Every finding on record at Harrogate Village

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following:On 02/05/2026 at 9:47 AM, the surveyor accompanied by the Director of Culinary Services (DOCS), observed the following in the kitchen: Upon entry to the kitchen the surveyor confirmed with the DOCS that the facility utilized a high temperature dish machine that was in operation for the post-breakfast meal service. The surveyor requested to see the dish machine temperature log prior to inspection of the dish machine. A review of the 'DISHMACHINE TEMPERATURE RECORD (HIGH TEMPERATURE MACHINE), dated FEB (February) 2026, revealed that the Wash temperature for breakfast on 1/5/2026 was recorded as 180 degrees and the Final rinse temperature was recorded as 165 degrees. Federal regulations require a minimum of 150-165 degrees Fahrenheit (F) for a minimum wash temperature and 180 F for a minimum final rinse temperature on a high temperature dish machine. Further review of the log did not reveal that any corrective actions had been taken at any meal period (breakfast, lunch and dinner) for the date range of 1/1/2026 through 1/5/2026 at breakfast.At approximately 9:54 AM, the surveyor and the DOCS went into the dish machine room to observe the dish washing operation. The surveyor observed the temperature gauges on the dish machine while the machine was in active service. The surveyor observed the following temperatures: Rinse: 130 F, Wash: 118 F. The DOCS then told the surveyor that the dish machine gauges had broken and that they had been broken for approximately one (1) week. The DOCS further explained that they utilized a temperature test strip to measure the dish machine temperature and ensured that it met minimum standards for wash and rinse temperature. The surveyor then asked the DOCS to attach a test strip to the interior of an empty plastic dish rack and run it through the dish machine to test for appropriate wash and rinse temperatures. The DOCS then proceeded to affix a test strip to the interior wall of the dish rack and then ran the plastic rack through the dish machine for a full wash and rinse cycle. Once the plastic dish rack departed the dish machine the surveyor and DOCS observed the dish washer temperature test strip. The surveyor observed that the test strip had 3 (three) white squares labeled as the following: 160 F (71C) (Celsius), 170 F (77C), and 180 F (82C). A review of the red lettering on the test strip revealed the following: When indicator turns black, stated temperature has been achieved. The test strip had no black squares and the squares remained white upon leaving the dish machine. The white squares indicated that the dish machine did not meet minimum required temperatures to ensure proper ware washing. A black square would indicate that the minimum required temperature had been met. The DOCS told the surveyor that he was shutting the dish machine down and instructed staff not to wash any more dishware. The DOCS stated that he would be contact their service representative and assured the surveyor that they would utilize paper products at the lunch meal and as necessary until the machine was repaired. On 02/05/2026 at 10:14 AM, the surveyor asked the DOCS if staff should ensure that the dish machine was operating properly before starting to wash dishes. The DOCS replied, Yes, the dishwasher should check that the machine met minimum temperatures before starting to wash dishware. He further explained that if it was not working properly the dishwasher (utility staff) was supposed to notify management immediately. At approximately 10:00 AM on 2/5/2026, the surveyor conducted an interview with the kitchen utility staff (US) who was responsible for ensuring the high temperature dish machine was operating properly prior to dish washing. The surveyor asked the US if he had checked the dish machine temperature gauges prior to initiating dish washing to ensure the machine was operating properly. The US told the surveyor Yes. The surveyor then asked how he determined that the machine was meeting minimum temperature standards. The US told the surveyor he used (read) the gauges. The surveyor then explained that the gauges were not operating properly and were stuck at the previously mentioned temperatures. The US then informed the surveyor in the presence of the DOCS that the dish machine gauges were broken and that he did not ensure that the machine was meeting minimum temperature standards as they could not be accurately measured.On 2/5/2026 at 2:21 PM, the surveyor met with the facility administration including the Director of Nursing (DON_, Licensed Nursing Home Administrator (LNHA) and the Regional Director of Clinical Services (RDCS) and discussed the concerns with the high temperature dish machine. The administrative staff informed the surveyor that the dish machine had been set up by service staff to run as a low temperature dish machine with chemical sanitizing until the dish machine could be repaired to run at a high temperature.On 2/9/2026 at 8:45 AM, the DOCS provided the surveyor with copies of the dish machine service provider work orders/invoices. A review of a service order dated 2/5/2026 at 14:30 (4:30 PM) had the following service comments: Bad heating contactor. Replaced. Bad fuse causing machine not to turn on. Will need to get replacement and return. Converted to low temperature until booster problem is fixed. A review of a service order dated 2/5/2026 at 16:39 (6:39 PM) revealed the following service comments: Return visit. Replaced fuse (blew again).Tested elements. 1 (One) bad element causing fuse to trip. Will return when I can locate one to replace. Machine is hooked up on sanitizer and is running low temp (temperature). A review of a service order, dated 2/6/2026 at 14:50 (4:50 PM) revealed the following service comment: Bypassed bad element on booster until replacement comes in. Rinse temp is now getting to 185-190. Wash temp was heating slowly. Bad wire on element. Reconnected .On 2/9/2026 at 12:23 PM, the DOCS informed the surveyor that the high temperature dish machine had been repaired and was operating as it should to meet minimum wash and rinse temperatures. The surveyor observed the DOCS enter an empty dish rack into the dish machine. The surveyor observed a wash temperature of 172 F and a final rinse temperature of 186 F.The surveyor reviewed the facility provided Policy #F019 DISHMACHINE TEMPERATURES policy, date revised: 1/24, which included: .Dish machine wash and rinse water should be maintained at temperatures that meet the guidelines established by the Food and Drug Administration. *State or local regulations will apply if stricter. Review of the High Temperature Machine section revealed that the machine, a multi-tank, conveyor, multi-temperature machine required a wash temperature of 150F and a final rinse temperature of 180-194F. The following was observed under PROCEDURES: Supervisor/Food and Nutrition Associate as assigned: High Temperature Dishmachine - record on Dishmachine Temperature Record form:Wash and final rinse temperatures during each period of use.Once a day, run a test strip (160F strip) through the dishmachine to verify the surface temperature of a dish. (The machine readings are the temperatures at the manifold of the machine, and not on the surface of the plate). Attach the used test strip to the Test Strips Result form. The test strip must verify that the surface temperature of the plate reached 160F. ALTERNATIVE: Use an irreversible maximum registering thermometer. Write the sanitizing rinse temperature on the Irreversible Max Temperature form.Director (In the event of inappropriate temperature)Determines if reading is due to malfunctioning temperature gauge or inappropriate temperature. If due to inappropriate water temperature (high temperature machine), or inappropriate concentration of sanitizer solution (low temperature machine, implements disposable service ware or use 3-compartment sink for sanitization. Notifies nursing units of use of disposable serviceware.Contacts sources of repairs.NJAC 18:39-17.2(g)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the required members were present during the quarterly Quality Assurance and Performance Improvement (QAPI) Committee Meetings. This deficient practice occurred during 1 of 4 meetings reviewed and was evidenced by the following:On 2/9/26 at 9:15 AM, during an interview with the Administrator and the Director of Nursing (DON), the Administrator stated that the facility held quarterly Quality Assurance Performance Improvement (QAPI) meetings on the third Tuesday of the month during the months of January, April, July and October. The surveyor then proceeded to review the facility provided Employee Education Attendance Records for the first quarter that was dated 4/17/25, the second quarter that was dated 7/15/25, the third quarter that was dated 10/15/24, and the fourth quarter that was dated 1/2025.At that time, the surveyor asked which staff members were required to attend the quarterly QAPI meetings. The DON stated the required participants were the directors of admissions, social work, dietary, activities, maintenance, nursing, the Infection Preventionist (IP) and vendors such as Consultant Pharmacist and the lab. The DON further stated, the Medical Director (MD) sometimes attended the monthly QAPI meetings, but he definitely attended the quarterly meetings.The surveyor then asked the Administrator to review the quarterly Employee Education Attendance Records signature panels to confirm the attendance of the required attendees. During the review, the surveyor noted that the MD did not sign in on the space provided for the quarterly QAPI meeting dated 4/17/25, which was also confirmed by Administrator. The DON stated that the MD was usually phoned in on a conference call and via phone was written on the signature panel of the form, but I must have missed it. When the surveyor asked if the MD's attendance via phone should have been documented on the form to confirm attendance the DON stated that the sign in sheet should have reflected that the Medical Director was present via teleconference.A review of the facility's QAPI policy, updated 1/20/2026, included: The community Administrator maintains the role of committee leader for QAPI and will provide an annual report to the Board of Directors. This information will also be shared with the management team, staff, and resident councils. Further review of the policy listed the members of the QAPI Committee which included Administrator/Abuse Coordinator, Medical Director, DON, and Infection Preventionist/Staff Educator.NJAC 8:39-33.1 (b)

Based on interviews and records review on 9/19/25, it was determined that the facility failed to ensure a resident (Resident #2) was free from a medication error when the medication nurse administered wrong medication to Resident #2; and the facility also failed to follow their policy for medication administration. The deficient practice was identified for 1 of 3 residents reviewed for medication administration.This was evidenced by the following.According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Type 2 Diabetes Mellitus, Respiratory Failure, Pneumonia and Toxic Effect of Tobacco Cigarettes. According to the Minimum Data Set (MDS), an assessment tool dated 07/25/2025, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the Resident was cognitively intact.According to the facility reportable form dated 08/28/2025 at 9:10 a.m., on 08/28/2025 at 9:10 a.m. when the Registered Nurse #1 (RN #1) was administering morning medications to residents, she prepared and administered 4 units of Novolog and 16 units of Lantus Insulin to Resident #2. (The intended recipient of the insulin was resident #2's roommate. During an interview on 09/19/2025 12:00 pm, RN#1 stated she became distracted during the medication administration and gave the insulin to Resident #2 instead of giving it to the resident's roommate. RN#1 stated that she immediately realized that she had administered the insulin wrongly to Resident #2 and that she then reported the incident to the Director of Nursing. RN #1 further stated that she called Resident #2's physician who ordered blood sugar monitoring for the resident. RN#1 stated that she should have asked Resident #2 their name and why they were getting the medication and should have followed the 5 Rights of Medication Administration which is the right patient, right dose, right time, right medication and right route. RN#1 further stated that she was rushing and should have checked the resident before administration and that she was wrong in not following protocols.During an interview on 09/19/2025 at 10:30 a.m., the Director of Nursing (DON) stated that facility policy required that prior to medication administration, the nurse would do the patient identification using the name band, ask the resident state their name and also check the resident face sheet picture.During a follow up interview with the DON on 9/19/2025 at 2:pm,the DON stated that Resident #2 had no negative consequence from the wrong medication they received from the nurse.A review of the facility's policy with revision date of April 2019 titled Administering Medications under Policy Statement revealed: Medications are administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation #9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 26. Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing services.NJAC 8:39-29.