Every finding on record at Concord Healthcare & Rehabilitation Center

Repeat DeficiencyBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent foodborne illness, b.) store unused disposable beverage accessories in a manner to prevent foodborne illness, and c.) maintain kitchen sanitation in a safe and consistent manner to prevent foodborne illness.This deficient practice was evidenced by the following:On 4/6/2026 at 5:05 PM, the surveyor conducted an initial tour of the kitchen and food storage areas with Cook.Findings include:1. A large grey plastic trash bin lined with clear plastic bag was uncovered with the lid on the floor. The bin was located next to the walk-in refrigerator. There were no staff using the trash bin at that time. [NAME] stated that there was nothing there. The surveyor observed several stalks of celery, a plastic container of seasoning, and water bottles on top of other trash inside the bin. The surveyor asked the cook if the bin should be covered. The cook put the lid on the bin.2. The surveyor observed another uncovered trash bin propping the kitchen door to the hallway across the dining room. There were no staff using the trash bin at that time. The plastic liner of the trash bin was touching the handle of a black bussing cart. The cart contained 4 unopened soda cans and 1 unopened bottle of water on the upper shelf. On the middle shelf of the cart, there was an aluminum tray containing unused packets of sugar, wipes, paper napkins, and individually wrapped plastic cutlery sets. The bottom shelf of the cart contained another aluminum tray holding several unused disposable plastic cups. 3. Inside the bulk/ dry storage area, the surveyor observed a large box of overripe browned bananas. [NAME] stated, it is garbage and proceeded to take the box out of the storage area.4. Inside the bulk/ dry storage area, the surveyor observed a green plastic crate on the floor. The crate was lined with an untied plastic bag containing several red, medium to large size onions. The plastic liner was spread out around the crate and touching the floor. [NAME] #1 did not say anything when asked if the onions should be on the floor.5. A large brown carton box stained into dark brown color with blackish areas of mottling was observed on top of a plastic wrapped beverage dispenser. The staining was very greasy to touch. Inside the box were unused paper coffee filters with diameter size of 13 inches x 5 inches. The cook did not reply to the surveyor when asked about the greasy box.On 4/7/2026 at 9:26 AM, during a revisit tour of the bulk/dry storage area with the Food Service Director (FSD), the surveyor smelled a strong banana odor upon opening the door. The surveyor observed a large box of overripe brown bananas. The FSD stated that it is used for baking banana cakes.On 4/9/2026 at 8:48 AM, during an interview with the surveyor, the FSD stated that trash bins are allowed to be uncovered while cleaning the kitchen or being used. The FSD also stated that food on the floor is not acceptable. The FSD stated that they ordered ahead the bananas because of the [name of holiday redacted]. The FSD stated that if it is not the [holiday redacted], they only order once a week.A review of the undated facility policy titled Disposal of Garbage and Refuse included under Policy Explanation the following: 2.) Garbage and refuse containers shall be durable, cleanable, and free from cracks or leaks and covered when not in use.A review of the undated facility policy titled Food Storage included under Policy the following: Dry storage areas will be kept in a condition which protects stored food from infestation. Included under Procedure were the following: 1.) All items must be stored at least 6 inches off the floor. 6.) Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods. N.J.A.C. 8:39 - 17.2 (g)

Based on observation, interview, and review of other facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area and parking area free of garbage and debris and failed to have a cover over the opening of 2 of 2 garbage containers/dumpsters.This deficient practice was evidenced by the following:On 4/6/2026 at 5:01 PM, the surveyor observed 2 green, 1 blue, and 1 grey plastic milk crates scattered in the parking lot next to a grey sports utility vehicle (SUV).On 4/6/2026 at 5:26 PM, during the tour of the designated garbage area with the Administrator in Training (AIT), the surveyor observed a green garbage dumpster/ compactor. The dumpster was half-open. There was no staff loading any trash in the dumpster. The surveyor observed [NAME] rolled the lid on the green dumpster. The AIT stated that [NAME] had been working in the area with them. Prior to this, [NAME] was actually with the surveyor on the initial tour of the kitchen and food storage areas.On 4/6/2026 at 5:27 PM, the surveyor observed several plastic milk crates on the ground along with 2 grey plastic carts near the dumpsters area.On 4/6/2026 at 5:28 PM, the surveyor observed a red dumpster designated for recyclable trash. One of the 2 plastic lids was in the open position. Nobody was loading anything in the dumpster. The lid was lifted by the AIT to cover the dumpster. The area surrounding the dumpster was observed to have garbage on the ground. The garbage included an untied red plastic bag, milk crate, folded cardboard boxes and other unidentified debris.On 4/9/2026 at 8:48 AM, during an interview with the surveyor, the Food Service Director (FSD) stated that dumpsters should be covered at all times except when being used.A review of undated facility policy titled Disposal of Garbage and Refuse included under Policy Explanation the following: 7.) Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. N.J.A.C. 8:39 - 19.3 (c)

Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to administer enteral nutrition through tube feedings (delivery of nutrients directly into the stomach through a surgical opening) according to Physician's Order (PO). This deficient practice was identified for 2 of 2 residents (Resident #8 and Resident #41) reviewed for receiving nutrition via Tube Feeding (TF).This deficient practice was evidenced by the following:1.) On 4/6/2026 at 6:02 PM, the surveyor observed Resident #8 in bed. A tube feeding pump was located to the left of the resident's bed. The pump was observed off. There was no nutritional formula or free water being administered to the resident at this time. On 4/7/2026 at 8:55 AM, the surveyor observed the resident in bed. Certified Nursing Assistant (CNA) was observed shaving the resident's face. The TF pump was observed off. There was no nutritional formula or free water hanging in the TF pole.The surveyor reviewed the medical record for Resident #8.A review of the admission Record (admission summary) reflected that Resident #8 was admitted to the facility with diagnoses that included but not limited to traumatic brain injury, ileus (disruption of intestinal movement), and protein-calorie malnutrition. There was no documented medical condition for which the feedings were ordered.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 3/31/2026, indicated that Resident #8 had short-term memory problem and moderate impairment of cognitive skills. The MDS also indicated that the resident received nutrition through TF.A review of the Order Summary Report (OSR) started on 4/4/2026 and active as of 4/7/2026, included the following order: Start and hang feeding at 4 PM, Jevity 1.5 (a tube feeding formula) 80 milliliters per hour (ml/hr) until total volume of 1,000 ml infused, one time a day for enteral nutrition support. The resident also had a physician diet order for NPO (nothing by mouth) diet, NPO texture, NPO consistency. A review of the corresponding April 2026 Medication Administration Audit Report revealed that the formula feeding was administered late on the following dates and specific times:On 4/4/2026, the feeding formula due at 4 PM, was signed administered/ hung at 10:42 PM by Registered Nurse (RN) #1. There was no documented reason why the feeding was administered late.On 4/5/2026, the feeding formula due at 4 PM, was signed administered/ hung at 6:21 PM by RN #1. There was no documented reason why the feeding was administered late.On 4/6/2026, the feeding formula due at 4 PM, was signed administered/ hung at 7:49 PM by RN #1. A note by RN #1 dated 4/6/2026, indicated that the resident was put to bed after dinner service and that their TF was started at 7 PM.A review of the individualized comprehensive care plan initiated on 1/22/2026, included a focus for potential complications r/t (related to) enteral feeding and hydration via G-tube (TF). One of the interventions included the following: Administer tube feeding as ordered initiated on 1/22/2026.On 4/8/2026 at 11:15 AM, during an interview with the surveyor, Licensed Practical Nurse/ Unit Manager (LPN/ UM) stated that resident refusal for TF is documented in the nurses' notes. LPN/ UM also stated that physician orders should be administered an hour before and after. LPN/ UM stated that if the administration is habitually late, they would address the issue with the nurse and educate the nurse.On 4/8/2026 at 11:39 AM, during an interview with the surveyor, the Registered Dietician stated that the expectation for a TF ordered to be administered at 4 PM, was to be given at 4 PM so it does not interfere with activities or care, plus or minus an hour. On 4/9/2026 at 9:46 AM, during an interview with the survey team, RN #1 stated that they should be documenting the progress notes when TF are administered late or when