Every finding on record at Job Haines Home For Aged People

Based on interview, record review, and review of pertinent facility documents it was determined that the facility failed to ensure a quarterly assessment was completed within 14 days. The deficient practice was identified for 1 of 4 residents (Resident # 44) reviewed for the Resident Assessment Task. The deficient practice was evidenced by the following: A review of Resident # 44's Electronic Medical Record under MDS [Minimum Data Set; an assessment tool] revealed a Quarterly Assessment with an Assessment Reference Date of 05/14/2026 that was found to be in an incomplete status. On 06/15/2026 at 12:18 PM during an interview with the surveyor, the MDS Coordinator confirmed the surveyor's finding that Resident # 44's MDS Quarterly Assessment was not completed or transmitted. The MDS Coordinator told the surveyor that it must have been an oversight. A review of the facility-provided MDS 3.0 NH Final Validation Report revealed that the MDS Quarterly Assessment from 5/14/2026 was completed as of 06/15/2026. The facility did not provide a policy or procedure. N.J.A.C. S 8:39-11.2 (e)

Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 1 of 5 residents, Resident #9, reviewed for immunization status. This deficient practice was by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 10/26/24, included the following. The CDC recommended administration of pneumococcal conjugate vaccine (PCV20 or PCV21) at least 1 year for all adults [AGE] years or older who have received PCV 13 only at any age. On 03/26/25 at 11:50 AM, the surveyor observed Resident #9, seated in the dining area with other residents while the staff prepared to serve lunch. The resident greeted the surveyor hello, then was observed looking around the room. The surveyor reviewed Resident #9's medical record. The Admission Record (AR, admission summary) reflected that Resident #9 was admitted to the facility with medical diagnoses which included but were not limited to: diabetes mellitus (high blood sugar), congestive heart failure (decreased contractility of the hearts ability to pump blood and the inability to fill with blood properly in between beats) and asthma (a long-term condition that affects the airways in the lungs). Resident #9's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 12/18/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out 15 which indicated the resident's cognition was severely impaired. Further review of the qMDS dated [DATE], under section O0300 A. Is the resident's Pneumococcal vaccine (PV) up to date? The response was marked 1, which reflected Yes. A review of the electronic Medical Record (eMR) under Immunization reflected Resident #9, last received Pneumovax on 11/18/22. The paper chart did not show the PV was offered, education was provided, or a declination had occurred. On 3/31/25 at 10:48 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) stated that every year, each resident who was alert were asked/offered the PV, when appropriate. For residents who had impaired cognition, the resident's family or representative were asked on behalf of the resident for permission to administer the PV. The resident's offer, education or declination were documented in the paper chart and/or the electronic medical record (eMR). At that time, the surveyor and the RN/UM reviewed Resident #9's immunization record together. The RN/UM stated the resident's record reflected the resident received Pneumovax on 11/18/22. During the review of the resident's medical record (electronic and paper), the proof of offer, education, and declination were not found. The RN/UM stated she would review the records, look for the documents, and inform the Director of Nursing (DON). On 3/31/25 at 10:57 AM, during an interview with the RN/Infection Preventionist, (RN/IP) the surveyor requested the information of the guidelines that the facility followed for the PV. On 4/1/25 at 8:52 AM, during a meeting with the surveyor and the DON, the RN/IP stated that the facility followed the current CDC guidelines and offered PCV 20 to their residents. The RN/IP provided the surveyor PV declination for Resident #9 dated on 8/20/24 and 10/27/23. At that time, the surveyor discussed the concern with the RN/IP and the DON regarding the qMDS dated [DATE] that reflected the resident's PV was current. On 4/1/25 at 9:43 AM, during an interview with the surveyor, the Licensed Practical Nurse/ MDS Nurse (LPN/MDSN) stated she inputted information in the MDS while the MDS Coordinator (MDSC) checked the MDS data for completion and accuracy. The surveyor and the LPN/MDSN reviewed section O0300 of the qMDS dated [DATE] together. At that time, the LPN/MDSN confirmed and acknowledged that Resident #9's PV was not current, the submitted MDS section O0300 was inaccurate/incorrect and was signed by the MDSC On 4/1/25 at 10:12 AM, during an interview with the surveyor, the MDSC stated that his signature meant he checked the MDS for completion and accuracy. At that time, the MDSC stated that the data entered for section O0300 qMDS dated [DATE] was a typographical error. On 4/1/25 at 12:27 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator, the DON and the ADON/IP, the surveyor discussed the concern regarding the Resident #9's inaccurate MDS for PV. A review of the provided facility policy for Minimum Data Set, dated dated /revised 7/2023 did not reflect the expectation that the submitted MDS were reviewed for accuracy prior to submission. A review of section Z0400 for the MDS dated [DATE], revealed that the person signing the MDS certified that the accompanying information accurately reflected the resident assessment information. No further information was provided. NJAC 8:39-33.2 (d)

Based on observation, interview, and record review, it was determined the facility failed to a) reconcile, identify and remove three of the expired medication intravenous medication supply set (IV set) located in the bottom of a medication cart observed in 1 of 1 of the subacute unit; b) ensure the accurate execution of a Drug Enforcement Agency (DEA) Form 222 (a federal narcotic requisition form), to enable accurate reconciliation of controlled-dangerous substances (medications, with high potential for abuse and tracked with detail), which was identified in 1 of 1 form reviewed. This deficient practice was evidenced by the following: 1) On [DATE] at 11:53 AM, the surveyor began the inspection of the non-controlled portion of the medication cart in the subacute unit in the presence of the Registered Nurse (RN). The surveyor observed three expired IV set. The surveyor and the RN further examined the sealed IV sets which reflected a manufacturer expiration date of [DATE]. At that time, the surveyor interviewed the RN who stated the expired IV set should not have been on the cart because the medication could have permeated and leaked through the IV bag. The RN also stated that she did not have any residents using the IV set at that time and it was stored in the cart as an emergency supply. On [DATE] at 1:28 PM, the surveyor was provided copies of the pharmacy provider invoices that included listings for IV sets by the Director of Nursing (DON). At that time, in the presence of the survey team, the DON was asked to clarify that the expired IV set found was the item listed on the invoices provided. The DON stated she would conduct further research. On [DATE] at 11:25 AM, in the presence of the survey team, the DON stated the pharmacy provider was unable to provide documentation to reconcile the items on the invoice was the expired IV set. At 11:54 AM, the DON provided an email from the provider Pharmacist and the Unit Inspection conducted by the Consultant Pharmacist. A review of the facility provided email from the provider Pharmacist reflected that the Provider pharmacy conducted a unit inspection on [DATE]. A review of the facility provided Unit Inspection conducted by the Consultant Pharmacist (CP) dated [DATE], did not indicate an expired IV set was observed. At 1:26 PM, during a follow up interview with the surveyor, the DON stated that medical supplies were supposed to be checked for expiration and removed from active inventory. The pharmacy provider, CP and the nursing staff, missed it. The DON confirmed that all residents were checked, and determined no resident was scheduled to use the IV set at that time. A review of the facility provided policy Storage of Medication, revised on ,d+[DATE] included, under Procedures, section 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The nurse is responsible to check al supplies before using them. Upon receiving the medical supplies, staff will check the packaging slip and keep them in a binder. Pharmacy consultant, pharmacist and staff will check supplies at least monthly and will remove all expired supplies. 2) On [DATE] at 1:04 PM, a review of the facility's DEA Form-222 reflected on the reverse side instructions required by Title 21 Code of Federal Regulations Part 1305. Further review revealed the facility did not execute the following: Part 1. Purchaser Information 3. Enter the total number of line items ordered. 