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 08/08/2024 from 09:24 AM until 10:00 AM, the surveyor observed the following in the kitchen in the presence of the Dietary Director #1 (DD#1): 1.The DD and the Food Service Worker (FSW#1) had facial hair and were not wearing beard guards. The DD#1 stated the beard guard is only used when on the line or direct handling of food. 2. In the walk-in freezer a frozen strawberry cream pie and a cookies and cream pie had no label and no date. The DD#1 stated it should be dated and he threw them away. On 08/13/2024 from 09:11 AM until 09:26 AM the surveyor observed the following in the satellite kitchen in the presence of the FSW#2 and DD#2: 3. In the refrigerator, a glass of orange juice, 2 glasses of white milk, 4 glasses of honey thick milk, and 4 glasses of honey thickened apple juice were covered. They had no label and no date. The FSW#2 stated I guess they should be dated. 4. In the refrigerator, 4 pieces of sheet cake wrapped in clear plastic wrap on glass dishes had no label and no date. The FSW#2 stated they should be dated. The DD#2 stated she will get rid of them. 5. In the refrigerator, individual pieces of cut watermelon were wrapped in clear plastic on glass dishes. The watermelon had no label and no date. The FSW#2 stated they should be dated. The DD#2 stated she will get rid of them. 6. In the small refrigerator, a prepared ham and cheese and tuna sandwich was on a glass plate wrapped with clear plastic wrap with no label and no date. The FSW#2 stated they should be dated. 7. In the small refrigerator, a container of egg salad and a container of tuna salad had a use by date of 8/12/24. The DD#2 stated they should have been thrown out last night. On 08/13/24 09:26 AM until 09:36 AM the surveyor observed the following in the kitchen with the DD#1. The DD#1 had facial hair and was not wearing a beard guard. The FSW#1 was wearing a beard guard however the mustache was exposed. The DD#1 stated the beard guard should be over mustache. The surveyor reviewed the facility provided policy titled, Food Storage with a revision date of 3/31/20 which reflected: all food items will be tightly covered and clearly labeled and identified. Leftover foods are labeled, dated, immediately placed under refrigeration. The surveyor reviewed the facility provided policy titled, Personal Cleanliness and Personal Hygiene with a revision date of 3/31/20 reflected that food production and dietary staff shall wear hair restraints such as hats, hair coverings or nets that effectively prevent cross contamination of all exposed foods, equipment, and supplies. The surveyor reviewed the facility provided policy titled, Labeling and Dating with a revision date of 5/5/22 which reflected 1. all perishables will be covered so no portion of the item is exposed, labeled with the item name, current date, and use by date. The use by date for perishable items is the current date plus three days or less. 2. Pre-portioned service tray items will be dated with current date and discarded in three days or less. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to A.) ensure that a resident received appropriate treatment and services to prevent urinary tract infections (UTI) to the extent possible specifically by failing to clean and store a urinary catheter drainage bag according to facility policy and B.) failed to obtain a physician's order to flush an indwelling catheter (a tube inserted into the bladder to assist with emptying the bladder). The deficient practice was identified for 2 of 2 Residents (Resident # 17 and 42) investigated for Urinary Catheter or UTI. The deficient practice was evidenced by the following: A review of the Electronic Medical Record (EMR) under, Diagnoses revealed that Resident # 17 was diagnosed with but not limited to urinary tract infection and retention of urine (inability to fully empty the bladder). A review of the EMR revealed physician's orders to but not limited to monitoring urinary output and catheter care every shift. A review of the EMR under Care Plans revealed a Care Plan focus titled, Risk for Urinary Tract Infection Risk for UTI initiated on 04/10/2024. The Care Plan also revealed a focus titled, Potential for the spread of multi-drug resistant organisms (MDROs) to other residents or staff during high contact related to: history of ESBL [extended spectrum beta-lactamase; bacteria that can't be killed by many of the antibiotics] and [tradename] cath. That focus was initiated on 07/30/2024. A review of the quarterly Minimum Data Set (An assessment tool) dated 7/23/2024 revealed under section, H that Resident # 17 had an indwelling catheter. On 08/08/2024 at 09:55 AM during the initial tour, Surveyor # 1 observed Resident # 17 in his/her wheelchair in their room. At that time, he/she confirmed they use an indwelling urinary catheter (device inserted into the bladder to facilitate the flow of urine). On 08/12/2024 at 9:39 AM during an interview with Surveyor # 1, the Infection Preventionist replied, They [staff] should be getting alcohol wipes to clean the end. They then store the large drain bag in a plastic bag with a cap. when Surveyor # 1 asked how the catheter drainage bags are to be stored. The Infection Preventionist also said that the bag is rinsed with water and then stored in the plastic bag. On 08/13/2024 at 10:04 AM during an interview with Surveyor # 1, the Certified Nurse Aide (CNA) # 1 assigned to Resident # 17 confirmed that the urinary catheter tube itself and the connections are cleaned. The surveyor then asked if a bleach solution is used to clean the catheter drainage bag and tubing. CNA # 1 stated, No bleach. A review of an unopened clear package of the urinary drainage bag revealed a blue end cap at the point of connection. On 08/13/2024 at 10:51 AM, Surveyor # 1 observed Resident # 17's urinary catheter drainage bag in a clear untied trash bag secured to the hand rail in the resident's bathroom. At that time, Surveyor # 1 could observe that there was no cap secured to the end of the tube. The bag also emanated an odor of urine. On the same date at 11:01 AM in the presence of Surveyor # 1, the Infection Preventionist confirmed the catheter drainage bag did not have a cap secured to the end of the tube. On 08/13/24 at 10:59 AM, the surveyor observed Resident # 42's urinary catheter drainage system in a clear open bag in the bathroom. The surveyor did not observe a cap secured to the end of the tube. When asked at that time the Infection Preventionist confirmed there was no cap and stated the tubing should have a cap. A review of the facility policy titled, Catheter Care, Urinary revised August of 2022 revealed under, Cleaning and Disinfecting Drainage Bags to, 1. Disconnect the drainage bag from the catheter; replace with a clean bag. 2. Use a soft, plastic squirt bottle to rinse the used bag with tap water and drain. 3. Cleanse the drainage bag with a dilute solution of 1 part regular household bleach (5.25 % concentration) mixed with 10 parts tap water (i.e., 15 mL bleach diluted with 150mL tap water). a. Instill the diluted bleach solution through the drainage tubing or top of the bag, and agitate the solution in the bag for 30 seconds. b. Drain the bleach solution, and allow the bag to air dry with the clamp open. c. Use bleach that is not scented or concentrated. d. When using a bleach solution, use gloves, aprons, and goggles to protect from fumes and irritation cause by contact. 4. After cleaning, air-dry the bag. After disinfection, cap the drainage bag tubing between uses, and disinfect the end of the tubing before reconnecting it to the catheter. 38680 B.) On initial tour of the facility on 08/08/2024 at 10:20 AM, Surveyor # 2 observed Resident # 42 in their wheelchair. According to the admission record, Resident # 42 was admitted with diagnoses which include but are not limited to benign prostatic hyperplasia (an enlarged prostate) with lower tract symptoms and obstructive and reflex uropathy. A review of the Quarterly Minimum Data Set, an assessment tool dated 07/18/2024 reflected that Resident # 42 had moderate cognitive impairment and utilized an indwelling catheter. On 08/09/2024 at 09:06 AM, Surveyor # 2 reviewed the Physician's Orders for Resident # 42 which reflected an order dated 10/27/2023 for catheter care every shift. On 08/12/2024 at 9:32 AM, Surveyor # 2 reviewed health status notes in the electric health record for Resident # 42. The health status notes dated 07/28/2024, 07/29/2024, and 08/03/2024 reflected that Resident # 42's indwelling catheter was flushed to prevent build up of debris in the bladder. The treatment administration records for Resident # 42 dated July and August of 2024 were reviewed and no documentation was observed to flush the indwelling catheter. During an interview on 08/12/2024 at 11:23 AM, the Registered Nurse stated that she is pretty sure that flushing an indwelling catheter is part of the policy. She stated that sometimes we have an order to flush a catheter, but we don't have one for Resident #42. During an interview on 08/12/2024 at 11:30 AM, the Director of Nursing stated that there should be an order to flush an indwelling catheter. A review of the facility-provided policy titled, Catheter Care, Urinary, revised August 2022 reflected that, 5. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. NJAC 8:39-11.2(b)

Based on observation, interviews, and record review, it was determined that the facility failed a.) to perform hand hygiene as indicated during wound care for 1 of 1 resident, (Resident # 265) reviewed for pressure ulcers, and b.) the facility failed to maintain a sanitary environment for 1 of 9 residents, (Resident # 3), observed for infection control. The deficient practice was evidenced by the following: a.) On 08/08/2024 at 09:50 AM, Resident # 265 was observed sleeping in bed. Resident # 265 was observed to be on an air mattress with a scoop overlay. A review of the Admission Record revealed that Resident #265 was admitted with diagnoses including but not limited to, Unspecified Severe Protein-Calorie Malnutrition, and Chronic Atrial fibrillation (an irregular and often very rapid heart rhythm). A review of the Minimum Data Set (an assessment tool) dated 08/02/2024, revealed that Resident # 265 had a stage 2 pressure ulcer (an open wound that affects both the top and bottom layers of the skin). A review of the Order Summary Report with active orders as of 08/09/2024 revealed a physician's order dated 08/06/2024 to cleanse the opening on the sacrum with wound cleanser, pat dry, apply Santyl (ointment for wound care) and a clean dry dressing daily. On 08/12/2024 at 11:28 AM the surveyor observed Licensed Practical Nurse (LPN) # 1 preform wound care for Resident # 265. The surveyor observed the LPN #1 remove her gloves after cleansing the wound and she donned a new pair of gloves without preforming hand hygiene. At that time, when asked about hand hygiene by the surveyor LPN replied, I forgot to sanitize my hands. On 08/14/2024 at 09:09 AM during an interview with the surveyor, the Registered Nurse Unit Manger (RN UM) stated, Every time you take off gloves you should wash your hands. On 08/14/2024 at 12:00 PM during an interview with the surveyor the Infection Preventionist (IP) stated, You should perform hand hygiene before and after wearing gloves. On 08/14/2024 at 12:42 PM during an interview with the surveyor the Director of Nursing (DON) replied, Yes, that is part of protocol, when asked if hand hygiene should be performed between glove changes. b.) A review of the Admission Record revealed that Resident # 3 had diagnoses which included but were not limited to Alzheimer's Disease (A brain disorder that causes memory loss, thinking problems and behavior changes) and long-term use of anticoagulants (a blood thinner). A review of the Order Summary Report revealed a physician's order dated 08/06/24 to cleanse open purpura (red, purple, or brown spots on your skin caused by bleeding under your skin's surface) on left forearm with wound cleanser, pat dry, apply bacitracin (an antibiotic that fights bacteria and prevents infection in minor cuts, scrapes, and burns), and versatel (a contact layer dressing coated with silicone) and a clean dry dressing daily. Versatel is changed every 5 days. There was also a physician's order dated 08/08/2024 to cleanse open purpura on right forearm with wound cleanser, apply bacitracin and clean dry dressing daily. On 08/08/2024 at 10:10 AM during initial tour, the surveyor observed Resident # 3 sleeping in bed with both forearms wrapped in bandages. The surveyor observed what appeared to a significant amount of blood on the sheets on the left side of the bed. On 08/12/2024 during an interview with the surveyor, the IP was asked if the bed should look like that. The IP replied, No the sheets should have been changed, [he/she] gives us a hard time, [he/she] pulls their bandages off all the time causing more skin tears. On 08/14/2024 during an interview with the surveyor, the DON was showed the picture taken on 08/08/2024 and, the DON replied, No, there should have been a barrier down to protect that dressing until the sheet was able to be changed. A review of a facility provided policy titled Handwashing/Hand Hygiene revised August 2019 revealed under the Policy Interpretation and Implementation that, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: m: after removing gloves. Also