the Rehab department and reported her observation to her coworker, the Occupational Therapy Assistant (OTA) then called the DR. During an interview on 2/24/21 at 10:24 p.m., the DR stated that on 2/10/21, in the afternoon (not sure of the time), she received a call from the OTA who reported that Resident #1 had a floor mat tipped on its side against the bed and 2 dressers were holding the floor mat in place against the bed. The DR immediately called UM and reported the incident to the UM. The DR informed the UM that she would notify the Administrator. During an interview on 2/24/21 at 10:53 a.m., the UM stated that on 2/10/21 around 1:30 p.m. she received a phone call from the DR who reported that the Rehab staff saw Resident #1 in bed with the floor mat and dressers against the bed. The UM immediately went to the unit and saw CNA #1 and CNA #2 and asked them what was going on? Neither CNA reported anything about Resident #1 or anything about the furniture against the bed to the UM. The UM also stated, I walked into the room and thought thank God I'm not a Department of Health Surveyor because this would get us in a (expletive) load of trouble. The left side of the bed was against the wall, the floor mat was upright against the opposite side of the bed with 2 dressers against the mat. I checked the resident to make sure he/she was okay. He/she was calm and was sleeping. The UM further stated that when she received morning report from the nurse no behaviors or falls were reported to her. She left everything in place and went to get the DON. I felt I needed someone to see it to prove it. The UM stated that she did not ask any other staff member to watch Resident #1 for safety while she left the unit to go get the DON. She returned to the unit with the DON, and at that time they put the floor mat back on the floor next to the bed and put the dressers back in place. The UM stated that it is everyone's responsibility to keep the residents safe and leaving the barricade in place still put his/her safety at error. I also made an error in judgement. During an interview on 2/24/21 at 10:55 a.m., the LPN stated, that nothing was out of place when she went into Resident #1's room to check the blood sugar at 6:00 or 6:10 a.m. on 2/10/21. The bed was in the lowest position and the resident was sleeping. No one else was in the room at that time. The LPN also stated that the staff did not report Resident #1 had any negative behaviors or attempted to climb out of the bed during the night. During an interview on 2/24/21 at 11:49 a.m., the day shift CNA #2 stated, at the start of her shift she made rounds around 7:00 a.m., and saw Resident #1 sleeping in bed with the floor mat upright against one side of the bed with dressers holding the mat in place and the other side of the bed was against the wall. The CNA reported that she did not remove the barricade because Resident #1 was combative and attempts to get OOB. She left the furniture in place because of his/her behaviors and did not think to report it to anyone. She also reported that the resident could have really hurt himself/herself and all the staff are responsible for the resident's safety. During an interview on 2/24/21 at 12:20 p.m., CNA #3 stated, that when she went in Resident #1's room she observed the bed against the wall and the floor mat against the bed and thought this is something new, however Resident #1 was never combative with her. The mat was there when she first came in at the beginning of her shift and the small end table was at the foot of the bed. She also agreed that it is a safety issue if there is a barricade around the bed and the resident could get hurt. During an interview on 2/24/21 at 12:38 p.m., RN#1 stated, that she observed the barricade in place around Resident #1's bed when she made rounds at the beginning of her shift, around 7:00 a.m. She reported that the left side of the bed was up against the wall and the right side of the bed had the floor mat standing upright behind 2 nightstands. At that time, she said the resident was calm and was sleeping but he/she would have periods of confusion and behaviors of being combative and would hit staff during care. The RN also agreed that it is a safety issue if there is a barricade around the bed and the resident could get hurt. Review of the Investigation Summary, dated 2/10/21,Conclusion and Plan, listed the following: Although the actions of the staff caring for Resident #1 could have been perceived as abuse, there was no intent to harm. There was only intent to keep the resident safe and uninjured by a fall. The staff as well as the employee assigned to care for Resident #1 on 2/10/21 were re-educated. Each staff member assigned will be monitored weekly for a period of one month. Daily room rounds will be completed to ensure appropriate fall interventions are in place. Findings will be recorded and reported during monthly Quality Assurance and