4 .Purchaser must make a copy of the order form for its records before mailing the original to the supplier. Order Form Number: 220405269 did not include the last line completed (bottom, left corner). The facility provided DEA Form-222 had a completed information for Part 4 Controlled Substance Shipment (to be filled out by the supplier). On [DATE] at 1:28 PM, the surveyor in the presence of another surveyor, discussed with the DON, the concern regarding the DEA Form-222. The DON stated the forms were new and was discussed with the medical director On [DATE] at 11:25 AM, in the presence of the survey team, the DON explained her process for executing the DEA Form-222. The DON stated she filled out the form and sent it to the pharmacy. At that time, The DON confirmed she did not make a copy of the DEA Form-222 before it was sent to the pharmacy. The provider pharmacy returned the form to the facility after they had filled out their portion. The DON stated she reconciled the DEA Form-222 with the items and the invoice received. At that time, the DON was unable to explain how the order form could be reconciled properly when a copy of the DEA Form-222 was not made and retained for its records prior to sending the form to the pharmacy. The DON informed the surveyors that moving forward she would retain a copy of the executed DEA Form-222 prior to sending to the pharmacy. A review of the facility provided policy Utilizing DEA form 222 for ordering CII medications for backup replacement revised ,d+[DATE] included, under procedures: Please send the original form to the pharmacy, a copy must be kept in your records for two years .Be sure to fill in Last line Completed. NJAC 8:,d+[DATE].4(a), 29.4(g), 29.7(c)

Based on observation and interview it was determined that the facility failed to ensure that controlled substances were stored in a manner to prevent loss or diversion. This was found in 2 of 2 medication refrigerators. The deficient practice was evidenced by the following: 1. On 3/10/21 at 1:29 PM, the surveyor inspected the medication refrigerator in the medication room on the first floor in the presence of the Unit Manager, Registered Nurse (UMRN). Inside of the refrigerator there was a locked storage box that was attached to a removable shelf. The UMRN unlocked the storage box. The storage box contained an opened bottle of [MEDICATION NAME] Concentrate (a sedative; controlled substance). The surveyor removed the shelf from the refrigerator with the locked box attached. The UM/RN acknowledged that the shelf was not permanently affixed within the medication refrigerator. 2. On 3/10/21 at 1:33 PM, in the presence of the UMRN, the surveyor inspected the second-floor medication storage room which contained the medication storage refrigerator. The medication storage refrigerator contained a clear plastic locked storage box which was located on the upper shelf inside the refrigerator and was able to be removed from the shelf as it was not affixed inside the refrigerator. There were no medications stored inside the clear plastic locked storage box. The UMRN stated that this was the narcotic storage box and was not sure why the clear plastic locked storage box was not affixed inside the refrigerator. On 3/10/21 at 2:15 PM, the surveyors brought the above concerns to the attention of the Administrator and the Director of Nursing. A review of the facility's policy and procedure for the storage of controlled substances. Under Policy Statement revealed the following: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal of s II and other controlled substances. NJAC 8:39- 29.4(b)2.

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness, and c.) failed to discard expired nutritional supplements. This deficient practice was evidenced by the following: On [DATE] at 09:48 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. In the food preparation area, the surveyor observed keys stored on a hook touching a cleaned whisk, the FSD stated that these keys should not have been stored with the whisk. 2. In the food preparation area, the surveyor observed grease-like brown colored particulates on the can opener. 3. In the food preparation area, the surveyor observed two ceramic plates stored on a shelf containing clean dishware, the two plates were soiled with black particles and a soiled napkin on top of one plate. The FSD stated that these plates should have been clean. 