revealed under the Applying and Removing Gloves that, 1. Preform hand hygiene before applying non-sterile gloves. A review of a facility provided policy titled Infection Prevention and Control Program revised on October 2018 revealed under the Policy Statement that, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. N.J.A.C. 8:39-19.4(n)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to A.) reevaluate and update a resident-centered Care Plan (CP) upon readmission, to include the use of an anticoagulant, B.) failed to develop and implement a comprehensive person-centered care plan that include the use of an indwelling urinary catheter and use of a wander guard, and C.) failed to reevaluate and update a resident-centered CP to include actual skin impairment. The deficient practice was identified for 4 of 4 residents (Resident # 15, # 17, #43, # 3) reviewed for Care Plans. A.) On 08/08/2024 at 9:24 AM, Surveyor # 1 observed Resident #15 in bed. The resident responded when Surveyor # 1 spoke to them. The resident had covers over them and Surveyor # 1 was unable to observe the resident's skin. A review of the Admission Record indicated that Resident #15 had diagnoses which included but were not limited to; atrial fibrillation (irregular heart rate), adult failure to thrive, and dementia. A review of the Annual Minimum Data Set (MDS) an assessment tool used to facility resident care dated 03/31/2024, included but was not limited to; Section N0415 - High-Risk Drug Classes: Use and Indication, documented that Resident #15 was taking anticoagulant medication. A review of the Order Summary Report active orders as of 08/09/2024, included but was not limited to; a physician's order dated 03/27/2024 for Eliquis (an anticoagulant) Oral Tablet 5 MG (milligram) (Apixaban) Give 1 tablet by mouth every 12 hours related to atrial fibrillation. Monitor for unusual/unexplained bleeding such as bruising, dark urine and dark tarry stool. A review of the Skin Evaluation dated 03/30/2024, included but was not limited to documentation that Resident #15 had bruising on the right wrist. A review of the facility provided resident-centered care plan failed to include the following: problem/focus area for the use of anticoagulant, goals with target dates, or any interventions/tasks for the use of the anticoagulant medication. On 08/08/24 at 1:45 PM, the Registered Nurse Unit Manager (RN UM) stated the process was to initiate a care plan on admission by the supervisor on duty. The next day each department would review and add their information to the care plan. The RN UM stated, I'm responsible for nursing. and stated that would include things such as anticoagulants and psychoactive medications. When asked about anticoagulants, the RN UM stated, We definitely would care plan Eliquis used for atrial fibrillation. On 08/09/24 at 9:50 AM, the Director of Nursing (DON) stated all staff were responsible for areas of the resident's care plan. She further stated that each department does their own assessment for the care plans. The DON stated that the information would be gathered from face-to-face assessments and identified needs, and that the electronic medical record would trigger things like medications, cardiac care plan, etc. The surveyor inquired about anticoagulant use being on the care plan and the DON stated, probably yes because the resident is at a risk for bleeding, and we need everyone to be aware of what could happen. The DON accessed Resident #15's medical record with the surveyor and showed the surveyor the most current care plan. The DON acknowledged that the use of the anticoagulant medication was not documented in the care plan. On 08/09/24 at 10:17 AM, the DON stated that in November 2023, the facility had a conversion of care plan programs and did not realize until the survey team brought it to their attention, that the care plans were not complete or comprehensive. The DON further stated that Resident #15's previous care plan included the use of anticoagulant, but the facility did not identify that it was not carried over to the current comprehensive care plan. Surveyor # 1 inquired about the quarterly resident interdisciplinary team meetings, and the DON stated that the facility never realized at the meetings that the care plans were not complete. A review of the facility provided policy, Care Plans - Baseline revised March 2022, included but was not limited to; Policy A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Interpretation and Implementation 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. initial goals based on admission orders . b. physician orders . 2. The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. 4. the baseline care plan . that includes, but is not limited to the following: a. the stated goals and objectives of the resident; b. a summary of the resident's medications and dietary instructions; . A review of the facility provided policy, Care Plans, Comprehensive Person-Centered revised March 2022, included but was not limited to; Policy A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented or each resident. Interpretation 1. The interdisciplinary team (IDT), . develops and implements a comprehensive, person-centered care plan for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, . e. reflects currently recognized standards of practice for problem areas and conditions. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; . c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required MDS assessment. 43936 B.) A review of the Electronic Medical Record (EMR) under, Diagnoses revealed that Resident # 17 was diagnosed with but not limited to urinary tract infection and retention of urine (inability to fully empty the bladder). A review of the EMR revealed orders to but not limited to monitoring urinary output and catheter care every shift. A review of the EMR under Care Plans did not reveal a specific focus or interventions for an indwelling urinary catheter. A review of the quarterly Minimum Data Set (An assessment tool) dated 7/23/2024 revealed under section, H that Resident # 17 had an indwelling catheter. On 08/08/2024 at 9:55 AM during the initial tour of the facility, Surveyor # 2 observed Resident # 17 in their room. At that time, Resident # 17 confirmed to the surveyor that he/she had a catheter. On 08/12/2024 at 9:39 AM during an interview with the Infection Preventionist, Surveyor # 2 asked if someone has a urinary catheter, should they have a specific care plan focus for it. The Infection Preventionist replied, Yes. On 08/13/2024 at 12:07 PM during an interview with the Director of Nursing (DON), Surveyor # 2 asked should a care plan focus for an indwelling urinary catheter care have been initiated. The DON replied, Yes. Surveyor # 2 then asked when should the care plan have been initiated. The DON replied, When [he/she] was readmitted . A review of Resident # 43's Physician's Orders located in the EMR revealed that he/she had an order for a Wander Guard (electronic bracelet used to monitor if a resident approached a facility exit) to the right ankle and to check placement and function every shift for monitoring. A review of Resident # 43's Care Plans located in the EMR did not reveal a Care Plan focus or interventions for a Wander Guard or elopement behaviors. A review of Resident # 43's diagnoses located in the EMR revealed diagnoses of but not limited to Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions) and Dementia (the loss of cognitive functioning, thinking, remembering, and reasoning; to such an extent that it interferes with a person's daily life and activities). On 08/08/2024 at 10:06 AM during the initial tour, Surveyor # 2 observed Resident # 43 in their bed. At that time, Surveyor # 2 observed a Wander Guard attached to Resident # 43's right ankle. At that time, Resident # 43 told Surveyor # 2 that it is used in case [he/she] leaves, they [the facility] can find him/her. Another review of Resident # 43's Care Plans located in the EMR revealed a focus for elopement. The focus included an intervention to check function and placement every shift for a Wander Guard to the left ankle. The focus and intervention were initiated on 08/13/2024. On 08/13/2024 at 12:07 PM during an interview with the Director of Nursing (DON), Surveyor # 2 asked when should a care plan for elopement been initiated. The DON replied, It should have been initiated the day that the Wander Guard went on. We saw that it was not on there so we added it. A review of the facility policy titled, Care Plans, Comprehensive Person-Centered with a revised date of March 2022 revealed under, Policy Interpretation and Implementation that, 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set] assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 49712 C.) On 08/08/2024 at 10:10 AM, Surveyor # 3 observed Resident # 3 in bed, with clean dry and intact bandages to both forearms. A review of the Admission Record revealed that Resident #3 had diagnoses which included but not limited to Alzheimer's Disease (A brain disorder that causes memory loss, thinking problems and behavior changes) and long-term use of anticoagulants (a blood thinner). A review of the Order Summary Report revealed a physicians order dated 08/06/2024 to cleanse open purpura (red, purple, or brown spots on your skin caused by bleeding under your skin's surface) on left forearm with wound cleanser, pat dry, apply bacitracin (an antibiotic that fights bacteria and prevents infection in minor cuts, scrapes, and burns), and versatel (a contact layer dressing coated with silicone) and a clean dry dressing daily. Versatel is changed every 5 days. There was also a physician's order dated 08/08/2024 to cleanse open purpura on right forearm with wound cleanser, apply bacitracin and clean dry dressing daily. A review of Resident # 3 resident-centered care plan failed to include the actual skin impairment identified on 08/06/2024 for the left forearm and 08/08/2024 for the right forearm. On 08/14/2024 at 09:09 AM during an interview with Surveyor # 3, the Registered Nurse Unit Manager (RN UM) said that we work as a team to get care plans done. The RN UM also stated, When an admission comes in, they are started by nursing, and then all disciplines come in and update. We then review quarterly. When asked what if something new is identified, the RN UM stated, If something new is going on, it should be added that day or the next. On 08/14/2024 at 12:42 PM during an interview with Surveyor # 3 the Director of Nursing (DON) stated, It depends on the resident and what it was when asked if actual skin impairments should be added to the care plan. When the surveyor asked about Resident #3's skin impairment, the DON replied, That just happened on the 9th. When the surveyor asked, should that be on the care plan now, the DON replied, I would hope so. NJAC 8:39-11.2 (d)(e)(h)

Based on observation, interview, and record review it was determined that the facility failed to accurately assess the status of a resident in the Minimum Data Set (MDS), an assessment tool. This deficient practice was identified for 1 of 2 sampled residents reviewed for elopement (Resident #16) and was evidenced by the following: On 08/08/2024 at 10:00 AM, the surveyor observed Resident #16 in the bed with a wander guard/elopement alarm on his/her left ankle. According to the Admission Record, Resident #16 was admitted to the facility with diagnoses including of but not limited to dementia and heart disease. Resident #16 had a Physician Order (PO) dated 02/18/2024 to apply a Wander guard to left ankle. A review of the Admission MDS dated [DATE] for Resident # 16, indicated under Section P0200 for alarms was coded as 0 indicating there was no wander/elopement alarm. During an interview on 8/12/2024 at 11:37 AM, the MDS Coordinator acknowledged that Resident #16's Admission MDS dated [DATE] should have been coded as having a wander/elopement alarm. NJAC 8:39-27.1(a)