residents refuse their TF. RN #1 further stated that they do not always have the time to document.On 4/9/2026 at 12:31 PM, during an interview with the survey team, the Director of Nursing (DON) stated that if tube feedings are administered late, it should be documented in the patient's record and that it is generally put in the progress notes.A review of the facility policy revised in February 2026, titled Enteral Nutrition indicated the following under Purpose: To provide adequate nutritional support through enteral nutrition is provided to residents as ordered. N.J.A.C. 8:39 - 25.2 (c) 2; 27.1 (a) 2.) On 4/6/2026 at 6:07 PM, the surveyor observed Resident #41 in bed. A tube feeding (TF) pump was located to the left of the resident's bed. The surveyor observed the pump to be off. There was no nutritional formula or free water being administered to the resident at this time. A private aide was with the resident. The resident mentioned to the surveyor that they can eat food. The private aide stated to the surveyor that the resident does not eat. On 4/7/2026 at 8:47 AM, the surveyor observed the resident in bed with TF of Jevity 1.5 infusing at 50 cubic centimeter/hour (cc/hr) simultaneous w/ water hydration.The surveyor reviewed the medical record for Resident #41.A review of the admission Record (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to dysphagia (difficulty swallowing), gastrostomy status (a surgical procedure used to directly provide nutrition to the stomach through a flexible tube, often referred to as a G-tube), and dementia.A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 2/23/2026, indicated that the resident had severely impaired cognition and that they received nutrition though TF.A review of the Order Summary Report (OSR) started on 3/2/2026 and discontinued on 4/1/2026, included the following order: Start &hang feeding at 6 PM Jevity 1.5 @ 30 ml/hr via G-Tube pump, run feeding until total volume infused of 720 ml, one time a day for Enteral Nutrition Support. On 3/7/2026, the PO was modified to the following: Start &hang feeding at 6 PM Jevity 1.5 @ 40 ml/hr via G-Tube pump, run feeding until total volume infused of 720ML, one time a day for Enteral Nutrition Support.A review of the corresponding March 2026 Medication Administration Audit Report revealed that the formula feeding was administered late on the following dates and specific times:On 3/2/2026, the feeding formula due at 6 PM, was signed administered/ hung at 10:42 PM by RN #1. TF was documented held in the day shift due to vomiting.On 3/3/2026, the feeding formula due at 6 PM, was signed administered/ hung at 10:04 PM by RN #1. There was no documented reason for late administration of TF.On 3/5/2026, the feeding formula due at 6 PM, was signed administered/ hung at 10:14 PM by LPN #1. Multiple attempts to administer the TF were documented refused by the resident.On 3/6/2026, the feeding formula due at 6 PM, was signed administered/ hung at 10:56 PM by RN #2. TF was documented refused due to nausea and vomiting.On 3/7/2026, the feeding formula due at 6 PM, was signed administered/ hung on 3/22/2026 at 6:10 PM by RN #1. There was no documented reason why the order was signed administered 15 days after the scheduled administration.On 3/8/2026, the feeding formula due at 6 PM, was signed administered/ hung on 3/22/2026 at 6:05 PM by RN #1. There was no documented reason why the order was signed administered 15 days after the scheduled administration.On 3/9/2026, the feeding formula due at 6 PM, was signed administered/ hung at 11:05 PM by RN #1. There was no documented reason why the TF was administered late.On 3/17/2026, the feeding formula due at 6 PM, was signed administered/ hung at 10:50 PM by RN #1. There was no documented reason why the TF was administered late.On 3/18/2026, the feeding formula due at 6 PM, was signed administered/ hung at 10:07 PM by RN #1. There was no documented reason why the TF was administered late.On 3/30/2026, the feeding formula due at 6 PM, was signed administered/ hung at 10:33 PM by RN #1. There was no documented reason why the TF was administered late.A review of the Order Summary Report (OSR) started on 4/2/2026 and active as of 4/7/2026, included the following order: Start &hang feeding at 4 PM Jevity 1.5 @ 50 ml/hr via G-Tube pump, run feeding until total volume infused of 720 ml, one time a day for Enteral Nutrition Support. The resident also had a physician diet order for Pleasure diet with mechanical soft texture and thin liquid.A review of the corresponding April 2026 Medication Administration Audit Report revealed that the formula feeding was administered late on the following dates and specific times:On 4/4/2026, the feeding formula due at 4 PM, was signed administered/ hung at 10:26 PM by RN #1. There was no documented reason why the TF was administered late.On 4/5/2026, the feeding formula due at 4 PM, was signed administered/ hung at 10:29 PM by RN #1. RN #1 documented in the progress notes that the resident refused the TF due to nausea and vomiting.On 4/6/2026, the feeding formula due at 4 PM, was signed administered/ hung at 10:19 PM by RN #1. There was no documented reason why the TF was administered late.A review of the individualized comprehensive care plan initiated on 8/18/2025, included a focus for TF related to protein calorie malnutrition. One of the interventions included the following: Monitor/document/report to MD PRN (as needed): Aspiration- fever, SOB (shortness of breath), tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration.On 4/8/2026 at 11:15 AM, during an interview with the surveyor, Licensed Practical Nurse/ Unit Manager (LPN/ UM) stated that resident refusal for TF is documented in the nurses' notes. LPN/ UM also stated that physician orders should be administered an hour before and after. LPN/ UM stated that if the administration is habitually late, they would address the issue with the nurse and educate the nurse.On 4/8/2026 at 11:39 AM, during an interview with the surveyor, the Registered Dietician stated that the expectation for TF ordered to be given at 4 PM so it does not interfere with activities or care, plus or minus an hour. On 4/9/2026 at 9:46 AM, during an interview with the survey team, RN #1 stated that they should be documenting the progress notes when TF are administered late or when residents refuse their TF. RN #1 further stated that they do not always have the time to document.On 4/9/2026 at 12:31 PM, during an interview with the survey team, the Director of Nursing (DON) stated that if tube feedings are administered late, it should be documented in the patient's record and that it is generally put in the progress notes.A review of the facility policy revised in February 2026, titled Enteral Nutrition indicated the following under Purpose: To provide adequate nutritional support through enteral nutrition is provided to residents as ordered. N.J.A.C. 8:39 - 25.2 (c) 2; 27.1 (a)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that the medication error rates was not 5% or greater. This deficient practice was identified for 1 of 7 residents (Resident #80), observed during the Medication Administration task. The deficient practice was evidenced by the following:On 04/07/2026 at 10:05 AM on the B Unit, the surveyor observed Registered Nurse (RN) #1 prepare Resident #80's medications for administration. At that time, RN #1, removed one Metoprolol Tartrate 25mg tablet (used to treat high blood pressure), two Sacubitril-Valsartan 15-16 mg Sprinkle Capsules (used to treat heart failure), one furosemide 20mg tablet (used to help the body get rid of extra fluid), and one Apixaban 2.5mg tablet (used to thin the blood to prevent formation of blood clots) and place them in the medication cup. At that time, the surveyor observed the Electronic Medical Administration Record (EMAR) on the medication cart computer with RN #1. The EMAR revealed that the Metoprolol was scheduled to be given at 8:00 AM and the Entresto, Furosemide and Eliquis at 9:00 AM.On the same date at 10:32 AM the surveyor then observed RN #1 enter Resident #80's room and administered the medications. On the same date at 10:34 AM during an interview with the surveyor, RN # 1 acknowledged that the medication was administered late. During an interview with the surveyor on 04/09/2026 at 12:30 PM the Director of Nursing (DON) stated that medications should be given up to one hour before to 1 hour after their scheduled time. A review of the policy titled, Administering Medications, revised February 2026, revealed under Policy Interpretation and Implementation number 4., Medications are administered in accordance with prescriber orders, including any required time frame. The policy further revealed under number 7., Medications are administered within one hour of their prescribed time.N.J.A.C.8:39-29.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate use of Personal Protective Equipment (PPE) during care to residents who required a.) Enhanced Barrier Precautions (EBP) (an infection control strategy focused on reducing the spread of multidrug-resistant organisms [MDRO] in nursing homes) and b.) Contact Precautions (CP), to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. This deficient practice was identified for 1of 2 residents (Resident #8) reviewed for Tube Feeding and 1 of 3 residents (Resident #7) reviewed for urinary catheter use.This deficient practice was evidenced by the following:Reference: Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.htmlReference: Providing hygiene refers to practices such as brushing teeth, combing hair, and shaving. Many of the high-contact resident care activities listed in the guidance are commonly bundled as part of morning and evening care for the resident rather than occurring as multiple isolated interactions with the resident throughout the day. Isolated combing of a resident's hair that is not otherwise bundled with other high-contact resident care activities would not generally necessitate use of a gown and gloves. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.htmlReference: Contact Precautions require the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident. The resident is given dedicated equipment (e.g., stethoscope and blood pressure cuff) and is placed in a private room. When private rooms are not available, some residents (e.g., residents with the same pathogen) may be roomed together. Residents on Contact Precautions are recommended to be restricted to their rooms except for medically necessary care, including restriction from participation in group activities. Contact Precautions are generally intended to be time limited and, when implemented, should include a plan for discontinuation or de-escalation. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html1.) On 4/7/2026 at 8:55 AM, the surveyor observed an EBP signage on Resident #8's door. A PPE bin was located on the right side of the doorway. The surveyor observed Certified Nursing Assistant (CNA) shaving Resident #8 and wiping their face with a wet towel from the right side of the resident's bed. CNA was wearing gloves but was not wearing a gown. The surveyor observed CNA leaning against the mattress to reach the resident's right side of the face. CNA's scrub suit was observed touching the bed sheet on the mattress.On 4/7/2026 at 9:40 AM, CNA opened the door of Resident #8's room. The surveyor asked CNA what care they provided the resident. CNA stated that they washed the resident in bed and changed them. The surveyor pointed to the EBP signage on the door. CNA stated to the surveyor, I need to wear a gown.The surveyor reviewed the medical record for Resident #8.A review of the admission Record revealed Resident #8 was admitted to the facility with diagnoses which included but not limited to Extended Spectrum Beta- Lactamase (ESBL) Resistance, neuromuscular dysfunction of the bladder, and unspecified open wound of the penis.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 3/31/2026, indicated that Resident #8 had short-term memory problem and moderate impairment of cognitive skills. The MDS also indicated that the resident received nutrition through Tube Feeding (TF) (delivery of nutrition through a surgical opening directly into the stomach or intestines). The MDS specified that the resident had an indwelling urinary catheter.A review of the Order Summary Report (OSR) active as of 4/7/2026, included the following orders: Start and hang feeding at 4 PM, Jevity 1.5 (a tube feeding formula) at 80 milliliters per hour (ml/hr) until total volume of 1,000 ml is infused, one time a day for enteral nutrition support; Foley catheter change every shift; and Maintain Transmission Based Precautions - EBP due to G-tube (TF) and Foley catheter.A review of Resident #8's comprehensive care plan initiated on 1/21/2026, indicated a focus for Foley catheter requirement due to neurogenic bladder (nerve damage that prevents the bladder from properly storing or emptying urine). The interventions included EBP. Another focus was for potential for complication related to enteral feeding (TF) and hydration. One of the interventions included EBP.2.) On 4/8/2026 at 11:54 AM, the surveyor observed the signage outside Resident #7's door that indicated the resident was on Contact Precautions. Outside the door was a PPE bin. The surveyor and the Registered Dietician performed hand hygiene and donned disposable yellow gown, gloves, and surgical masks and entered the resident's room to look at the resident's feeding tube pump. While inside the room, the surveyor observed Phlebotomist wheeling their rolling container inside the room. The phlebotomist wore gloves with no gown and mask and proceeded to put a blue tourniquet around the resident's right upper arm to draw blood. The surveyor called the attention of the phlebotomist and pointed the signage on the door. Phlebotomist said that they did not see the signage.The surveyor reviewed the medical record for Resident #7.A review of the admission Record revealed Resident #7 was admitted to the facility with diagnoses which included but not limited to Methicillin-resistant Staphylococcus aureus (MRSA) (a bacteria resistant to several antibiotics) infection, gastrostomy status (presence of surgical opening in the stomach for delivery of nutrition), and sepsis due to MRSA. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 3/17/2026, indicated that Resident #7 had long-term and short-term memory problems and moderate impairment of cognitive skills. The MDS also indicated that the resident received nutrition through Tube Feeding (TF). The MDS specified that the resident had an indwelling urinary catheter, 1 stage 3 pressure ulcer wound, and a central intravenous (IV) line.A review of the Order Summary Report (OSR) active as of 4/7/2026, included the following orders: Contact precautions related to MRSA of the blood.A review of Resident #7's comprehensive care plan initiated on 1/5/2026, indicated a focus for actual skin breakdown in the sacrum, enteral feeding, and Foley catheter use with interventions that included EBP.On 4/9/2026 at 8:58 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that employees and visitors are alerted to any precautions by signages at the door and PPE at the doorway.On 4/9/2026 at 12:31 PM, during an interview with the survey team, the Director of Nursing (DON) stated that vendors are asked by staff to follow signages for transmission-based precautions.A review of facility policy updated in February 2026, titled Enhanced Barrier Precautions under Policy Interpretation and Implementation included the following: 3.) Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .d.) providing hygiene. N.J.A.C. 8:39 - 19.4 (a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen equipment in a clean, safe, and sanitary manner and was evidenced by the following: On 12/16/24 at 09:45 AM, in the presence of the Food Service Director (FSD) the surveyor observed the ice machine which had a black sediment on the interior of the ice machine dispenser shoot. When the surveyor asked the FSD what it was, the FSD responded it was Black Mold and he would have it cleaned immediately. On 12/16/24 at 10:20 AM, the surveyor interviewed the FSD who stated the ice machine was cleaned quarterly but it seems to be needed more often. The FSD acknowledged that the interior of the dispensing shoot had black sediment in it. The FSD further stated that the ice machine is responsible for the food tray line and the ice coolers on the nursing units that provide ice to the residents. The FSD stated he would have all the ice chests pulled from the nursing units to be cleaned. On 12/17/24 at 9:50 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss the ice machine findings. The LNHA acknowledged the black sediment in the surveyors findings. On 12/20/24 at 10:09 AM, the surveyor interviewed the LNHA, who confirmed that the ice machine was cleaned quarterly and had just been done in the beginning of November. After reviewing the pictures, the LNHA acknowledged the black sediment found on the interior of the dispensing shoot. On 12/20/24 at 10:30 AM, the survey team met with the LNHA and DON and both acknowledged the surveyors findings. A review of the Ice Machines and Ice Storage Chests, dated revision January 2024, revealed . Policy: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy Interpretation and Implementation: 1) Ice making machines, ice storage chests/ containers, and ice can all become contaminated by: c) colonization by microorganisms. 2) To help prevent contamination of ice machines, ice storage chest/containers or ice, staff shall follow these precautions: Clean and sanitize the tray and the scoop daily. 3) cleaning interior according to manufacture instructions. A review of the manufacturers cleaning, sanitation and maintenance user manual, date 12/2018, revealed . The ice machine requires 3 types of maintenance: 1) remove the buildup of mineral scales from the ice machine's water system and sensors. 2) Sanitize the ice machines water system and the storage bin or dispenser. 3) Clean or replace the air filter and clean the air cooled condenser It is the user's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Without humane intervention, sanitation will not be maintained. Ice machines also require occasional cleaning of their water systems. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to provide privacy and promote dignity during medication administration for 3 of 8 residents observed (Residents #16, #34 and #93) on 1 of 2 nursing units and for 1 of 3 nurses observed. This deficient practice was evidenced by the following: During the medication administration observation of the A unit on 10/27/23 at 7:39 AM, the surveyor observed the Registered Nurse (RN) administer medications to Resident #16. The surveyor observed the resident awake and seated in their wheelchair in the doorway of their room. The RN sanitized their hands, donned gloves, and without providing Resident #16 with privacy the RN cleaned Resident #16's finger with an alcohol swab and performed a capillary blood glucose test (finger prick to obtain a blood sugar level using a glucometer). The door to the resident's room remained opened and the resident continued to be visible from the hallway as the RN performed the test. The surveyor reviewed the medical records of Resident #16 which revealed the following: Resident #16 was admitted with diagnoses which included but were not limited to: Type 2 diabetes mellitus (DM) and mood disorder. Review of Resident #16's Quarterly Minimum Data Set (MDS), an assessment tool, dated August 20, 2023, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 11 out of 15 which indicated that the resident's cognition was moderately impaired. Review of Resident #16's October 2023 Physician Order Summary (POS) Report reflected a physician order (PO) for Humalog Solution 100 units/milliliter (ml) (Insulin Lispro) Inject as per sliding scale: if 201-250 give (=) 2 units; 251-300=4 units; 301-350=6 units; 351-400=8 units; 401-450=10 subcutaneously before meals for DM; if blood glucose monitoring (BGM) is less than 70 or greater than 400 notify the MD. On 10/27/23 at 8:09 AM, the surveyor observed Resident #34 seated in their wheelchair in the hallway outside of their room. The RN asked Resident #34 to go to their room. The RN put gloves on, cleaned Resident #34's fingertip with an alcohol pad and performed a capillary blood glucose test. The door to the resident's room remained opened and the resident continued to be visible from the hallway as the RN then administered Artificial Tears 1 drop (gtt) to each eye and then used an eye scrub pad to each eye. The surveyor reviewed the medical records of Resident #34 which revealed the following: Resident #34 was admitted with diagnoses which included but were not limited to: Type 2 diabetes mellitus and Alzheimer's disease. Review of Resident #34's Quarterly MDS, dated [DATE], revealed that Resident #34 had a BIMS of 14 out of 15 which indicated that the resident's cognition was intact. Review of Resident #34's October 2023 POS reflected a PO for Novolog Solution 100 unit/ml for BGM if less than 70 or greater than 400 notify the MD; PO for Artificial Tears Solution 1.4% instill one gtt in both eyes two times a day for allergies; Provide Privacy; Eye Scrub External Pad apply to both eyes topically two times a day for redness/swelling. On 10/27/23 at 8:16 AM, the surveyor observed the RN enter Resident # 93's room. Resident #93 was awake in bed. The RN stated that the resident was aphasic but communicated by using a communication board and using thumbs up and thumbs down. The RN put gloves on, cleaned Resident #93's fingertip with an alcohol pad, and performed a capillary blood glucose test. The RN pulled up Resident #93's gown exposed his/her adult brief, gastrostomy tube, urinary catheter tubing, and administered 8 units of Insulin subcutaneously to Resident #93's abdomen in the upper right quadrant. The door remained open and the resident continued to be visible from the hallway. At that time, the surveyor asked the RN to step out of Resident #93's room and asked the RN if she should have provided the resident with privacy by pulling the resident's curtain and closing the door. The RN replied, yes, but [the resident] is so far back and nobody is usually back here. The surveyor reviewed the medical records of Resident #93 which revealed the following: Resident #93 was admitted with diagnoses which included but were not limited to Type 2 diabetes mellitus, aphasia following cerebral infarction (stroke), and Gastrostomy Status (a tube inserted through the belly that brings nutrition directly to the stomach). Review of Resident #93's Quarterly MDS dated [DATE], revealed that Resident #93 had a BIMS of 3 out of 15 which indicated that the resident's cognition was severely impaired. Review of Resident #93's October 2023 POS reflected a PO dated 9/9/23 for Humalog Injection Solution 100 units/ml (Insulin Lispro) inject per sliding scale: if 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 =10 units, subcutaneously three times a day for DM call MD if less than 70 or greater than 400. During an interview with the surveyor on 10/27/23 at 12:07 PM, the RN stated that she should have provided privacy by closing the residents' door during care, capillary blood glucose testing, administration of eye drops, eye scrubs, insulin, and medications given via the gastrostomy tube. The RN acknowledged that she did not provide privacy during those times. On 11/2/23 at 11:25 AM, the surveyor team met with the Regional Administrator, Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Nurse, and Infection Preventionist Nurse to discuss the above observations and concerns. The DON stated that the RN should provide privacy during care, treatments, and medication administration. Review of a facility policy titled, Resident Rights, dated January 2023, included but was not limited to; Employees shall treat all Residents with kindness, dignity, and respect. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include .privacy and confidentiality. Residents are entitled to exercise their rights and privileges to the fullest extent possible. NJAC 8:39-4.1(a)(12)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to follow professional standards of clinical practice with medication administration for 1 of 8 residents (Resident #93) observed for medication pass. 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 state: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing a medical regimen as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey state: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 10/27/23 at 8:16 AM, the surveyor observed as the Registered Nurse (RN) prepared medications to be administered via a gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach) to Resident # 93. The RN removed the resident's medication bingo cards (a multidose card containing individually packaged medications) from the medication cart and checked them against the Medication Administration Record (MAR). The RN removed the tablets from the bingo cards, put them in a small plastic bag, and crushed the three tablets together. The RN administered the 3 crushed medications together via the Gastrostomy tube (g-tube). During an interview with the surveyor on 10/27/23 at 12:07 PM, the RN stated that it was her regular practice to crush and administer all the tablets together via a g- tube. The surveyor asked the RN what the facility's policy was for administering medications via a g-tube. The RN replied she wasn't sure. The surveyor asked the RN if she had received a medication administration in service and competency. The RN replied she had received both but wasn't sure who provided the training or completed the competency. On 11/2/23 at 11:25 AM, the surveyor team met with the Regional Administrator, Licensed Nursing Home Administrator (LNHA), Administrator in training, Director of Nursing (DON), Regional Nurse, and Infection Preventionist Nurse to discuss the above observations and concerns. The DON stated that the facility's policy was to administer medications individually one at a time via the g-tube. Review of the facility's Administering Medications policy, revised April 2023, did not address the administration of medications via a gastrostomy tube. Review of the Facility's Competency Validation for Medication Administration reflected .Respect resident's right to privacy .when administering medication through a g-tube do not mix several medications together .flush tube between each medication with at least 5 ccs of water. Review of the RN's Competency Validation for Medication Administration reflected that the Infection Prevention Nurse (IPN) had completed a competency with the RN during her orientation on 9/13/23. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to perform proper hand hygiene for 1 of 3 nurses who administered medications to 1 of 8 residents (Resident # 93) observed during medication administration. This deficient practice was evidenced by the following: On 10/27/23 at 8:16 AM, the surveyor observed the Registered Nurse (RN) administer insulin and medications via a gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach) to Resident # 93. The surveyor then observed the RN remove her gloves to wash her hands. The RN applied soap and lathered her hands for seven seconds out of the stream of running water. She rinsed her hands and turned off the faucet with her bare hands then dried her hands with a paper towel. The surveyor reviewed the medical records of Resident #93 which revealed the following: Resident #93 was admitted with diagnoses which included but were not limited to Type 2 diabetes mellitus and aphasia following a cerebral infarction (stroke) and Gastrostomy Status. Review of Resident #93's Quarterly MDS dated [DATE], revealed that Resident #93 had a BIMS of 3 out of 15 which indicated that the resident's cognition was severely impaired. During an interview with the surveyor on 10/27/23 at 12:07 PM, the RN stated that the process for handwashing included lathering hands together with soap and water for 20 seconds and that the whole process should take 30 seconds. The RN stated that the importance of handwashing was to prevent the spread of infection. On 11/2/23 at 11:25 AM, the surveyor team met with the Regional Administrator, Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Nurse, and Infection Preventionist Nurse to discuss the above observations and concerns. During an interview with the Infection Preventionist Nurse (IPN) on 11/2/23 at 1:36 PM, the IPN stated that the RN should have washed her hands following the facility handwashing policy which instructed to vigorously lather hands with soap and scrub them for at least 20 seconds. The IPN further stated that the RN should have turned the faucet off with a clean paper towel. A review of the facility's Handwashing/Hand Hygiene policy, revised December 2022 reflected .this facility considers hand hygiene the primary means to prevent the spread of infections .Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions:before and after direct resident care; before and after performing any invasive procedure (e.g., fingerstick blood sampling) .vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least 15-20 seconds covering all surfaces of the hands and fingers .rinse hands thoroughly under running water .dry hands thoroughly with paper towels and then turn off faucets with a clean dry paper towel. A review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. NJAC 8:39:19.4 (a)(n),27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident received treatment and services to promote healing of a chronic stage two (Stage II) pressure ulcer. This deficient practice was identified for 1 of 3 residents, (Resident #19) reviewed for pressure ulcers and was evidenced by the following: On 08/2/21 at 07:11 PM, the surveyor observed Resident #19 sitting upright and asleep in his/her bed on a fully inflated and functioning pressure reducing air mattress. On 08/5/21 from 10:03 AM to 10:17 AM, the surveyor in the presence of another surveyor and the Registered Nurse/Unit Manager (RN/UM) observed the Licensed Practical Nurse (LPN) perform the wound treatment to Resident #19's sacral (lower back) wound. The following observations were made: At the treatment cart, the LPN gathered the required supplies which included island dressing (a sterile gauze bandage which is centered in a square adhesive pad), wooden tongue depressor (for medication application), and squeezed [MEDICATION(S)] (a paste which aids in wound healing) into a small medication cup. The LPN, while at the treatment cart used her ungloved hand to open and date the outside of the island dressing. At 10:08 AM, the LPN performed hand hygiene using soap and water and laid a dry clean pad on the bedside table and placed the supplies. The LPN proceeded to turn Resident #19 with the assistance of the RN/UM exposing a clean, oval shaped, reddish-pink, healing Stage II pressure ulcer (opening in the skin that is superficial, not reaching the full thickness of the skin) on his/her sacrum. The LPN then performed hand hygiene using alcohol based hand rub and put on clean gloves. The LPN dampened a clean gauze with normal saline solution and cleaned the wound. The LPN then disposed of the soiled gauze and immediately grabbed new, clean, dry gauze and patted the wound dry. There was no observed glove change or hand hygiene performed after the disposal of the soiled gauze and the application of the clean gauze. The LPN using the same gloves, then applied the [MEDICATION(S)] with the tongue depressor to the resident's wound. Then the LPN without any observed glove change or hand hygiene applied the clean pre-dated island gauze dressing to the resident's wound and then removed her gloves and preformed hand hygiene. The surveyor reviewed Resident #19's medical record. A review of the Admission Record reflected that the resident was readmitted to the facility in June 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 05/21/21, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated that the resident had moderately impaired cognition. A further review of the MDS Section M - Skin Conditions, reflected that the resident had no active pressure ulcers. A review of a telephone physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Progress Notes reflected a Skin/Wound Note dated 8/3/21, that the resident had a deep tissue injury that evolved into a stage II pressure ulcer measuring 2x2.5x0.2 centimeters (cm) in size. The plan was clean wound with normal saline solution and apply [MEDICATION(S)] with clean dry dressing daily and as needed if soiled. A review of the resident's individualized care plan reflected that the resident had a focus area dated 6/27/21, for the potential for skin breakdown related to compromised skin integrity on admission and comorbidities: [CONDITION(S)] (decrease in red blood cells), kidney failure, gout, arthritis, incontinence (lack of voluntary control over bowel and/or bladder), scar tissue to sacrum and bilateral (both) knees. Interventions included; to administer treatment per physician orders. On 08/5/21 at 11:53 AM, the surveyor interviewed the LPN who stated that the process to perform wound care would be to remove the dressing off the wound, assess the wound for any sign of infection, clean the wound as ordered, remove gloves, sanitize hands, put on new clean gloves and then apply medication and new dressing as ordered. When the surveyor asked the LPN if she missed any of these steps during the wound care, the LPN replied that she could not remember. On 08/5/21 at 12:07 PM, the surveyor interviewed the RN/UM who stated to that the procedure for wound care after gathering supplies and checking physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When the surveyor asked the RN/UM if the LPN had missed any of these steps, the RN/UM replied that she could not remember. On 8/5/21 at 12:54 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the procedure for wound care would be to wash hands, put on clean gloves, remove dressing already in place, dispose of dirty dressing and dirty gloves, perform hand hygiene, put on new gloves, clean wound site as ordered, dispose of gloves and perform hand hygiene, and apply treatment medication and clean dressing. On 08/6/21 at 09:23 AM, the Vice President (VP) in the presence of the DON, Licensed Nursing Home Administrator, and the survey team stated that, The nurse who forgot to change her gloves, she should have. She knew what to do, but she got scared. A review of the facility's Wound Care Procedure for Major Wounds policy dated revised 2009, included the procedure for wound care is to remove soiled dressing, remove gloves and discard, wash hands, clean the wound according to the order, place soiled gauze used for cleaning in (trash) bag, remove gloves, put on new gloves, apply clean dressing as ordered, remove gloves, and initial, date and time dressing. NJAC 8:39-27.1(e)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to provide the correct consistency of diet according to physician's orders. This deficient practice was identified for 1 of 4 residents (Resident #58) reviewed for nutrition and evidenced by the following: On 8/4/21 at 11:45 AM, the surveyor observed the Certified Nursing Aide (CNA) place a lunch meal tray in front of an unsampled resident. The meal ticket on the tray identified the meal was for sampled Resident #45 and contained a peanut butter and jelly sandwich, jello, creamed celery, health shake (nutritional supplement) and thin liquids (consistency) of water and gingerale. The CNA set-up the meal by placing a spoon in the soup, opened all three beverage containers, and cleaned the resident's hands. The surveyor observed no identification on the resident so they asked the resident what his/her name was. The resident had not responded and the CNA told the resident to tell the surveyor his/her name. The resident identified him/herself as Resident #58 and the CNA confirmed this. At this time, the CNA left the resident alone with the meal tray to eat and drink. On 8/4/21 at 11:50 AM, the surveyor asked the Licensed Practical Nurse/Unit Manager (LPN/UM) to identify Resident #58, which the LPN/UM confirmed that the resident was Resident #58. At this time, the surveyor asked the LPN/UM to accompany them to the resident's tray and identify whose lunch tray this was. The LPN/UM confirmed that the tray was Resident #45's and not Resident #58's. The LPN/Um immediately removed the lunch tray and put it at the nurse's station. The LPN/UM stated that it had not appeared that the resident had eaten or drank from the lunch tray. At this time, the surveyor observed a list on the cabinet entitled Residents with Thickened Liquids/Fluid Restrictions Ordered dated revision 8/4/2, which indicated that Resident #58 was on nectar thick liquids (consistency slightly thicker than thin liquids) and not the thin liquids he/she was served on Resident #45's lunch tray. On 8/4/21 at 11:53 AM, the surveyor observed Resident #58's lunch tray which contained chopped carrots and cheese blintz, pudding, cream of celery, health shake, and nectar thick cranberry juice and nectar thick lemon beverage. On 8/4/21 at 11:54 AM, the surveyor interviewed the CNA who stated that he was given Resident #45's lunch tray and was told to give it to Resident #58. When asked who the person was, the CNA responded that he could not remember, but confirmed that he was suppose check the tray as well to ensure that correct resident received the correct tray. The CNA confirmed that Resident #58 drank nectar thick liquids, but he was unsure the liquid consistency that he/she received on the other resident's tray. The surveyor reviewed the medical record for Resident #58. A review of the Admission record reflected that the resident was admitted to the facility in April of 2021, with diagnoses which included dementia with behavioral disturbance, protein-calorie malnutrition, heart failure, anorexia (lack or loss of appetite for food), and gastro-[CONDITION(S)] reflux disease (acid reflux). A review of the admission Minimum Data Set, an assessment