4. In the dry storage area, the surveyor observed a random sampling of dented cans which were in rotation for use. The surveyor observed the following: - A #10 sized can of sauerkraut with a ,[DATE] inch dent on the lower lip of the can, - A # 10 sized can of pineapples with a ,[DATE] inch dent on body of the can, - A # 10 sized can of peaches with a ,[DATE] inch dent on body of the can, - A # 10 sized can of garbanzo beans with a ,[DATE] inch dent on upper lip of the can, - A # 10 sized can of mushroom with a 1 inch dent on body of the can, - A # 10 sized can of butterscotch pudding with a ,[DATE] inch dent on body of the can, The surveyor reviewed the facility's policy titled, Storage of Utensils dated [DATE]. The policy indicated that utensils will be stored above the cooks table and ensure that they are sanitized and cleaned. The surveyor reviewed the facility's policy titled, Canned Food Free from Damages dated [DATE]. The policy indicated that the cooks and servers must inspect cans for damages before use and to remove any dented or damaged cans from service and place in designated damage area. 5. On [DATE] at 1:29 PM, the surveyor inspected the medication refrigerator, located on the first floor medication room, in the presence of the Unit Manager, Registered Nurse (UMRN). After inspecting the medication refrigerator, the surveyor observed that there were storage shelves in the medication room which held nutritional supplements. The surveyor counted 23 containers of a nutritional supplement that were honey thick liquid consistency with a best by date of [DATE]. The UMRN acknowledged that the supplements were expired and said that there were no residents on the unit that were prescribed honey thick liquids. The surveyor asked the UMRN how often she checked the supply of nutritional supplements. The UMRN said she checked them monthly. She said she last checked the supplements on [DATE] but she must have missed them. On [DATE] at 2:15 PM, the surveyors brought the above concerns to the attention of the Administrator and the Director of Nursing. On [DATE] at 1:00 PM, the facility was not able to provide a policy regarding the storage of nutritional supplements. NJAC 8:,[DATE].2(g)

C# NJ 4 Based on interviews, review of Medical Records (MR), and pertinent facility documents on 10/12/2018, it was determined that facility staff failed to provide a two person assist with transfer in accordance with the Resident's Minimum Data Set Assessment ((MDS) dated [DATE], for 1 of 3 sampled residents (Resident #2), who on 4/10/2017 was assisted to the bathroom with one person which resulted in a fall and a fracture to the tibia and fibula of the right leg. This required Resident #2 to be transferred to the hospital for an open reduction and internal fixation (ORIF) surgical procedure. This deficient practice was evidenced by the following: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Pneumonia, Weakness, [MEDICAL CONDITION] and [MEDICAL CONDITION] following Cerebral Infarction affecting the right dominant side, a history of falling, and right foot drop. According to the MDS, an assessment tool dated 4/5/2017, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9/15, indicating that Resident #2 had moderate cognitive impairment. The MDS also indicated that Resident #2 required extensive two person assist for transfers, and extensive assist for Activities of Daily Living (ADLs). A review of a Facility document titled, Falls Evaluation, an assessment tool dated 3/30/17, revealed Resident #2 had a score of 16. According to the Falls Evaluation document A resident who scores a 10 or higher is at risk for falls. The Care Plan (CP) initiated 3/30/2017, identified Resident #2 as a High risk for Falls related to: Deconditioning, Gait/Balance Problems, [MEDICAL CONDITIONS], Right Leg [MEDICAL CONDITION] with Foot Drop, History of Falls, and Hearing Problems. According to the Occupational Therapy Plan of Care, Assessment, dated 3/31/2017, under section Short Term Goal (s), Current Level of Function, the Resident . utilizing grab bars while using toilet/commode requiring maximum assistance x 2 (76-99% assist with 2 people). A review of Resident #2's Incident/Accident Report, dated 4/10/17 at 11:00 a.m., completed by the nurse, revealed that the Certified Nursing Assistant (CNA #1) was assisting Resident #2 to the bathroom when the Resident had a [MEDICAL CONDITION] episode after prolonged standing and fainted. The Fall Investigation Worksheet (FIW) dated 4/10/17, revealed Resident #2 sat on the floor after the [MEDICAL CONDITION] episode and became responsive after 2 to 5 minutes. In addition, the FIW revealed that Resident #2's leg was swollen and that the Medical Doctor (MD) was notified. A review of the physician's orders [REDACTED]. Review of the x-ray report titled Portable X-ray Report dated 4/10/2017, and untimed, under section Right Ankle 3 views: revealed the following: An acute, moderately displaced comminuted proximal metadiaphysis fibula fracture. There is an acute, moderated displaced spiral oblique [MEDICAL CONDITION] metadiaphysis of the tibia. No joint