Based on observation, interview and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On [DATE] from 09:43 AM -11:09 AM, the surveyor toured the kitchen in the presence of the Director of Food and Beverage (DFB) and the Executive Chef (EC) and observed the following: 1. In the line refrigerator, there was one sealed clear bag containing tan oval patties, the DFB identified as hash browns, with no label, no use by or expiration date. The DFB stated there should have been a label and use by date then removed the bag from the refrigerator. 2. In the walk-in refrigerator, there was a wheeled metal rack covered with a clear plastic bag with no label or date. The DFB stated the plastic bag was so no debris fell on the food items and that the food on the rack was prepped that day. On the rack there was one tray of individual pastry in pie plates, that the DFB identified as pie shells, that were partially covered with clear plastic wrap with the pie shells visible and exposed to air and marked with a sticker dated [DATE] use by [DATE]. There was one tray of individual pieces of tan dough, that the DFB identified as danish, that were partially covered with clear plastic wrap with the danish visible and exposed to air and marked with a sticker dated [DATE] use by [DATE]. There were two trays of light yellow pieces of meat, that the DFB identified as prepped pieces of chicken, that were partially covered with clear plastic wrap with the chicken visible and exposed to air with no use by or expiration date. There was one tray of light red strips of meat, that the DFB identified as raw bacon, that was partially covered with clear plastic wrap with the bacon visible and exposed to air that was marked with a sticker dated [DATE] use by [DATE]. There was one tray of light red strips of meat, that the DFB identified as raw bacon, with a piece of wax paper resting on the bacon with a sticker marked [DATE]. The DFB stated that was the date the bacon was prepped. During an interview at that time, the DFB acknowledged the uncovered and partially covered food that was exposed to air. The DFB stated that it was important that the food should have been covered for freshness and dated so everyone would have known when it was made and when it should have been served. 3. In the walk-in refrigerator, on an enclosed metal cart, there was one five pound sealed plastic bag containing small pink bits of meat, that the EC identified as bacon bits, with no label and no use by date. The EC stated that the bag should have had a label and a use by date. The DFB stated it was important to label and date food for proper identification and to know when it was received. There were three undated 6 ounce containers of sauteed vegetable base, two undated 16 ounce containers of clam base, and one undated 16 ounce container of lobster base all with no use by or expiration dates. The DFB acknowledged that the bases should have had a received on date and stated that they were good for one year but that they would not be used because the received date was unknown. The DFB further stated it was important to have a use by and expiration date so that staff were aware that the items were not expired prior to use. The DFB discarded the containers. 4. In the freezer, there was one large strip of frozen red meat, that the EC identified as filet [NAME], in a sealed plastic bag with no label and no received or use by dates. The EC acknowledged there was no label or received or use by dates and stated there should have been a received date and a label so staff would have known what the meat was and how long it was good for. The DFB told the EC that the meat was garbage and the EC discarded the meat in the trash. There was one opened ten pound box of breaded flounder fillets with an unsealed internal plastic bag containing white pieces of fish that were visible and exposed to air. The DFB acknowledged the fish was not stored properly and removed the box from the freezer and discarded it into the trash. The DFB stated it was important to store food correctly so that no debris fell into the product. There were two large loaves of bread wrapped together in clear plastic wrap with no label and no use by date. There was one sealed clear package containing six brown square pieces of dough, the DFB identified as waffles, with no label and no use by dates. The DFB acknowledged the missing labels and dates and stated the bags should have been labeled and dated. There was one opened box of 30 portion beef steak fritters with an unsealed internal plastic bag containing pieces of light tan meat that were visible and exposed to air. The DFB acknowledged the open bag and the exposed meat and threw the box into the trash. 5. In the dry storage room, there was one opened 25 pound bag of brown rice that was wrapped in clear plastic wrap with no open or use by dates. There was one opened 20 pound bag of white rice wrapped in clear plastic wrap with no open or use by dates. The DFB acknowledged the opened bags and stated there should have been a label that stated rice with the date of expiration. The DFB discarded the bags of rice into the trash. On the metal can rack there were two 6.39 pound cans of baby corn with large dents, one 55 ounce can of ripe olives with a large dent, one 7.31 pound can of cranberry sauce with a large dent, and one 5.52 pound can of whole fire roasted red peppers with a large dent. The DFB removed the cans and stated that the dented cans should not have been stored on the can rack and that all dented cans got thrown away. The DFB stated it was important to not use dented cans because residents could have gotten botulism. 6. In the ice machine, on the inside edge of the guard, there was black debris. The DFB acknowledged the debris and stated it should not have been there and that the machine gets cleaned quarterly. The DFB stated it was important to keep the ice machine clean to prevent resident illness. 7. On the clean pot rack, there were five large white cutting boards observed with brown stains, black smudges and gouges. The DFB acknowledged the stains and stated they were from wear and tear and that the cutting boards were cleaned and sanitized each use. 8.The meat slicer was observed to have white debris on the blade and on the base. The DFB stated the slicer was cleaned, acknowledged the debris and then instructed the cook to clean the slicer. The DFB stated it was important to keep the slicer clean to prevent food contamination. The surveyor reviewed the facility's policy, Food Storage, revised [DATE], which revealed Procedure: 1) All food items will be tightly covered or packaged and clearly labeled and identified. Leftover foods are labeled, dated .4) All food items must be stored in packages, covered containers, or wrapped . The surveyor reviewed the facility's policy, Labeling and Dating, revised [DATE], which revealed Policy: It is the policy of the community to label and date all food items. Standard: Date marking is required for food items that meet the following criteria; Ready to eat, Refrigerated, Held for more than 24 hours, Prepared on site, and Perishables (TCS). Perishables (TCS) include: Leftover food items, Leftovers are; any food that is prepared, cooked, raw, or ready to eat that remains at the end of meal service, end of the recipe preparation, or is the remainder or a food product for a newly opened can, container, or case. All food items removed from their original containers. Procedure: 1) All perishables (TCS) will be labeled with the item name, current date, and USE BY date. The USE BY date for perishable items (TCS) is current date plus three days or less. 3) Fresh Bakery items will be dated upon arrival with a USE BY date of seven days .11) Non potentially hazardous (TCS) food items in dry storage opened, will be labeled and dated with a USE BY date of one month .14) Frozen food items from an opened case that remain frozen will be labeled when opened and dated with a USE BY date . The surveyor reviewed the facility's policy, Dented Cans, revised [DATE], which revealed Policy: It is policy of the community to ensure that all dented cans are removed . Procedure 1. When we receive a delivery, if discovered, cans are removed . The surveyor reviewed the facility's policy, Safe Food Preparation & Service, undated, which revealed Procedure: 1) Food shall only contact surfaces of equipment and utensils that are cleaned and sanitized. 7) Cutting boards will be cleaned and sanitized between uses. Once weekly cutting boards will be bleached. NJAC 8:,d+[DATE].2(g)

Based on interview and review of pertinent facility documents it was determined that the facility failed to ensure there was a consistent process for tracking and securing accurate documentation of the vaccination status of all contracted staff for Covid-19, a contagious respiratory infection. This deficient practice was evidenced by the following: A review of the covid vaccination status list reflected that all staff identified as contracted were not listed. On 11/30/22 at 10:59 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON stated Laboratory (lab) Technicians (LT) were considered contracted staff but were not on the contracted staff vaccination status list. The DON stated that she did not have copies of the vaccination status of the LTs but had confirmed with the lab company via email that all the contracted LTs were vaccinated. The DON acknowledged she was unable to confirm their vaccination status prior to surveyor inquiry. On 11/30/22 at 12:38 PM, the surveyor interviewed the Registered Nurse/Assistant Director of Nursing/Infection Preventionist (RN/ADON/IP) in the presence of the survey team. The RN/ADON/IP stated LTs were all vaccinated but were not expected to get a covid vaccine booster based on the laboratory company's policy. The RN/ADON/IP stated she was unable to confirm the contracted staff vaccination status as she was not responsible for tracking them and that she would have to ask the DON. On 12/01/22 at 09:53 AM, the surveyor interviewed the DON, who stated, generally two (2) to three (3) regular LTs would come to the facility's long term care unit around 6:00 AM to complete their lab draws, prior to proceeding to the assisted living part of the facility. She further stated that the laboratory company and the facility had an agreement which included all their [lab] staff had to be vaccinated. The DON emphasized the facility hoped that everyone was doing the right thing by being vaccinated. The DON stated that she and the Licensed Nursing Home Administrator (LNHA) were tracking the vaccination status of the contracted staff. The DON concluded they were not diligent in consistently tracking the contracted staff vaccination status. On 12/01/22 at 10:13 AM, the LNHA stated vaccination status tracking was shared responsibility between the DON, the Human Resource (HR) department, and the LNHA. He stated that all contracted staff were required to be vaccinated and that the facility did not allow anyone with vaccination exemption. The LNHA explained to be considered vaccinated, staff must have the first two doses of the covid vaccine, and all employees at the facility were required to have the booster, but the contracted LTs were only required to have the two vaccine doses and not the booster. He stated, upon first entering the facility, contracted staff were required to provide their vaccination card, and he only tracked if they were vaccinated and did not follow up to confirm if they were up to date. The LNHA stated that contracted staff should be following the facility's policy and that he had verbal conversations with the contracted companies to ensure only vaccinated staff were sent to the facility. On 12/02/22 at 09:24 AM, the LNHA, in the presence of the DON and the survey team, stated he was not consistently and accurately tracking the covid vaccination status for the contracted staff. The LNHA explained when it came to consistently and accurately tracking the contracted staff vaccination status, he only listed staff he considered to be contracted instead of listing everyone that was contracted staff in addition to not following up on the accuracy of the vaccination status. The LNHA acknowledged that he should not assume that everyone was following the guidelines and should have consistently and accurately tracked all contracted staff covid vaccination status. A review of the facility policy titled COVID-19 Vaccination effective 09/06/22, included .This policy applies to all employees of Harrogate. This policy goes into effect on September 2, 2021. All employees are required to receive the COVID-19 vaccination . Employee(s) is defined as any regular staff member whether they are full-time, part-time, or PRN [per diem], which may also include, for the purpose of this policy, specified contracted or temporary staff . A review of the facility's updated policy titled COVID-19 Vaccination effective 11/30/22, included .Contractors: All contractors entering Harrogate will be required to show proof of vaccination in-order to provide services . A review of the facility policy titled Skilled Nursing Facility COVID-19 Vaccine-Employees/Staff revised 12/01/22, included . 23. Staff under contract or arrangement who provide services on a regular basis will be required to provide a copy of their vaccine cards upon their first visit .These records will be maintained by the Administrator or designee . Harrogate will follow-up with the providers on a regular basis to ensure their documentation is up to date. The contracted providers will be responsible for following State and Federal guidelines. NJAC 8:39-5.1(a)