Performance Improvement (QAPI). CNA #2 verified that she was in-serviced on Abuse at the Facility upon hire 11 months ago, and that she was aware that barricading a resident in bed is a form of restraint and restraints are a type of abuse. CNA #2 also stated that the staff are responsible for the resident's safety and Resident #1 could have really been hurt. Several attempts were made to interview CNA #1 by phone, however, she failed to return phone calls from the Surveyor. Review of the Facility's In-Service Training Record showed CNA #1 was in-serviced on the topic Abuse Training on 9/3/20. Review of the Facility's In-Service Training Record showed CNA #2 was in-serviced on the topic Abuse Prevention and Reporting on 9/3/20. Review of the Facility's In-Service Training Record showed CNA #3 was in-serviced on the topic Abuse Training on 9/2/20, and she reported yearly in-servicing on abuse. Review of the Facility's Course Training Record showed the RN was educated on Abuse Prohibition on 8/26/19, and Dementia Care on 2/8/20. According to the Facility Policy titled Abuse Prohibition with an effective date of 6/1/96, and a Revision date of 7/1/19, revealed under Policy, (Facility Name) prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Centers also strive to comply with the Elder Justice Act (EJA). Under the EJA, employees are designated as mandated reporters and are obligated to immediately report any suspicion of a crime against a resident. Reporting a suspicion of a crime only to an immediate supervisor does not meet the obligation to report. Retaliation in any form against an employee who reports a suspicion is strictly prohibited. According to the Facility Policy titled Reporting, under Federal Law, Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made. Report allegations involving neglect, exploitation or mistreatment (including injuries of unknown source) and misappropriation of resident property within 24 hours if the event does not result in serious bodily injury. Resident #1, a cognitively impaired resident was barricaded in bed by a CNA on 2/10/21, with a floor mat upright and dressers. Several staff members observed the barricade/restraint and failed to report the incident immediately to the Supervisor or Administration or remove the furniture until 7 hours later. This deficient practice placed Resident #1, as well as all residents with cognitive impairment in an Immediate Jeopardy (IJ) situation. The Removal Plan was verified on 2/24/21, the second day of the survey. The Immediate Jeopardy was past Non-Compliance. Interventions to remove the Immediacy were verified on 2/24/21, the second day of the survey and included, in-servicing, disciplinary action and education to employees who failed to report the incident, and suspension and education of the CNAs. N.J.A.C.8:39-4.1(a)5

Based on observation, interview and record review, it was determined that the facility failed to develop interventions to address safety measures for a resident with Pica behavior. The resident was admitted to the facility with a [DIAGNOSES REDACTED]. The behavior was identified by family members prior to admission and was communicated to the facility staff, according to the Admission note dated 8/18/14. This behavior continued in the facility from August 2014 to September 2015. In August 2015, the resident was admitted to the hospital and underwent surgery for [REDACTED]. Upon re-admission to the facility, care plan interventions were not revised and the resident had another incident on 9/17/15, of attempting to eat a sock. This resulted in an Immediate Jeopardy situation that was identified on 9/18/15 at 11:45 a.m., and corrected on 9/18/15 at 1:50 p.m., based on an acceptable plan of correction that was implemented by the facility. The resident's behavior and the facility's lack of supervision and safety interventions, posed a serious and immediate threat to the safety of Resident #12, who was 1 of 12 residents reviewed for safety interventions. This deficient practice was evidenced by the following: The surveyor reviewed the medical record of Resident #12 on 9/17/15 at 9:00 a.m., which indicated that the resident had [DIAGNOSES REDACTED].#12 was admitted from home via ambulance. At that time the resident was Spanish speaking and very confused with a Brief Interview for Mental Status (BIMS) score of 0 indicating severe mental impairment. The note also indicated that the resident's daughter stated the resident had Pica and would eat anything he/she saw, even his/her own feces. The surveyor observed Resident #12 on 9/17/15 at 10:00 a.m., asleep on top of the bed in his/her room. The resident's room was located down the farthest end of the hall from the nurses' station, where he/she shared the room with a roommate. The surveyor observed Resident #12's side of the room to be void of any objects or personal items, while the roommate's side of the room had multiple personal items