tool dated 7/9/21, reflected a Brief Interview of Mental Status (BIMS) score of 0 out of 15 which indicated cognitive impairment. A further review of the MDS in Section G - Functional Status, indicated that the resident required extensive assistance of one person physical assistance for eating. A review of the active Order Summary Report dated 8/4/21, reflected a physician's order dated 7/15/21, for nectar thick liquids. A review of the Progress Notes reflected a Nursing Progress Note dated 7/15/21, that the Speech Therapist (ST) stated that the resident was coughing during session (speech therapy) so diet was downgraded to mechanical soft (food texture) with nectar thick liquids. A review of the resident's individualized care plan reflected a focused area dated 7/6/21, that the resident has a nutritional problem or potential nutritional problem with regards to dementia and at risk for varied by oral intake. Interventions included to feed self after tray set up; staff will monitor for sign and symptoms of dysphagia (difficulty swallowing); and staff will provide and serve diet as ordered. On 8/4/21 at 12:29 PM, the surveyor re-interviewed the CNA who stated that the resident was able to feed him/herself, but required assistance with the set-up. The CNA stated that staff observed the resident eating to ensure that the resident took small bites and drank plenty of liquids to prevent pocketing of food or aspiration (when something such as food or liquids enters your airway or lungs by accident). On 8/4/21 at 12:36 PM, the surveyor re-interviewed the LPN/UM who confirmed that the resident fed him/herself, but it had not appeared that the resident had touched anything on Resident #45's lunch tray. On 8/4/21 at 1:09 PM, the surveyor interviewed the ST via telephone who stated that Resident #58 was currently receiving speech therapy. The resident arrived to the facility with a diet order of regular texture food and thin liquids. The ST stated that she had observed the resident two weeks later eating poorly and he/she seemed congested so she put the resident in speech therapy and changed the diet order to mechanical soft food texture with nectar thick liquids with a goal to return back to regular texture food and thin liquids. The ST stated that thin liquids were not dangerous to the resident, and if the resident were to receive, they would not be at risk for choking or death. On 8/5/21 at 1:11 PM, the surveyor in the presence of the Licensed Nursing Home Administrator, Director of Nursing, Regional Nurse, and survey team addressed this concern. A review of the facility's undated Meal Tray Policy and Procedure which included that staff passing trays will check the meal ticket to identify the correct resident before passing each tray and special or altered diets listed on the meal ticket will be verified before the resident begins eating. NJAC 8:39-17.4(a)(1,2); 27.1

Based on observation, interview and record review, it was determined that the facility failed to properly dispose of medications and document medication administration for 1 of 1 resident, during medication cart inspection (Resident #10). This deficient practice was identified for 1 of 3 medication carts and was evidenced by the following: On 10/15/19 at 12:28 PM, the surveyor inspected the low side medication cart located on the A-Unit, in the presence of LPN #2. The surveyor observed a small unlabled clear medication cup which contained applesauce, a powerdered substance with particles and a white plastic spoon. This small medication cup was along with its contents was placed inside a larger clear cup and was inside the locked narcotic drawer. During an interview at the time of the observation, LPN #2 identified the powerdered substance as crushed medications. She stated the crushed medications were [MEDICATION NAME] 300mg, [MEDICATION NAME] 75mg, [MEDICATION NAME] tablet for Resident #10. LPN #2 stated that the resident did not want to take the medication at the prescribed time and she did not want to waste the pills. LPN #2 stated it was not nursing practice to leave crushed medication in the medication cart and also stated that she did something stupid. LPN #2 stated she should have wasted the medication when the resident refused at the time of administation. When interviewed on 10/17/19 at 12:38 PM, the Assistant Director of Nursing (ADON) stated that that the crushed medications, applesauce, and spoon that were stored in the narcotic box, was an infection control issue and went against the facility's medication storage policy. The ADON stated that the storage of the crushed medication was wrong. Review of the facility policy titled, Storage of Medications and dated 10/11/18, revealed under the Interpretation and Implementation section: 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. NJAC 8:39-29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to follow a physician's order for the application of hand rolls (a type of splint that provides a barrier between the fingers and the palm to prevent injury to the palm from finger contracture) to bilateral hands for 1 of 2 residents (Resident #61) reviewed for positioning and mobility. The deficient practice was evidenced by the following: 1. According to the Admission Record, Resident #4 was admitted to the facility with medical [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/2/18, reflected the resident was severely cognitively impaired, totally staff dependent for activities of daily living as well as having impaired use of the upper and lower extremities on both sides of the body During the initial tour of the facility on 11/14/18 at 10:08 a.m., the surveyor observed Resident #61 sitting in a reclined wheelchair. The surveyor observed that the resident had limited range of motion of the right and left hands. When interviewed, Resident #61 was unable to provide answers about the application of hand rolls. At that time, the surveyor did not observe hand rolls to Resident #61's bilateral hands. The surveyor made the same observations on 11/16/18 at 12:47 p.m. and 11/20/18 at 10:35 a.m. On 11/19/18 at 8:57 a.m., the surveyor observed Resident #61 in bed with the head of bed elevated. The surveyor did not observe hand rolls to Resident #61's bilateral hands. Later at 11:09 a.m., the surveyor observed Resident #61 sitting in a reclined wheelchair in his/her bedroom. The surveyor observed a hand roll to Resident #61's left hand. The resident did not have a hand roll to the right hand. The surveyor reviewed an Occupational Therapy (OT) Evaluation and Plan of Treatment dated 6/1/18 which reflected the reason for referral was that Resident #61 exhibited exacerbation of bilateral hand flexor (a muscle whose contracture bends a limb or other part of the body) tone. The 6/13/18 OT discharge summary recommendation reflected that Resident #61 tolerated the hand rolls to both hands at all times. The OT discharge summary also indicated to remove the hand rolls for hygiene and skin checks, in order to maintain skin integrity and decreased risk of contractures. The surveyor also reviewed Resident #61's ongoing Care Plan (CP). The CP revealed a Focus of impaired wheelchair positioning due to limited range of motion, strength, and contractures that was initiated on 11/18/17. The CP further revealed an intervention, initiated on 6/1/18, the resident would tolerate hand rolls to bilateral hands at all times. The surveyor reviewed the (MONTH) Order Summary Report which included a 6/4/18 physician's order to Apply hand rolls to B/L (bilateral) hands at all times. Remove for hygiene and skin checks. The surveyor also reviewed Resident #61's (MONTH) (YEAR) Treatment Administration Record (TAR) and Medication Administration Record (MAR). The surveyor observed that the 6/4/18 physician's order for the application of hand rolls to bilateral hands had not been transcribed onto Resident #61's MAR and/or TAR. On 11/20/18 at 11:00 a.m., the surveyor interviewed the Certified Nursing Assistant (CNA) responsible for caring for Resident #61. The CNA stated Resident #61 was totally dependent for activities of daily living. The CNA also stated she was aware the resident used hand rolls and the resident would be unable to remove the hand rolls when applied by staff. On 11/20/18 at 11:05 a.m., the surveyor interviewed the Licensed Practical Nurse (LPN) responsible for caring for Resident #61. The LPN stated that Resident #61 was totally dependent for activities of daily living and had a hand roll to be applied to one hand. The LPN further stated the resident's hand roll was applied by the night nurse and that it was kept on throughout her shift. The surveyor and the LPN walked to Resident #61's room at which time, the LPN confirmed that Resident #61 did not have the hand rolls applied to bilateral hands. The LPN located the resident's hand roll on the nightstand. The LPN restated the resident had one hand roll and she would have to go check to see which hand to apply the hand roll. On 11/21/18 at 8:30 a.m., the surveyor interviewed the Director of Nursing (DON) who confirmed that Resident #61's hand rolls should have been applied as ordered. The surveyor reviewed the facility's Assistive/Adaptive Devices/Splints policy with an updated date of (MONTH) 20, (YEAR), provided by the Director of Nursing. The policy reflected that the facility would make use of adaptive devices and splints as needed and or advised by therapy. The policy further reflected that it would also be added to the resident's care plan. NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to complete