Based on observation, interview, medical record review, and other facility documentation, it was determined that the facility failed to don (wear) appropriate personal protective equipment (PPE) of eye protection and gown for a resident identified as person under investigation (PUI) for possible COVID-19 exposure in order to mitigate the transmission of COVID-19. On 2/25/21 at 9:04 AM, the surveyors conducted an entrance conference with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Associate Executive Director. The DON stated that the facility had three residents located on the High Side Nursing Unit that were newly admitted to the facility. These residents were considered PUIs and were on transmission based precautions (TBP) for fourteen days in effort to mitigate the transmission of COVID-19. The DON stated that staff donned PPE of a N95 (respirator) mask, gown, eye protection (either goggles or face shield), and gloves prior to entering that resident's room. The DON stated that PPE was located in a bin outside the resident's door. At 10:40 AM, the surveyor observed outside of Resident #1's room a PPE bin and signage indicating the resident was on TBP. At this time, the surveyor in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM) observed the Occupational Therapist (OT) enter Resident #1's room wearing only a N95 mask, gloves, and prescription eye glasses. The OT propelled the resident from the doorway to the bed. The OT then proceeded to shut the door. At this time, the LPN/UM confirmed that Resident #1 was on TBP and the OT should be wearing a gown and eye protection in that room. The LPN/UM confirmed that prescription eye glasses were not considered PPE. The LPN/UM opened the PPE to obtain additional PPE to enter the resident's room, but there was no eye protection or N95 masks in that bin so she needed to obtain them. At 10:45 AM, the surveyor accompanied by the LPN/UM entered Resident #1's room. The surveyor observed the OT conducting therapy treatments with the resident. At this time, the LPN/UM stopped the OT and informed her that she needed to don a gown and eye protection. The OT then proceeded to remove her gloves and preformed hand hygiene prior to exiting the room to obtain additional PPE. At 10:50 AM, the surveyor interviewed the OT who stated that she had not realized that the resident was on TBP. The OT also stated that she had thought that her prescription eye glasses were considered eye protection. At 12:17 PM, the surveyor interviewed the Registered Nurse/Infection Preventionist (RN/IP) who stated that for resident's on TBP, staff donned a N95 mask, gown, eye protection, and gloves prior to entering the room. The RN/IP confirmed that prescription eye glasses were not considered eye protection. The RN/IP stated that the OT had just recently returned to the facility to work for a therapist out on medical leave. The RN/IP stated that in the past, the OT was in-serviced by the facility, but she was unable to find any in-services that were conducted with the OT upon her return. At 12:54 PM, the surveyor team informed the LNHA, DON, RN/IP, and Associate Executive Director their concerns. The Administration team acknowledged that the OT should have wore a gown and eye protection in Resident #1's room. A review of the facility's undated Outbreak Response Plan included that new admissions will be treated as a PUI until allotted period, as designated by CDC, without showing any sign or symptoms. Staff should wear appropriate infection control PPE as needed on precautions. A review of the New Jersey Department of Health Communicable Disease Services (NJDOH/CDS) Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated revised date 10/22/2020 included residents that were new or re-admissions from the community or other healthcare facilities should be placed in an observation area cohort for fourteen days to monitor for symptoms that might be compatible with COVID-19. The plan also included that these residents be placed on TBP with PPE which included N95 mask, eye protection, gloves, and gown. NJAC 8:39 19.4

Based on observation, interviews, medical record review and review of other pertinent facility documentation, it was determined that the facility failed to consistently implement and modify Care Plan safety interventions to prevent falls on a resident who was identified as a high fall risk. This deficient practice was identified for Resident #23, 1 of 3 sampled residents reviewed for incident and accidents, and was evidenced by the following: On 09/24/2020 at 11:30 AM, during facility tour, Resident #23 was observed seated in a chair in the activities room. The surveyor was unable to interview due to the resident's cognitive loss. The surveyor reviewed Resident #23's medical record: According to the Admissions Record, the resident was admitted to the facility with Irritable Bowel Syndrome (IBS), Cognitive Communication Deficit, and Diabetes Mellitus (DM). The significant change Minimum Date Set (MDS), an assessment tool dated 07/30/2020, indicated that the resident had moderate cognitive impairment and required limited assistance with toileting, transfers and ambulation. The MDS also indicated that the resident had a history of [REDACTED]. The Morse Fall Scale dated 08/06/2020, indicated that the resident was at a high risk of falling. On 09/28/20 11:32 AM, the surveyor reviewed the facility Incident and Accidents Reports (IAR) dated: 06/26/2020, 07/30/2020, 08/08/2020, 08/20/2020, 08/24/2020, 08/31/2020, and 09/05/2020 which revealed that Resident #23 had fallen on each one of these dates and that the CP was not updated to include new interventions to reduce the risk for falls after each fall was identified. The Care Plan (CP), dated 04/23/2020, reflected that the resident was at risk for falling related to (r/t) deconditioning, gait and balance problems. The CP listed dates of actual fall without injury on 06/26/2020, 07/07/2020, 07/30/2020 and an unwitnessed fall on 08/06/2020 that resulted in a bruised nose. There was no revision to the CP to include the date of the resident's fall, as identified in the IARs dated 08/20/2020, 08/24/2020, 08/31/2020, and 09/05/2020, nor was there documentation of an intervention after each of these fall incidents. The Plan of Treatment for Outpatient Rehabilitation form, dated 07/29/2020, reflected that Resident #23 had several falls in the past 12 months and demonstrated gross physical and mobility dysfunction resulting in gait impairment. The form also indicated that when the resident ambulated near and around objects the resident lacked the proper safety awareness and unsafe speed. The Physical Therapy (PT) Discharge Summary, dated 09/10/2020, reflected that Resident #23 reached maximum functional potential and displayed a decreased safety awareness, impulsive behavior and was an overall increased risk for falls. On 09/28/2020 at 12:03 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN UM) who stated that Resident #23 was cognitively impaired and had poor safety awareness. She stated the resident had a [DIAGNOSES REDACTED]. She stated that the resident had a frequent falls when he/she lived in assisted living and that when the resident attempted to walk in his/her room without assistance, he/she would lose balance and fall. She added that the resident was incontinent at times and that most of his/her falls were related to his/her bowel issues. The LPN UM explained the process for completing the IARs. She said that the nurse, who identified the fall, would complete the IAR. The report would then go to the DON for review and the DON would write up a summary. The DON would then bring the IAR to the morning meeting to review possible new interventions to prevent continued reoccurrences of the resident falling. The following disciplines attended the meeting: Activity Director, LPN UM, Assistant Director of Nursing (ADON), Director of Nursing (DON), Social Worker (SW), Director of Rehabilitation, MDS Coordinator, and Dietician. The LPN UM stated, We go over the incident to see what we could have done better and talk about possible interventions we could put into place to help and reduce the risk for falls. The nurse that fills out the incident report collects statements and would put an intervention to reduce the risk of fall on the CP. On 09/28/2020 at 12:14 PM, the surveyor interviewed the DON who stated that the process for IAR investigations included: the nurse who identified the incident or accident was supposed to fill out the incident report, obtain statements and update the care plan with new interventions that were put into place to prevent further reoccurrences. The IAR packet would then be submitted to the DON for review and compliance. I look at the whole packet for completion and then it is taken to morning meeting for review. The DON confirmed that not every IAR report investigation or CP was completed with new interventions to prevent a further reoccurrence of falls for Resident #23. I could usually argue the point, but I cannot argue that there were no documented interventions on every fall for Resident #23. On 09/29/2020 at 08:24 AM, the surveyor interviewed the DON who stated that she was aware that fall interventions were not documented on the resident's CP after each fall and stated she takes full responsibility for the lack of documentation for fall interventions on the Resident #23 care plan. On 09/29/2020 at 09:40 AM, the surveyor interviewed the primary care Certified Nursing Assistant (CNA) who stated that Resident #23 was cognitively impaired and was impulsive with poor safety awareness. She stated that Resident #23 was a fall risk secondary to unsteady gait and required extensive assistance with toileting and ADLs. She also added that he had occasional incontinence of bladder and bowels and wore protective briefs for vanity and hygiene. She stated that she tried to keep him on a schedule and tries to keep an eye on him because he attempts to get up without assistance and has an unsteady gait. On 09/29/2020 at 11:21 AM, the surveyor interviewed the Licensed practical Nurse (LPN #1) who stated that if a resident falls, We then update the CP and come up with a new intervention to prevent further accidents. LPN #1 revealed that he was caring for Resident #23 when he/she fell on [DATE] at 3:42 PM, and did not know why he did not put in a new intervention on the residents CP to reduce the risk for falls. On 09/29/2020 at 12:09 PM, the surveyor attempted to conduct a telephone interview with LPN #2 but there was no answer. A message was left. The facility policy titled, Fall Risk Assessment, dated March 2018, indicated that the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The facility policy titled, Falls-Clinical Protocol, dated March 2018, indicated that if an individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. The facility policy titled, Falls and Falls Risk, Managing, dated March 2018, indicated that based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risk and causes to try and prevent the resident from falling and try to minimize complications from falling. NJAC 8:3.9-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to minimize the potential spread of infection to residents during medication administration for 1 of 2 nurses observed during medication administration on 1 of 2 units. This deficient practice was evidenced by the following: On 04/11/19 from 07:56 AM to 08:20 AM, the surveyor observed the medication pass on the Blue/East Unit with the Licensed Practical Nurse (LPN). On 04/11/19 at 08:02 AM, the surveyor observed the LPN pour, prepare and administer medications to Resident #12. Without performing hand hygiene, the surveyor observed the LPN then pour, prepare and administer medications to Resident #8 at 08:06 AM. On 04/11/19 at 08:10 AM, the surveyor observed the LPN wash his hands with soap for six seconds under water, the LPN then turned off the faucet with his wet hand and then dried both hands with a paper towel. The LPN donned gloves and applied an icy hot patch to the lower back of Resident #3. The LPN then removed his gloves and washed his hands in the same manner for eight seconds. When interviewed on 04/11/19 at 1:12 PM, the LPN told the surveyor that he should have washed his hands for 20 seconds. On 04/11/19 at 1:12 PM, the surveyor interviewed the Administrator. The Administrator confirmed that the nurse should wash his hands for 20 seconds, outside of the stream of water and the nurse should use a paper towel to turn off the faucet. On 04/16/19 at 09:02 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the LPN was in-serviced on hand washing. The DON further stated that the LPN should follow the hand washing policy. The surveyor reviewed the facility's Handwashing/Hand Hygiene policy, revised 04/11/19. The policy revealed that staff should wash their hands before preparing or handling medications. The policy further reflected that staff will vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds, rinse hands thoroughly under running water, dry hands thoroughly with paper towels, and then turn off faucets with a clean, dry paper towel. NJAC 8:39-19.4(a)