and wound dressings displayed within reach of Resident #12. Further review of the medical record revealed multiple entries in the Progress Notes describing the Pica behavior of Resident #12 as eating non food items such as plastic, paper, briefs, and napkins. On 8/3/15 the resident was admitted to the hospital with [REDACTED]. A 10 cm plastic object was found lodged in the resident's intestine at that time. Resident #12 was re-admitted to the facility on [DATE]. The surveyor reviewed the Care Plan of Resident #12 on 9/17/15 at 11:00 a.m. An initial care plan dated 8/28/14 identified that the resident exhibited socially inappropriate behavior, as evidenced by a history of putting objects in his/her mouth. Review of care plan interventions were non-specific and standard in nature and did not specifically address how supervision would be provided to the resident. On 9/17/15 at 11:15 a.m. the Director of Nursing (DON) told the surveyor that the IDC Team was aware of the resident's Pica behavior, and that the care plan interventions were working. The DON further stated that the care plan was revised post-operatively when the resident was readmitted to the facility. The surveyor reviewed the resident's post op (re-admission) care plan at that time which indicated no change in interventions from the pre hospital care plan. Further Review of the POS [REDACTED]. On 9/17/15 at 11:20 a.m., the administrator told the surveyor that 1:1 supervision could not be provided to residents in the facility. The administrator further stated that measures such as 15 minute checks, consulting S-Cope to develop a behavior plan, or moving the resident closer to the nurses' station had not been considered. The DON further stated that investigations of the above incidents had not been done. On 9/18/15 at 10:00 a.m., the administrator told the surveyor that 15 minute checks had been initiated for Resident #12, S-Cope was notified for consultation and the resident's room was moved closer to the nurses' station. These interventions were all initiated after surveyor inquiry of the issues. At 10:30 a.m., the administrator told the surveyor that 1:1 supervision would be provided to Resident #12 and the resident would be re-assessed for appropriate placement. On 9/18/15 at 11:45 a.m., the facility was notified of Immediate Jeopardy and that the lack of effective interventions for the safety of Resident #12 posed a serious and immediate threat. On 9/18/15 at 1:50 p.m., the facility submitted an acceptable Plan of Correction which was verified by the survey team. The plan included the following: 1) The Center will immediately implement a one on one supervision for this resident. An RN will complete an assessment, including abdomen sounds and GI evaluation. The physician has been notified. The resident will be placed in a private room. The room has been inspected and any identified ingestible items will be removed. The care plan was updated to reflect new interventions. S-Cope has evaluated the resident. All recent incidents of patient's attempts to ingest inedible objects will be investigated. 2) This is the only resident residing in the center with the [DIAGNOSES REDACTED]. Staff will be inserviced on identifying patients at risk for ingestion of non-edible objects and to care plan this risk and appropriate interventions applied. Staff will also be inserviced on completion of investigation of incidents whenever a resident attempts (or actual) ingestion of inedible objects, as well as new interventions for Resident #12. 3) Unit Managers will identify all residents with the [DIAGNOSES REDACTED]. On a monthly basis unit Managers will audit all medical records of residents identified at risk for this unsafe practice. They will also audit their care plans, interventions and incident reports for completeness and trends monthly. 4) The Director of Nursing will evaluate the Unit Manager reports for accuracy, trends and appropriate follow up. The Director of Nursing will report her findings to the Center CQI Committee on a monthly basis. On 9/21/15 at 9:00 a.m., the surveyor confirmed via sign-in sheets and interview with staff that inservice training had been conducted according to the POC. Review of the Care Plan revealed a new care plan dated 9/17/15, which identified the potential for intestinal bowel obstruction related to [DIAGNOSES REDACTED]. Refer to F 323 NJAC 8:39-11.2