the required documentation on the Controlled Drug Administration Record (CDAR) for 2 of 3 Units (B and C) reviewed. This deficient practice was evidenced by the following: On 11/16/18 at 10:19 AM on the C Unit in the presence of a Licensed Practical Nurse (LPN), the surveyor reviewed the Controlled Drug Administration Record (CDAR) (a narcotic medication sheet used to document the date a medication was used, the nurse's signature and a declining count of the medication) for Medication Cart C. The CDAR revealed the count-down medication documentation for 30 tablets of [MEDICATION NAME] 0.5 mg (milligram) (an anti-anxiety medication) for Resident #03. The surveyor further observed, in the upper right-hand corner of the CDAR, the facility would document the Amount Received, the Date Received, and the Nurse Signature when the medication was received from the pharmacy. The surveyor observed the Amount Received, the Date Received, and the Nurse Signature were blank. At that time, the surveyor interviewed the LPN. The LPN confirmed the missing documentation and was unable to provide further information. On 11/16/18 at 10:31AM on the B Unit in the presence of a Licensed Practical Nurse (LPN), the surveyor reviewed the following CDAR sheets for Medication Cart B: One CDAR sheet for 30 tablets of [MEDICATION NAME] 0.5 mg (an anti-anxiety medication) for Resident #63. One CDAR sheet for 28 capsules of [MEDICATION NAME] 100 mg (an anti-epileptic medication, also called anticonvulsant) for Resident #52. The surveyor observed the Amount Received, Date Received and Nurse Signature on the upper right-hand corner of each CDAR sheet was blank. At that time, the surveyor interviewed the LPN. The LPN confirmed the missing documentation and was unable to provide further information. On 11/20/18 at 12:35 PM, the surveyor met with the facility's Administrator and the Director of Nursing (DON). The DON confirmed that the CDAR sheets for residents #03, #63, and #52 were missing information including the Amount Received, Date Received and Nurse Signature on the upper right-hand corner of each CDAR sheet. The DON further stated that the CDAR sheets should have been completed. The surveyor reviewed the facility's Controlled Drug Administration Record - Accounting/Documentation policy with a reviewed date of 11/16/18. The policy revealed, The facility will maintain controlled drug records properly documented. The policy stipulated a process that included, 3. Once the manifest is signed the nurse will also sign the amount received, date received, & nurses' signature on any controlled drug administration records. 4. As a second check the nurses will check during count that in fact all sheets have the top right corner completed. 5 as a third check the nurse administering the pill will also check to see that it has been completed properly. 6. Periodic audits will be completed to ensure that the controlled drug administration record is completed properly as needed. NJAC 8:39-29.7(c)

Based on observation, interview and record review it was determined that the facility failed to execute medication and treatment orders in accordance with the physician's orders [REDACTED].# 4, 8, 14 and 15. The evidence was as follows: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing a 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 with in the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 8/11/16 at 8:50 a.m. the surveyor observed the medication nurse administer medication to Resident #14. The physician's orders [REDACTED]. [MEDICATION NAME] is a medication used to prevent [MEDICAL CONDITION]. The medication nurse administered 4 [MEDICATION NAME] 50 mg chewable tablets to provide 200 mg of [MEDICATION NAME] for administration in the morning. The surveyor asked the medication nurse why she had not administered 2 of the 100 mg capsules, the medication nurse told the surveyor she had not realized they were in the drawer of medications. Upon going through the resident's medications, the medication nurse then found the Bingo card containing the [MEDICATION NAME] 100 mg capsules. The prescription label on the card identified 2 caps=200 mg [MEDICATION NAME] capsules are a long acting product while the chewable tablets are an immediate release product. Therefore the two different formulations of [MEDICATION NAME] are not interchangeable. 2. On 8/12/16 at 10:40 a.m. the surveyor proceeded to enter the room of Resident #8 in order to observe the nurse provide wound care to the resident. The treatment nurse and the Certified Nurses Assistant had the curtain pulled and were providing care to the resident when the surveyor entered the room and inquired about the pressure sore treatment. The nurse told the surveyor that the resident appeared to be in pain when positioning the resident so she was going to stop and get pain medication for the resident. Upon review of the physician's orders [REDACTED].#8 had an order on the for pain management by the physician dated 7/6/16 Medicate resident prior to wound tx (treatment) daily. Resident #8 was not pretreated for [REDACTED].> 3. Resident #4 had an order on the current POS originally dated 6/28/2016 for Skin Prep Mis Spray, Apply to left sacrum periwound with each dressing change daily. The resident had another order on the current POS originally dated 7/12/2016 to Apply Foam Dressing to Right Sacrum, Skin Prep to periwound prior to dressing changed and cover W/Combine after NSS cleanse daily. According to surveyor interview with the Unit Manager (UM) on 8/11/2016 at 11:10 a.m. she stated that the 7/12/2016 order was the order which was actively being done on Resident #4 at this time and that the other order should have been caught during recaps and discontinued from the POS. 4. Resident #4 had an order on the current POS originally dated 3/15/2016 to Cleanse open area scrotum then pack W/Plain Packing and cover W/Dry Dsg daily. According to surveyor review of the medical record, the order had been discontinued via a telephone verbal order on 6/14/16 but continued to be printed on the subsequent POS'. According to surveyor interview with the UM on 8/11/16 the order should have been caught and discontinued during recaps. 5. Resident #4 had an order on the current Medication Administration Record (MAR) for [MEDICATION NAME] CR 60 milligrams one tablet by mouth every 12 hours for pain. The order was not on the current POS, which actually drives the order on the MAR and comes from the Physician. On 8/16 and 8/17/2016 during surveyor interview with the facility Administration the Director of Nurses agreed that the above order should have been written on the POS and transcribed onto the MAR and not vice versa as was the case. 6. Resident #15 had an order a current telephone verbal order dated 8/11/16 and timed at 3:00 p.m. for Predinsone 40 mg to be given by mouth daily for 3 days then [MEDICATION NAME] 30 mg by mouth daily for 3 days, then [MEDICATION NAME] 20 mg by mouth daily for 4 days, then [MEDICATION NAME] 10 mg by mouth daily for 5 days, then d/c (discontinue). On 8/12/16 at 8:50 a.m. the surveyor observed the medication nurse outside of Resident #15's room prepare medications. At that time the surveyor asked the medication nurse how much [MEDICATION NAME] did she administer to the resident. The medication nurse checked the MAR and stated that she had given the resident 40 mg and 5 mg as indicated on the MAR. Later that day the surveyor interviewed the UM and inquired about the [MEDICATION NAME] orders for Resident #15, the UM stated that she would contact the primary physician and get clarification on the orders. At 11:35 a.m. the UM provided the surveyor with a new telephone verbal order dated 8/12/16 and read order clarification [MEDICATION NAME] 40 mg + [MEDICATION NAME] 5 mg today then stop [MEDICATION NAME] 5 mg on 8/13/16 and resume on 8/27/16, when the titrating down order for [MEDICATION NAME] is completed. N.J.A.C. 8:39-27.1 (a)

Based on observation and record review, it was determined that the facility failed to maintain professional standards of clinical practice when accounting for administered medications for 1 of 7 residents observed during the medication pass of 7/24/15. This deficient practice was evidenced by the following: On 7/24/15 at 8:15 a.m., the surveyor observed the Licensed Practical Nurse (LPN) administer 5 medications to a resident during the medication pass. At 8:16 a.m., the LPN washed her hands and returned to the medication cart and proceeded to prepare and administer medications to another resident without signing the Medication Administration Record [REDACTED]. 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. N.J.A.C. 8:39 - 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to properly discard of a medication that was wasted during Medication Pass observation. This deficient practice was identified for Resident #13, 1 of 7 resident's observed during the Medication Pass of 7/24/15. This deficient practice was evidenced by the following: On 7/24/15 at 9:13 a.m., during medication pass, the surveyor observed Resident #13 spit out a medication, which landed on the floor. The Licensed Practical Nurse (LPN) picked up the medication, (a single tablet), with a paper towel and proceeded to throw it in the garbage can in Resident #13's bathroom. When interviewed by the surveyor at 9:16 a.m., the LPN stated that she usually throws it in the trash. On the same day at 9:19 a.m., the surveyor observed the LPN remove the plastic liner that contained the pill from the garbage can. The LPN then placed the bag into a large garbage can in the shower room. On/7/24/15 at 1:02 p.m., the surveyor reviewed the facility policy titled Destroying Medications, which indicated under General Guidelines number 2: Non controlled medications that may have been dropped or spit out by the resident should be discarded in one of the following ways: a. Crushed and discarded in sharps container. b. Crushed and sprinkled into garbage. c. Disposed in pill buster in medication room. N.J.A.C. 8:39 - 29.4(i)