Based on interview and record review, it was determined that the facility failed to ensure that the required members were present during the quarterly Quality Assessment and Assurance (QAA) committee meetings. This deficient practice occurred during 3 of the 4 QAA committee meetings and was evidenced by the following: During the Entrance Conference, the surveyor requested the Administrator to produce the committee member attendance documentation for the last four QAA quarterly meetings. The Administrator was unable to provide the QAA quarterly attendance documentation for three quarters in (YEAR). When interviewed on 04/12/19 at 12:20 PM, the Administrator stated that there was a change in the Director of Nursing (DON) in (MONTH) 2019. The Administrator further stated that the attendance documentation was kept by the former DON and he was unable to locate the paperwork. NJAC 8:39-33.1(b)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to a.) sanitize, store, and maintain kitchen equipment to prevent microbial growth; b.) store, label and date potentially hazardous foods to prevent food borne illness; and c.) maintain potentially hazardous food temperatures below 41 degrees Fahrenheit (F) or above 135 degrees Fahrenheit. The deficient practice was evidenced by the following: On 3/16/18 at 9:19 AM, the surveyor toured the kitchen with the Director of Dining Services (DDS). The following was observed: 1. Two, large ricotta cheese containers opened in the walk-in refrigerator labeled with a received date of 2/5/18. There was no open date. 2. One, opened quart of heavy cream in the walk-in refrigerator. There was no open date. The packaging indicated to use within seven days of opening. 3. One, large bottle of lemon juice stored on the spice rack. The lemon juice was labeled opened on 3/14/18. The packaging indicated to refrigerate after opening. 4. One, bacon mozzarella quiche in the main line reach-in refrigerator labeled 3/8/18. The DDS stated that prepared foods should be discarded after three days. 5. One Canadian bacon wrapped in plastic wrap in the main line reach-in refrigerator. The plastic wrap was opened exposing the bacon to air. 6. One, portable steam table not in use. The dial had caked-on debris around the serving surface. The DDS stated the steam table should have been cleaned daily. He confirmed it was not cleaned after previous use. 7. At 9:47 a.m., the surveyor observed on the cook table two cold food stations utilizing two stacked hotel pans and ice. The stations included bacon, Canadian bacon, four raw eggs in shells, two semi-full liquid pasteurized eggs, one semi-full liquid egg whites, and French toast egg batter. The DDS calibrated the facility's thermometer to 32 degrees Fahrenheit (F). The DDS took the temperatures of the above foods. The temperatures were as followed: bacon 70 degrees (F); raw egg 62 degrees (F); liquid pasteurized eggs 65 and 54 degrees (F); liquid egg whites 70 degrees (F); and French toast egg batter 58 degrees (F). The DDS confirmed these temperatures were above acceptable levels and discarded. 8. One fruits of forest pie in the Coke refrigerator labeled with a use-by date of 3/14/18. 9. Two, eighteen-quart plastic containers which contained ceasar and balsamic dressings. Both containers contained metal ladles and the lids were ajar. The DDS confirmed the utensils should not be stored in the dressing. At 10:33 AM, the surveyor entered the Health Care Center kitchenette with the DDS. They observed the following: 1. Two, juice machine nozzles with black buildup inside. The DDS stated the nozzles were supposed to be soaked every night. The DDS stated the nozzles definitely were not soaked last night. He could not speak to when it was last soaked. At 11:40 a.m., the surveyor observed one basket resting above the coffee machine in the kitchenette. The basket contained three coffee filters with coffee grinds. The basket was not covered, which exposed the coffee to air. On 3/23/18 at 12:30 p.m., the Administrator stated that the facility used the same kitchen, products, and dietary staff for both the Health Care Center (HCC) and Independent Living (IL). The Administrator stated that although the food commingles with the HCC and the IL, the food/breakfast temperatures taken on 3/16/18 were to be served for the residents in the IL, and not the HCC, as the residents in the HCC were already served breakfast. The Administrator acknowledged that it was the same dietary staff in the kitchen for the HCC and IL, and the practice of holding temperatures was not consistent with standards of practice to prevent food-borne illness. The surveyor reviewed the facility's undated Labeling and Dating Policy. The policy included to label and date all food items. The policy further indicated that all opened fluid milk products should be used by seven days of opening. The policy further included that all opened dairy products will be dated with a use by date of fourteen days. The policy also included in the Dating Reference Sheet that all leftovers, thawed frozen food items, perishable, plated items, tray items, and ready to eat foods should be used by three days. The surveyor reviewed the facility's undated How Do You Hold Cold Food policy. The policy included that cold food may be held without refrigeration for up to six hours at a temperature below 41 degrees (F). Discard any cold food that reaches a temperature of 70 degrees (F) or higher. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to develop an individualized, resident-centered care plan for: a.) a resident with bilateral upper and lower extremity contractures to prevent further decline and/or injury, and b.) a resident who preferred his/her privacy and had been identified to have an over-the counter-medication in his/her room. This deficient practice was identified for 2 of 23 residents reviewed for development of individualized care plans (Resident #1 and #6), and was evidenced by the following: 1. On [DATE] at 10:57 AM, the surveyor observed the door closed to the private room of Resident #6. At that time, the surveyor knocked on the door and requested to enter. Resident #6 allowed the surveyor to enter. At that time, the surveyor observed Resident #6 sitting in a wheelchair going through his/her personal belongings in a top dresser drawer positioned against the wall. The surveyor observed inside the opened, top dresser drawer a bottle of [MEDICATION NAME] pills (an over-the-counter supplement to aid in sleep), with a undetermined dosage. The drawer was not locked. The surveyor asked the resident if he/she took the [MEDICATION NAME] that was in the dresser drawer, and the resident immediately stated, Oh, these? These (pills) are not mine. I don't know who they belong to. The resident then picked up the bottle and stuffed it to the back of the dresser drawer out of sight from the surveyor. The surveyor requested to interview Resident #6 further but the resident refused and stated that he/she preferred privacy. On [DATE] at 11:01 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA). The CNA stated that resident was fully alert and oriented and could make his/her own decisions and had no known behaviors. She further stated that Resident #6 was a pretty private person. If (he/she) can do it herself (he/she) doesn't ask. The CNA stated that the resident gets all medications from the nurse, and that to her knowledge the resident does not self-administer medications. She further told the surveyor that she had never seen any medications in the resident's room or elsewhere, but that if she did she would tell the nurse right away. On [DATE] at 11:05 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN). The LPN stated that the resident was alert and oriented to person, place, and time, and takes his/her medications whole. She further indicated that all medications were administered by the nurse and that the resident does not have a physician's order to self-administer medications. She stated that the resident was a private person who likes the door shut. The surveyor asked the LPN if the resident had ever been found to have medications in his/her room, and the LPN stated Never. The surveyor discussed with the LPN the bottle of [MEDICATION NAME] observed in the resident's open top drawer while the resident was going through his/her belongings. The LPN immediately stated that Resident #6 can't have pills in the room and that his/her family representative probably brought them in. At 11:10 AM, the surveyor observed the LPN knock and enter the room of Resident #6, in order to get the bottle of [MEDICATION NAME] from the resident. The LPN then came out of the room very soon after entering without the bottle of [MEDICATION NAME]. The LPN told the surveyor that she went into the room to talk to the resident and the resident would not give her the bottle of [MEDICATION NAME], and that the resident seemed angry. The LPN further told the surveyor that the resident never requested for a sleep aid and/or had stated he/she had difficulty sleeping at night. She could not speak to whether the resident had taken the [MEDICATION NAME]. At that time, the LPN stated that she would have to get the Director of Nursing (DON) to get the [MEDICATION NAME], and/or assess whether the resident wants to self-administer medications. The LPN further stated, This has never happened before. One week later, on [DATE] at 10:00 AM, the surveyor reviewed the medical record for Resident #6. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating a fully intact cognition. A review of the Physician Order Sheet (POS) for (MONTH) (YEAR) reflected that there were no physician orders for the medication supplement, [MEDICATION NAME]. In addition, there was no evidence for a physician order to reflect that it was ok for the resident to self-administer medications. A review of the resident's individualized, resident-centered care plan dated [DATE] and [DATE] did not address the resident's preference for privacy with his/her personal belongings to not be touched by staff. In addition, the resident's care plan did not address the [MEDICATION NAME] found in the resident's room on [DATE] and how the staff were ensuring the resident would remain safe when the resident did not like staff to go through his/her belongings with the new knowledge that unauthorized over-the-counter medication had been found in the resident's room. A review of the Interdisciplinary Care Conference Meeting sheet dated [DATE], reflected a meeting was held with the resident and his/her family representative. The Care Conference Meeting summary included that the resident had no moods or behaviors that occurred in the previous quarter. The Care Conference Meeting notes did not include the resident's preference for privacy and/or that [MEDICATION NAME] had been found at the resident's bedside. On [DATE] at 10:15 AM, the LPN and surveyor reviewed the resident's care plan together. The LPN confirmed there was no care plan to address the resident's privacy preferences and the bottle of medication found at his/her bedside. The LPN stated that she would have to ask the DON if there should be a care plan for that, but confirmed that the resident had been upset for a few days after the [MEDICATION NAME] was removed from the room. The surveyor asked the LPN how staff are ensuring the resident's preference for privacy and safety are ensured if there was no care plan to address the resident's individualized needs. The LPN replied that she did not think the resident had access to any other medications as the pills had been removed from his/her room on [DATE], but could not speak to the plan to monitor. At 10:18, in the presence of the LPN, the LPN/Charge Nurse (LPN/CN) stated to the surveyor that the family representative removed the [MEDICATION NAME] at the resident's bedside. The LPN/CN stated that she believed that the medication came from the family representative. She was unable to provide the surveyor evidence of a plan of care for the resident's preference for privacy and the potential impact the resident's preference for privacy had on his/her safety after the medications were found in his/her room. The LPN/CN stated that the surveyor would need to speak to the social worker and DON regarding the resident's care plan. On the same day on [DATE] at 10:30 AM, the surveyor interviewed the Licensed Social Worker (LSW) who stated that the interdisciplinary care team (IDT) had a care conference with the resident and the family representative on [DATE] and confirmed the Care Conference Meeting sheet dated [DATE] did not reflect evidence of the resident's plan of care to ensure his/her safety after the [MEDICATION NAME] had been found on [DATE]. The LSW stated that the care conference on [DATE] only included a brief review of the topic of self-administration of medications in the future, and not about the [MEDICATION NAME] found in the resident's room. The LSW stated that the DON had a further discussion with the family representative at another time, and it was not included in the care conference meeting notes. The LSW confirmed that there was no documented care plan for the resident's preferences for privacy with his/her personal belongings. On [DATE] at 10:35 AM, the surveyor interviewed the DON who stated that she believed the [MEDICATION NAME] came with the resident from when he/she lived in the Independent Living (IL) section of the community, and was not from the resident's family representative. She stated that the [MEDICATION NAME] found in the resident's room expired in (YEAR) and that the resident never took it because the bottle was full. The DON further stated that the resident was able to independently make decisions, and was a very private person, and that it would be infringing on (his/her) rights if we went through (his/her) belongings. The DON confirmed that the family representative was educated that over-the-counter medications were not be brought in and given to the resident without physician authorization. The DON acknowledged there was no care plan to address the resident's preferences for privacy as well as the [MEDICATION NAME] found stating, It's because we already removed it, and we educated the (family representative) and that the resident therefore did not have access to any other medications. On [DATE] at 10:00 AM, the surveyor interviewed the DON in presence of the survey team. The DON confirmed that the furniture came down with the resident when he/she moved from IL, and that the resident was a very private person. The DON acknowledged that the resident should have had a care plan regarding his/her preference for privacy and how those preferences could impact his/her safety. 