Based on observation, interview and record review, it was determined that the facility failed to provide adequate supervision and a safe environment for a resident with maladaptive behavior. The resident was admitted to the facility with a [DIAGNOSES REDACTED]. According to the initial assessment note, dated 8/16/14, this behavior was identified by family members prior to admission, and continued in the facility from August 2014 to September 2015, a period of 13 months without specific interventions to monitor this behavior for possible self injury. In August 2015, the resident was admitted to the hospital and underwent surgery for [REDACTED]. Upon re-admission to the facility, the resident continued to attempt to eat non-food items without specific interventions on the plan of care. The resident's behavior and the facility's lack of supervision and safety interventions, posed a serious and immediate threat to the safety of Resident #12, who was 1 of 12 residents reviewed for safety interventions. This resulted in an Immediate Jeopardy situation that was identified on 9/18/15 at 11:45 a.m., and corrected on 9/18/15 at 1:50 p.m., based on an acceptable plan of correction that was implemented by the facility. This deficient practice was evidenced by the following: The surveyor reviewed the medical record of Resident #12 on 9/17/15 at 9:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED].#12 was admitted from home via ambulance. Review of the notes revealed that the resident was Spanish speaking and very confused, with a Brief Interview for Mental Status (BIMS) score of 0 indicating severe mental impairment. The note also indicated that the resident's daughter stated that the resident had Pica and would eat anything he/she saw, even his/her own feces. The surveyor observed Resident #12 on 9/17/15 at 10:00 a.m., asleep on top of the bed in his/her room. The surveyor observed the resident's room to be located at the farthest end of the hall from the nurses' station, where he/she shared the room with a roommate. The surveyor observed Resident #12's side of the room to be void of any objects or personal items, while the roommate's side of the room had multiple personal items and wound dressings displayed within reach of Resident #12. Further review of the medical record on the above date and time, revealed multiple instances from 8/18/14 to 9/17/15, ( a period of 13 months), of Resident #12's Pica behavior. The Progress Notes included the following: On 11/12/14, the resident ate an incontinence brief. In addition, the resident was noted to pick up objects from the floor and try to eat them. The note further indicated that Resident #12 was wandering in and out of resident's rooms. On 12/20/14, Resident #12 was noted by staff drinking Tea Tree Shampoo. The Poison Control Center was notified. On 12/25/14, the Interdisciplinary Team (IDCP) identified the resident to be at risk for bowel obstruction, because the resident places non-edible objects in his/her mouth. On 3/9/15, the resident was observed putting plastic sandwich wrappers, napkins and briefs in his/her mouth. On 6/28/15, the physician noted that while being examined, the resident was eating a napkin. On 7/31/15, at 23:10, the resident was observed lying in bed with his/her hand on his/her stomach. The resident refused to eat at dinner despite encouragement and was noted touching his/her stomach and complained of a stomachache. The resident was encouraged to go to the bathroom, but did not have a bowel movement (BM). Resident #12 was offered prune juice and consumed 60%, then pushed the hand of the nurse away. According to the note, Dulcolax 10mg suppository was given rectally for constipation. The resident was noted to be bearing down while moving his/her bowels, and had a small hard stool. The physician was notified of the resident's condition and new orders were obtained, for 1) Fleet enema rectally x 1 dose, 2) Senna 2 tabs at bedtime. The note indicated that the resident had a large amount of yellowish liquid vomitus after given the fleet enema. The resident was asked if he/she felt better and he/she nodded. On 8/1/15 at 23:49, the resident vomited a large amount of yellowish liquid vomitus. The resident refused to eat. The resident had no BM and Milk of Magnesia (MoM) was given for constipation, with no results. A Dulcolax Suppository was then given rectally and the resident had a small, hard stool. On 8/2/15 at 06:42, the resident complained of stomach discomfort. At 12 a.m., the resident vomited a moderate amount of foul smelling brownish vomitus. The resident had a moderate amount of formed stool and passed a lot of foul smelling gas all night, according to the note. On 8/2/15 at 22:50, the resident was observed to be confused and walking the hallways. The resident's appetite was documented as poor. The resident's abdomen was documented to be soft, non-distended and positive for bowel sounds. MOM was given for constipation, with no results. A Dulcolax suppository was given rectally and the physician was notified of the resident's status. The physician ordered an x-ray of the resident's abdomen. On 8/3/15 at 7:10, the resident complained of abdominal discomfort, and did not have a bowel movement all night. On 8/3/15 at 15:31, the resident did not have a bowel movement and was hand fed by staff, but only ate 25% of breakfast. The resident refused to eat lunch and vomited a moderate amount of undigested food from breakfast. The