Based on observation, interview and record review, it was determined that the facility failed to provide a sanitary environment for the storage and preparation of food. This deficient practice was evidenced by the following: During the initial tour of the kitchen on Thursday, 7/23/15 at 10:10 a.m., the surveyor observed two dry food storage areas in the presence of the Food Service Director (FSD). The first area was on the main floor of the facility, which was a small room the could only accommodate three large racks of canned foods. The floor under the canned goods was heavily soiled with dust. The ceiling vent above one rack was also heavily soiled with dust which was dangling down from the vent cover. At that time, the FSD stated that the room was cleaned once a week. In the basement, the surveyor observed a larger area of dried food products including more canned goods, as well as cereals, dried beans and salad dressings, and an emergency supply of water. The floor also had an accumulation of dust and debris including plastic silverware and pieces of saran wrap on its surface. When asked how often that area was cleaned, the FSD said that housekeeping was responsible for cleaning the floor. The FSD also stated that there was a water leak in the basement the previous day and all of the racks had to be moved. The surveyor observed visible dust on the floor. In the main kitchen, there were two fluorescent lights that had several dead bugs trapped in the glass covers of the fixtures. The surveyor observed that one was near the coffee urn and juice dispenser area. The other light was over the meat preparation counter. The FSD stated that the maintenance department cleaned the glass covers every two weeks. On Monday,7/27/15 at 9:40 a.m., in the presence of the administrator and the FSD, the surveyor revisited the store rooms. The basement floor had been swept and mopped clean. However, the ground floor storage area was in the same dusty condition as it was on 7/18/15. On 7/29/15 at 12:55 p.m., the administrator gave the surveyor a copy of a cleaning schedule which indicated that the basement storage area was swept and mopped every Monday and Thursday. There was no cleaning schedule provided for the small canned goods area. On 7/30/15 at 9:20 a.m., in the presence of the FSD, the surveyor observed that the glass cover for the lamp near the beverage area was clean. However, the fluorescent light over the meat preparation counter had 12 winged dead bugs visible in the light fixture. NJAC 8:39-31.4 (a)

Based on observation, interview and record review it was determined that the facility failed to provide medications in accordance with professional standards for Resident #4, #5 and #12. This deficient practice was evident for 3 of 20 residents reviewed and was evidenced as follows: 1. On 9/4/14 at 8:45 a.m. the surveyor observed the unit nurse administer medications to Resident #12. The resident had physician orders [REDACTED]./325 mg. every 12 hours, [MEDICATION NAME] ER 45 mg. every 12 hours and [MEDICATION NAME] 1 mg. three times daily. Each of these medications are controlled drugs which are stored separately in a locked drawer and require signing a Declining Inventory Sheet (DIS) for the accountability of the drugs. The nurse removed the three bingo cards which contained each of the medications from the locked drawer. After pouring the medications into a medication cup the nurse returned the bingo cards to the locked drawer. The nurse did not sign the corresponding DIS at the time the medications were poured. The nurse then poured the other medications that Resdient #12 was scheduled to receive. After doing that, the nurse signed the DIS for the [MEDICATION NAME] and the [MEDICATION NAME]. As the nurse was putting the binder away the surveyor alerted the nurse that she had not signed the sheet for the [MEDICATION NAME]. The nurse then reopened the binder and signed the DIS for the [MEDICATION NAME]. The nurse did not compare the number of tablets of each controlled drug that remained on the bingo card with the number of tablets remaining on the Declining Inventory Sheet. The nurse did not validate that the counts for the three controlled drugs were accurate. 2. On 9/3/14 at 10 a.m. the surveyor observed Resident #5 seated in a wheelchair in the bedroom with family members at the bedside. The Director of Nursing (DON) stated the resident received [MEDICAL TREATMENT]. The surveyor reviewed the resident's medical record on 9/5/14. The resident was admitted to the facility with End Stage [MEDICAL CONDITION] and received [MEDICAL TREATMENT] three times a week. A review of the July, 2014, Consultant Registered Pharmacist recommendations revealed a note cautioning the use of Milk of Magnesia (MOM) for a resident with [MEDICAL CONDITION]. The physician responded to the recommendation by discontinuing the order for MOM. A new order was initiated on 7/31/14 for the use of a [MEDICATION NAME] suppository as needed on the 4th day of no bowel movement if MOM is ineffective. The surveyor discussed the physician's orders [REDACTED]. At 10 a.m. the ADON stated to the surveyor that the order was clarified. 3. On 9/3/14 at 9:50 a.m. the surveyor observed Resident #4 awake in bed watching television. The DON stated the resident had a history of [REDACTED]. The surveyor reviewed the resident's physician orders [REDACTED]. to 150 mg. daily at bedtime. The Primary Medical Doctor approved the order on 3/28/14. The September 2014 Medication Administration Record [REDACTED] "Order date 3/28/14. [MEDICATION NAME] XR Tab 150 mg. 1 tablet by mouth (300 mg.) at bedtime Dx: [MEDICAL CONDITION] Disorder." The surveyor interviewed the ADON on 9/3/14 at 11 a.m. to clarify the correct dosage of [MEDICATION NAME]. The ADON confirmed the order was written incorrectly. A new physician order [REDACTED]. daily at bedtime. On 9/4/14 at 9 a.m. the ADON provided the surveyor with documentation from the provider pharmacy that one 150 mg. tablet of [MEDICATION NAME] was administered to the resident daily since the medication was ordered on [DATE]. On 9/8/14 at 10:10 a.m. the DON stated the [MEDICATION NAME] was ordered correctly by the physician, however, the pharmacy erroneously entered 300 mg. after the order. She did not explain why the order had not been clarified by nursing. NJAC 8:39-29.4(k) 8:39-11.2(b)

Based on observation, interview, and record review it was determined that the facility failed to provide fluids in accordance with a physician ordered fluid restriction for Resident #5. This deficient practice was evident for 1 of 2 residents reviewed for fluid restriction as follows: On 9/3/14 at 10 a.m. the surveyor observed Resident #5 seated in a wheelchair in the bedroom with family members at the bedside. The Assistant Director of Nursing (ADON) stated the resident received [MEDICAL TREATMENT] and was on a physician ordered fluid restriction. On 9/4/14 at 8:30 a.m. the surveyor observed the resident in bed being fed by the Certified Nursing Assistant (CNA). The breakfast tray contained the following fluids: 4 ounces apple juice (120 milliliters), 6 oz. milk (180 ml.), 8 oz. coffee (240 ml.), totalling 540 ml. The dietary slip on the breakfast tray indicating what the resident was to receive listed fluid amounts as follows: apple or cranberry juice 4 oz. (120 ml.), whole milk 4 oz. (120 ml.), coffee 6 oz. (180 ml.) totalling 420 ml. The resident received 120 ml. more than the allotted amount of fluids. On 9/5/14 at 8:30 a.m. the surveyor again observed Resident #5's breakfast tray which contained 4 oz. apple juice (120 ml.), 8 oz. milk (240 ml.), 8 oz. coffee (240 ml.) totalling 600 ml. The dietary slip listed fluid amounts as follows: apple or cranberry juice 4 oz. (120 ml.), whole milk 4 oz. (120 ml.), coffee 6 oz. (180 ml.) totalling 420 ml. The resident received 180 ml. more than the allotted amount of fluids. On 9/4/14 at 8:30 a.m. the CNA stated to the surveyor that the resident was on a fluid restriction. The CNA further stated the resident drinks most of the liquids on the meal trays. The CNA did not indicate knowledge that the fluids provided on the breakfast tray were more than the allowed amounts. The surveyor reviewed the resident's medical record on 9/5/14. The resident was admitted with End Stage [MEDICAL CONDITION] and received [MEDICAL TREATMENT] three times a week. The resident was assessed with [REDACTED]. According to the September 2014 physician's orders [REDACTED]. per day. The daily fluid allowance provided by the Dietary Department was calculated as: Breakfast 420 ml., Lunch 240 ml., Dinner 240 ml., totaling 900 ml. per day from the Dietary Department. The remaining 300 ml. were to be provided by Nursing. On 9/5/14 at 9:30 a.m. the surveyor spoke with the ADON and the Registered Dietician (RD) regarding the 9/4/14 and 9/5/14 breakfast observations of fluids served that were in excess of the allowable amount. The RD stated the resident did not have fluid overload concerns and was well controlled. She further stated staff would be re-educated regarding residents on fluid restriction. NJAC 8:390-27.1(a)