2. On [DATE] at 12:30 PM, the surveyor observed Resident #1 sitting upright in a geri-chair at a table with 4 other residents in the assisted feeding dining room area at lunch. The resident's hands were contracted (a condition resulting in shortening and hardening of muscles, tendons and/or other tissues leading to joint deformities) to his/her chest. The surveyor observed a Certified Nursing Assistant (CNA) slowing spoon-feeding the resident a pureed meal. On [DATE] at 8:42 AM, the surveyor observed a CNA perform morning care to Resident #1. The resident was awake, alert, and unable to be interviewed due to a cognitive impairment. The surveyor observed that the resident's bilateral lower extremities were contracted at the knee and that the resident's bilateral upper extremities were contracted at the elbow. The resident's fingers on both hands were also fixed and contracted at the knuckles. At that time, the surveyor interviewed the CNA. The CNA stated that she was familiar with the resident, and that the resident was admitted to the facility several months ago with advanced [MEDICAL CONDITION] and had contractures since admission to his/her bilateral upper and lower extremities. The surveyor reviewed the medical record for Resident #1. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [DATE] reflected that the resident had a severe cognitive impairment. A review of the resident's occupational therapy plan of care note dated [DATE] indicated that the resident presented with end-stage dementia and fixed contractures throughout his/her body. The goal of the therapy was for the resident reduce the risk of contractures progression to the bilateral upper extremities. A review of the resident's interdisciplinary resident-centered care plan dated ,[DATE] did not address the resident's bilateral upper and lower extremity contractures. The care plan did not include specific care needs related to his/her contractures. On [DATE] at 9:55 AM, the surveyor interviewed the resident's Physical Therapist (PT). The PT stated that the resident was admitted to the facility with contractures and recalled that the resident's lower extremities were bent at a 65 degree angle when he/she was first admitted to the facility. The PT further stated that she worked with the resident for positioning and comfort due to the contractures and that when the staff tried to perform passive range of motion to the resident's arms and legs, it caused the resident to become agitated. The PT stated in the interview that if a resident had contractures, the contractures should be something that the resident should have a care plan for, but more in regards to as the contractures affect positioning and the potential for skin breakdown. On [DATE] at 10:18 AM, the surveyor interviewed the DON. The DON acknowledged that the resident did not have a care plan for his/her bilateral upper and lower extremity contractures and this was something that moving forward the team was going to address. NJAC 8:,[DATE].2 (e)

Based on observation, interview, and record review it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag was stored in a manner to prevent urinary tract infections. This deficient practice was identified for 1 of 2 residents reviewed with an indwelling urinary catheter (Resident #53), and was evidenced by the following: 03/16/18 12:05 PM, the surveyor observed the vacant room for Resident #53. At that time, the surveyor observed a used plastic bag tied to a handrail in the resident's bathroom. Inside the plastic bag was a used indwelling urinary catheter drainage bag, a urinal, and paper towels. The urinary catheter drainage tubing was not capped, and was in direct contact with the plastic bag. On 3/20/18 at 8:48 AM, the surveyor observed the resident resting in bed with his/her eyes closed. The surveyor attempted to interview the resident, but the resident was not able to respond appropriately to surveyor questions due to a cognitive impairment. The resident's bed was in the low position and there was a safety floor mat adjacent to the resident's bed. At that time the surveyor observed that the resident had an indwelling urinary catheter (a flexible tube inserted into the bladder for urinary drainage). The Indwelling catheter tubing had visible yellow urine occupying the full length of the tubing, and the tubing was in direct contact with the safety floor mat. The urinary drainage bag was was in a privacy bag. On 3/22/18 at 9:37 AM, the surveyor observed Resident #53 in his/her bed. The bed was in the low position. The surveyor observed clear, yellow urine occupying the indwelling catheter tubing. The indwelling catheter tubing was in direct contact with the safety floor mat in the resident's room. On 3/22/18 at 11:39 AM to 11:49 AM, the surveyor observed the resident in bed. The indwelling urinary drainage bag and catheter tubing were in direct contact with the safety floor mat in the resident's room. A Certified Nursing Assistant (CNA) was setting up to provide care to the indwelling urinary catheter for Resident #53. The surveyor interviewed the CNA at that time. The CNA stated that the indwelling urinary catheter drainage bag would not be discarded because it was a new bag and not due to be changed. The surveyor observed a handwritten date of 3/11/18 on the indwelling urinary catheter drainage bag in black marker. The CNA further stated that she would place the indwelling urinary catheter drainage bag in a plastic bag and store it in the resident's room. On 3/22/18 at 12:38 PM, the surveyor further interviewed the CNA who provided Resident #53's indwelling catheter care. The CNA stated that the tubing at the end of the indwelling urinary catheter drainage bag should be capped when stored. The CNA further explained that the indwelling urinary catheter drainage bag and tubing should never be touching the floor in the resident's room. On 3/23/18 at 8:45 AM, the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN stated that when an indwelling urinary catheter drainage bag was not in use, staff were required to clean it, place the catheter bag in a plastic bag and put a cap at the end of the tubing. The LPN further stated that placement of an indwelling urinary catheter drainage bag should hang low below the level of the resident's bladder and should not come in contact with anything on the floor. The surveyor reviewed the medical record for Resident #53. According to the resident's (MONTH) (YEAR) Physician order [REDACTED]. According to the resident's most recent significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 3/1/18, reflected that the resident had a Brief Interview of Mental Status (BIMS) of 1 out of 15, which indicated a severe cognitive impairment. A review of the (MONTH) (YEAR) POS revealed Physician Order's dated 2/8/18 for care to be performed on the indwelling urinary catheter every shift and to change the drainage bag every two weeks. The POS reflected that the indwelling catheter was for [MEDICAL CONDITION]. A review of a urinary culture lab dated, 1/30/18 indicated that the resident had a urinary tract infection. The final urine culture indicated that the sample of urine contained a colony count of bacteria greater than 100,000 colony forming units. A review of the resident's individualized Interdisciplinary Care Plan (ICP) revised on 3/8/18 included a focus area that the resident had urinary incontinence and the presence of an indwelling urinary catheter related to chronic [MEDICAL CONDITION]. The goal of the ICP included that the resident would have adequate urinary output and will not have further UTI's (Urinary Tract Infections). Interventions of the ICP included catheter care every shift and change the drainage bag as ordered. On 3/26/18 at 9:12 AM, the surveyor reviewed the facility's policy and procedure on Catheter Care/Indwelling Urinary Catheter. The policy included that licensed nursing personnel are to, 7) Maintain a sterile, continuously closed drainage system. The catheter and drainage tube should not be discontinued unless specified by a physician. (&) 10) The only place, in the closed system, intended to be open is the empty spout at the bottom of the drainage bag. (Note: Caution should be taken not to allow the end of the spout to touch anything that will contaminate it). NJAC 8:39-19.4(a)5

Based on observation, interview and record review, it was determined that the facility failed to administer a medication in accordance to manufacturer specifications during the medication pass observation. The deficient practice was identified for 1 of 2 nurses administering medications to 1 of 7 residents, (Resident #4), and the evidence was as follows: On 3/20/18 at 9:28 AM, the surveyor observed the Licensed Practical Nurse (LPN) preparing to administer four (4) medications, which included one tablet of Aripiprazole ([MEDICATION NAME]) 2 mg, to Resident #4. The LPN stated that she received a report from the nurse in the morning during the shift change and was told that the resident preferred his/her medications to be crushed and put into pudding. The LPN also stated that the Medication Administration Record [REDACTED]. At that time, the surveyor observed the LPN crush three (3) medications which included the [MEDICATION NAME] 2 mg tablet and place the crushed tablets into the pudding. In addition, the LPN opened a capsule of the anticonvulsant medication, [MEDICATION NAME] 125 mg and placed the contents of the capsule into the pudding. The LPN stated that the capsule cannot be crushed but was allowed to open the capsule according to what was indicated in the MAR. The LPN then administered the medications in the pudding to the resident. On 3/20/18 at 9:40 AM , the surveyor with the LPN, reviewed the label for the [MEDICATION NAME] 2 mg tablets for the resident. The label reflected a pharmacy cautionary statement which reflected, Swallow whole. Do not chew or crush. The LPN stated that she did not see the cautionary statement and should not have crushed the [MEDICATION NAME] tablet. At that time, the surveyor also reviewed the resident's MAR for (MONTH) (YEAR) which revealed a physician's orders [REDACTED]. Further review of the MAR indicated [REDACTED]. A review of the physician's orders [REDACTED]. On 3/20/18 at 10:25 AM, the surveyor interviewed the Licensed Practical Nurse/Charge Nurse (LPN/CN) with regard to Resident #4. The LPN/CN stated that she had administered medications to the resident and that the resident had trouble swallowing in the past. She further explained that although the resident had some difficulty swallowing in the past, the resident was able to swallow small tablets. The LPN/CN added that the resident's medications had been reviewed and that was why there were instructions for the [MEDICATION NAME] capsule to be opened, but the [MEDICATION NAME] tablet was small enough for the resident to swallow without crushing. The LPN/CN further stated that cautionary warnings should be followed and if the resident could not swallow the tablet then the physician would have to be notified. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility on of 9/8/2016 with [DIAGNOSES REDACTED]. On 3/20/18 at 12:30 PM, the survey team met with the Director of Nursing (DON) who stated that the nurses report to each other how medication were to be administered to each resident during change of shift report, and how to administer medications if a nurse was not familiar with the residents. The DON stated that the LPN was recently hired. The DON also stated that the pharmacy cautionary warnings for medications such as do not crush must be followed, and confirmed that the LPN should not have crushed the [MEDICATION NAME] tablet. A review of the current undated facility policy and procedure for Medication Administration provided by the DON on 3/20/18 at 12:16 PM, revealed that the nurses should Read and follow any special instructions written on labels. In addition, Crush medication only after checking with the pharmacy because the medication may be time-release capsules or [MEDICATION NAME] coated drugs. The Manufacturer's specifications for [MEDICATION NAME] tablets indicate that the medication should be swallowed whole. NJAC 8:39-29.2 (d)