abdominal x-ray was performed, as ordered by the physician. The results of the x-ray revealed the bowel gas pattern was without obstruction or free air, no renal stone or mass visible. The physician was notified of the results and ordered to send the resident to the hospital for further evaluation. Resident #12 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of the hospital records revealed an initial History and Physical (H&P), in which the physician documented that the resident had a small bowel obstruction of unclear etiology. The note further indicated the patient could have eaten something that caused small bowel obstruction. The H&P further noted the patient had a history of [REDACTED]. On 8/3/15, the resident had a CT of the Abdomen performed, which showed a small bowel obstruction, with moderate to severe dilation of the proximal and mid small bowel. On 8/7/15, the resident underwent [REDACTED]. The bowel was cut open, revealing a plastic-appearing foreign body. On 8/19/15 at 02:32, the resident returned to the facility. According to the Progress Notes, the resident was ambulatory at that time. On 9/17/15 at 15:08, Resident #12 was noted removing his /her sock and put in in his/her mouth. The resident was encouraged to give it to the nurse. The resident initially refused, but was able to be redirected and eventually gave it to the nurse. The surveyor reviewed the Care Plan of Resident #12 on 9/17/15 at 11:00 a.m., which revealed an initial care plan dated 8/28/14, which identified the resident to exhibit behavior, socially inappropriate as evidenced by a history of putting objects in his/her mouth. Review of care plan interventions revealed that they were non-specific and standard in nature and did not specifically address how supervision would be provided to the resident. On 9/17/15 at 11:15 a.am. the Director of Nursing (DON) told the surveyor that the IDC Team was aware of the resident's Pica behavior, and that the care plan interventions were working. The DON further stated that the care plan was revised post- operatively, when the resident was readmitted to the facility. The surveyor reviewed the resident's post op care plan at that time which was exactly the same as the initial care plan. On 9/17/15 at 11:20 a.m., the administrator told the surveyor that 1:1 supervision could not be provided to residents in the facility. The administrator further stated that measures such as 15 minute checks, consulting S-Cope to develop a behavior plan, or moving the resident closer to the nurses' station had not been considered. The DON further stated that investigations of the above incidents had not been done. On 9/18/15 at 10:00 a.m., the administrator told the surveyor that 15 minute checks had been initiated for Resident #12, S-Cope was notified for consultation and the resident's room was moved closer to the nurses' station. At 10:30 a.m., the administrator told the surveyor that 1:1 supervision would be provided to Resident #12 and the resident would be re-assessed for appropriate placement. On 9/18/15 at 11:45 a.m., the facility was notified that the lack of effective interventions for the safety of Resident #12 posed a serious and immediate threat. On 9/18/15 at 1:50 p.m., the facility submitted a Plan of Correction, which included the following: 1) The Center will immediately implement a one on one supervision for this resident. An RN will complete an assessment, including abdomen sounds and GI evaluation. The physician has been notified. The resident will be placed in a private room. The room has been inspected and any identified ingestible items will be removed. The care plan was updated to reflect new interventions. S-Cope has evaluated the resident. All recent incidents of patient's attempts to ingest inedible objects will be investigated. 2) This is the only resident residing in the center with the [DIAGNOSES REDACTED]. Staff will be inserviced on identifying patients at risk for ingestion of non-edible objects and to care plan this risk and appropriate interventions applied. Staff will also be inserviced on completion of investigation of incidents whenever a resident attempts (or actual) ingestion of inedible objects, as well as new interventions for Resident #12. 3) Unit Managers will identify all residents with the [DIAGNOSES REDACTED]. On a monthly basis unit Managers will audit all medical records of residents identified at risk for this unsafe practice. They will also audit their care plans, interventions and incident reports for completeness and trends monthly. 4) The Director of Nursing will evaluate the Unit Manager reports for accuracy, trends and appropriate follow up. The Director of Nursing will report her findings to the Center CQI Committee on a monthly basis. On 9/21/15 at 9:00 a.m., the surveyor confirmed via sign-in sheets and interview with staff that inservice training had been conducted according to the POC. NJAC 8:39-27/1 (a)