Based on observation, interview and record review, it was determined that the facility failed to store and label potentially hazardous foods to prevent food borne illness as evidenced by the following: On 1/10/17 from 8:30 a.m., to 9:00 a.m., in the presence of the Executive Chef (EC) the surveyor observed the following in the walk in refrigerator: 1. A package containing 20 knockwurst sealed in plastic from the manufacturer with a manufacturers' date of 11/22/16. The EC explained that the package should have been dated and had been previously frozen. No additional label or date was on the package which indicated this. 2. Eleven sealed packages in plastic containing three raw hamburger patties in each package dated 1/4/17. The EC explained 1/4 was the date the hamburger meat was received from the distributor. No label was on the package indicating the use by date. 3. A block of deli pastrami meat stored in plastic wrap with no label and date. 4. Nineteen cans of anchovies with no observable manufacturer date on the cans. Three of the cans were labeled and dated 6/28/16. One of the cans was labeled and dated 12/4/16. The surveyor observed a greenish white substance on four of the 19 anchovy cans. The EC took the soiled anchovy cans off the shelf in front of the surveyor and explained how the cans needed to be cleaned. 5. The surveyor observed a sheet of carrot cake covered in white frosting not labeled and dated. 6. In the presence of the Assistant Food Service Director (AFSD) on 1/10 at 9:05 a.m. inside the healthcare refrigerator, the surveyor observed three small plastic containers with ketchup in them, not labeled and dated. The surveyor reviewed the Harrogate- Dining Services Department Labeling Food Requirements on 1/10 at 11:45 a.m. The policy stated: All potentially hazardous, ready-to-eat foods prepared on site must be properly labeled. Any food removed from its original package must be put in a clean sanitized container, properly covered, and properly labeled. Each label must include: NAME OF THE FOOD, DATE FOOD WAS PREPARED, USE-BY DATE, EMPLOYEE INITIALS. The surveyor interviewed the Food Service Director (FSD) and EC on 1/13/17 at 10:00 a.m. The FSD explained to the surveyor that some of the meats such as the hamburger patties were received from a local butcher who places a label on the foods the date they are received by the facility, however does not provide a use by date label. The FSD acknowledged at that time that the food items were not labeled properly and the facility was currently working on a new labeling system with the local butcher. NJAC 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to provide medications according to physician orders [REDACTED].#8) reviewed for accuracy of administering medications, as evidenced by: On 1/10/17 at 9:05 a.m., during the initial tour, the RN Unit Manager (UM) told the surveyor that Resident #8 was readmitted recently from the hospital and was receiving nectar-thick liquids by mouth and feeding formula via a gastrostomy tube, but now was receiving nothing by mouth and continued on just tube feeding. On 1/10/17 at 11:40 a.m., the surveyor observed Resident #8 asleep with the feeding formula infusing at 80 milliliters per hour (mls/hr) via a feeding pump. On 1/10/17 at 11:50 a.m., the surveyor reviewed Resident #8's medical record. A PO dated 1/4/17 indicated that Resident #8 should be on a pureed diet with nectar thick liquids. A PO dated 1/9/17 indicated, Hold by mouth (po) feeding today. There was no documented evidence indicating how Resident #8 should receive medications previously administered by mouth. Review of the Medication Administration Record [REDACTED] [MEDICATION NAME] 75 milligrams (mg) tab po daily at 9 a.m., [MEDICATION NAME] 5 mls po every 8 hours (hrs) at 6 a.m., 2 p.m. and 10 p.m. [MEDICATION NAME]-levedopa 25-100 mg tab po at 11a.m. Aspirin 81 mg tab po daily at 9 a.m. [MEDICATION NAME] 5 mg tab po daily at 9 a.m. Ropinirole 2 mg tabs po 4x a day at 9 a.m. and 1 p.m. [MEDICATION NAME] 500 mg po 3x a day at 2 p.m. Linagliptin 5 mg tab po daily at 9a.m. [MEDICATION NAME] iron complex 150 mg capsule (cap) po 2x a day at 9 a.m. The following medications were not signed as administered on 1/10/17: [MEDICATION NAME] 75 mg tab po daily at 9 a.m. [MEDICATION NAME] 5 mls po every 8 hrs at 6 a.m. and 2 p.m. [MEDICATION NAME]-[MEDICATION NAME] 25-100 mg tab po at 11 a.m. Aspirin 81 mg tab po daily at 9 a.m. [MEDICATION NAME] 5 mg tab po daily at 9 a.m. Ropinirole 2 mg tabs po at 9 a.m. and 1p.m. [MEDICATION NAME] 500 mg po at 6 a.m. and 2 p.m. Linagliptin 5 mg tab po daily at 9 a.m. [MEDICATION NAME] iron complex 150mg capsule (cap) po daily at 9 a.m. During an interview on 1/10/17 at 1:25 p.m., the Licensed Practical Nurse (LPN) acknowledged that all of the medications that were previously administered by mouth to Resident #8 were not administered on 1/10/17 because Resident #8 should have nothing by mouth. The LPN further stated that the only medication she administered to Resident #8 was the [MEDICATION NAME] Tartate 25mg tab via the GT at 9 a.m. since there was an order to give that medication via GT. The LPN further stated that the administration route for Resident #8's other medications had not yet been clarified with the doctor. Review of a Physician order [REDACTED]. During an interview on 1/11/17 at 9:15 a.m., the UM acknowledged that Resident #8 receives other medications via GT and told the surveyor that there's no good reason why the resident did not receive all medications via GT and the nurse should have clarified the Physician Order. NJAC 8:39-27.1(a); 29.2(d)

Complaint #NJ 396 Based on observation, interview and record review, it was determined that the facility failed to provide a safe environment and safety measures to prevent accidents. This deficient practice resulted in a resident sustaining 3rd degree burns due to improper application of a hot pack, and another resident ingesting a cleaning substance from a coffee mug. This deficient practice was identified for 2 of 5 residents reviewed for accidents, Resident # 10 and # 16, as evidenced by the following: 1. On 6/13/12 at 12:30 p.m., the Director of Nursing (DON) reported to the team that Resident #16 sustained a thermal injury (burn) to the back caused by the placement of a hot pack. The surveyor reviewed the medical record of Resident #16 on 6/14/12 at 10:00 a.m., which revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 6/14/12 at 10:15 a.m., the surveyor reviewed the clinical record of Resident #16. An Interdisciplinary Care Plan note (IDCP) dated 6/8/12 at 2:00 a.m., indicated "Call out to Dr ... ordered moist heat pack for 20 minutes." Review of another IDCP Note dated 6/8/12 at 2:05 a.m., revealed "Returned to room, placed warm pack on back wrapped in protective cover and bath blanket." An IDCP Note dated 6/8/12 at 2:25 a.m., revealed "Resident calling out - my back hurts, and is hot. Resident had removed bath blanket wrap and was rolling in bed to get off compress." An IDCP Note dated 6/8/12 at 2:30 a.m., indicated "Back noted red + (and) blistered. - Cool moist towel applied. Dr ... made aware, Resident refused to go to hospital. Order received for dsg (dressing) to site." On 6/14/12 at 10:30 a.m., the surveyor observed the nurse administer a treatment to Resident #16's thermal injury. The area was reddened; inside the wound some yellow tissue was noted. The nurse measured the wound and recorded the following measurements: 18 cm x 11.5 cm. The yellowish area inside the wound measured 6 cm x 13 cm. During the dressing change the resident indicated that his back was "killing him," and he rated his pain at "10" on a scale of 1 to 10. On 6/14/12 at 10:45 a.m., the surveyor interviewed the nurse involved with the incident. The nurse relayed that she was not aware of the protocol for the use of the hot pack from the Physical Therapy (PT) Department. The nurse told the surveyor that Resident #16 did not get relief from the analgesic offered on 6/8/12 at 12:00 a.m. The nurse stated that at 2:00 a.m., she called the physician to suggest that a warm moist compress be used to relieve his discomfort. The nurse informed the surveyor that she was not aware of the steps to follow regarding the protocol for the use of the hot pack. The nurse indicated that she set the timer for 30 minutes to remind her to check on the resident. The nurse revealed that when she went in at 2:25 p.m., the resident had sustained a thermal injury to the back area. She applied a cold compress and called the physician. The physician could not be reached for the remainder of the shift. The resident refused to go the hospital for evaluation. She notified the family who also refused the admission to the hospital. At 7:00 a.m., she informed the 7-3 nurse for follow up. On 6/14/12 at 11:00 a.m., the surveyor interviewed a family member who stated that the nurse called at 4:00 a.m., to inform her of the incident. The family indicated that she was not told of the severity of the injury and the nurse called again on 6/10/12 to inform her that the resident needed to go to the hospital for evaluation, but she declined the transfer. When she asked about the size of the burn, the nurse told her that she could not find the measurement. On 6/14/12 at 11:15 a.m., the nurse interviewed the resident regarding the incident. The resident stated that night (of the incident) he "kept calling and calling but they did not come." On 6/14/12 at 11:30 a.m., the surveyor reviewed the Accident/Incident Report dated 6/6/12, which indicated "Resident c/o (complain of ) back pain- Tyl (Tylenol) given. -Warm compress applied for 30 min (minutes) - when turned back red- raw blisters Tx (treatment) order rec'd." Review of the Individual Statement Form dated 6/8/12, revealed that the nurse wrote, "Resident calling out at 2:25 a.m. Went to room to remove moist compress. Resident had taken off protective covering by moving around bed, subsequently, hot pack was directly on back.- causing an area (9 x 9) cm (centimeter) cool compress applied and tx (treatment) + dsg (dressing) ..." On 6/14/12 at 11:45 a.m., the surveyor conducted a tour of the Physical Therapy environment and the hot pack equipment with the Physical Therapy Director (PTD). The hydrocollator (a machine containing heated water used to heat and store hot packs) was observed in the right corner of the PT room. The temperature of the hydrocollator measured 160 degrees F (Fahrenheit). The PTD revealed to the surveyor that she was made aware of the accident on 6/8/12. The PTD stated that nurses were not trained on how to use the hot pack from the hydrocollator. The hot packs were used in the Physical Therapy Department only. The PTD indicated that the manufacturer recommended the use of 6 to 8 layers of towels to wrap the pack before applying the hot pack. The PTD revealed that the hot pack should never be sandwiched between the resident and a closed surface such as mattress or the back of a wheelchair. The PTD went on to state that the heat could not escape from the pads if the hot pack was sandwiched between the resident and a closed surface, and injury could occur. She further stated that a staff member should remain with the resident and check the skin every 5 to 10 minutes. On 6/14/12 at 12:45 p.m., the surveyor interviewed the Director of Nurseing (DON), regarding the use of a hot pack by nursing staff. The DON stated that nurses were to use a warm towel for compresses and should never use the hot pack from the hydrocollator. On 6/14/12 at 1:15 p.m., the PTD provided the manufacturer's instructions for the use of the hot pack. The instructions documented that the hot pack could be used for pain, and to use the hot pack with caution with confused or disoriented patients who cannot give feedback concerning the temperature / comfort. The instructions further indicated: a) The water temperature should be checked with thermometer and should be maintained at approximately 150-170 degrees. b) Instruct the patient of the treatment purpose and the safe temperature they should be experiencing during the treatment. c) Position the patient comfortably, and drape the area to be treated exposed. d) Remove the hot pack from the hydrocollator unit, place pack in cloth cover or wrap in 6-8 towels. It is best to put the pack on the patient rather than putting the patient on the pack. e) Always look at the skin prior to the application of the pack. Skin must be checked every 5-10 minutes during the treatment. An interview with the unit nurse on 6/14/12 at 1:30 p.m., revealed that Resident #16 had short term memory problems, and his mental function varied over the course of the day. Review of Interdisciplinary Notes (IDCP) Notes dated from 5/12/12 to 6/14/12, revealed that the resident was oriented with period of confusion. On 6/15/12 at 10:30 a.m., the resident's attending physician stated that he was considering alternative pain management to the Percocet Tabs 2 that the resident was currently receiving, that would not be detrimental to the resident's mental capacity. The physician told the surveyor at that time that the resident had 3rd degree burns to his back, as a result of the application of the hot pack. Complaint #NJ 874 2. The surveyor reviewed the medical record of Resident # 10 on 6/13/12 at 11:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. Further review of the Interdisciplinary Progress Notes (IDCP) dated 5/23/12 at 2:30 p.m., revealed a note which indicated that the CNA reported to the nurse that the resident was offered a drink from his mug. The CNA lifted the mug to the resident's mouth and the resident sensed it was not water and spit the fluid out. According to the note, the mug had bleach in it from a previous request by the resident to soak the mug. The CNA immediately reported the incident to the nurse. The physician was notified and the resident was examined by the nurse. It was determined that the resident was unharmed from the incident. The facility immediately initiated an investigation which revealed that on 5/23/12 at 2:15 p.m., the resident asked the CNA to put bleach in his coffee mug to soak the stains out of it. The CNA went to the laundry room where a laundry attendant gave her some bleach to put in the mug. The CNA left the mug at the resident's bedside to soak. Another CNA entered the room and when the resident asked for a drink, lifted the mug to him to drink. The CNA noticed the yellow color of the liquid in the mug and asked the resident if lemonade was in the mug. The resident said no, and proceeded to take a drink and spit the bleach out. On 6/13/12 at 11:00 a.m., the surveyor interviewed the resident who stated that he did not know how or who put the bleach in the mug on 5/23/12. The resident said he did not suffer any harmful effects from the incident. On that same day at 11:30 a.m., the Director of Nurses' (DON) told the surveyor that both CNAs were terminated as a result of the incident and that extensive inservices had been conducted to educate staff that it was not the policy of the facility to leave chemicals at the resident's bedside. NJAC 8:39-27.1(a)