dislocation. There is diffuse soft tissue swelling. There are vascular calcifications. Resident #2's Interdisciplinary Progress Notes, dated 4/10/2017 at 2:00 p.m., revealed that the Resident's right lower extremity was swollen and the Resident had pain to touch. The documentation also revealed that Resident #2's leg was turned outward, discolored, with a positive pulse and warm to touch. In addition, the Interdisciplinary Progress Notes, dated 4/10/2017 at 9:30 p.m., showed x-ray results of the right leg were reported to the MD. The document also revealed that the MD gave an order to transfer the Resident to the Hospital for an evaluation. Further review of the Interdisciplinary Progress Notes dated 4/11/17 at 5:30 a.m., indicated Resident #2 was admitted to the hospital with [REDACTED]. A second review of Resident #2's CP dated 4/11/17, showed the following interventions: Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential cause if possible. Educate resident/family/caregivers/IDT (Interdiplinary Care Team) as to cause. During an interview with the Director of Nursing (DON) on 10/12/2018 at 1:40 p.m., the DON indicated, that on 4/10/17, Resident #2 did not fall but fainted and twisted his/her knee. In addition, the DON stated that he/she called the Doctor and explained to the Doctor what occurred and the Doctor said the Resident had a [MEDICAL CONDITION] episode. The DON specified that CNA #1 did not take Resident #2 to the bathroom alone, the Resident's daughter assisted the CNA. The DON also explained that he/she did not consider it a fall because the Resident did not reach the floor. During a post survey interview on 10/17/2018 at 11:02 a.m., with CNA #1, the CNA stated, while assisting Resident #2 to the bathroom, the Resident lost his/her balance. In addition, CNA #1 stated he/she held the Resident up while calling for the nurse. CNA #1 also explained Resident #2 required two person assistance for transfers. Review of the Facility's Policy titled, Nursing Interdisciplinary Team, Subject: Caring Planning with an effective date of (MONTH) 11, (YEAR), included but were not limited to the following: 3. Each resident's comprehensive care plan will: e. Identify the professional services that are responsible for each element of care; f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels and; g. Enhance the optimal functioning of the resident. NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to rotate the insulin injection sites. This deficient practice was identified for Resident # 13, 1 of 14 residents reviewed for medications and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/11/18 at 9:30 AM, the surveyor reviewed Resident #13's medical record which revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The medical record also revealed Resident #13's physician's orders [REDACTED]. On 4/11/18 at 10:00 AM, the surveyor reviewed Resident #13's (YEAR) (MONTH) and (MONTH) electronic medication administration records (EMAR) which revealed the following Insulin [MEDICATION NAME] Solution 100 u/ml injection documentation: 1. On 3/1/18 at 9:08 PM, location of injection: Arm-left. The next documented injection was recorded on 3/3/18 at 4:27 PM, location: Arm-left. 2. On 3/5/18 at 4:30 PM, location of injection: Arm-right. The next documented injection was recorded on 3/6/18 at 4:31 PM, location: Arm-right. 3. On 3/9/18 at 3:47 PM, location of injection: Abdomen-LLQ (left lower quadrant). The next documented injection was recorded on 3/10/18 at 8:50 PM, location: Abdomen-LLQ. 4. On 3/12/18 at 9:00 PM, location of injection: Arm-left. The next documented injection was recorded on 3/13/18 at 3:35 PM, location: Arm-left. 5. On 3/17/18 at 11:47 AM, location of injection: Arm-left. The next documented injection was recorded on 3/17/18 at 4:41 PM, location: Arm-left. 6. On 3/17/18 at 8:58 PM, location of injection: Arm-right. The next documented injection was recorded on 3/18/18 at 11:35 AM, location: Arm-right. 7. On 3/27/18 at 11:30 AM, location of injection: Arm-right. The next documented injection was recorded on 3/27/18 at 4:30 PM, location: Arm-right. 8. On 4/4/18 at 11:48 AM, location of injection: Arm-left. The next documented injection was recorded on 4/4/18 at 9:46 PM, location: Arm-left. 9. On 4/6/18 at 4:20 PM, location of injection: Arm-left. The next documented injection was recorded on 4/7/18 at 4:34 PM, location: Arm-left. The next documented injection was recorded on 4/8/18 at 4:53 PM, location: Arm-left. 10. On 4/10/18 at 11:11 AM, location of injection: Arm-left. The next documented injection was recorded on 4/11/18 at 11:27 AM, location: Arm-left. On 4/11/18 at 10:30 AM, the Licensed Practical Nurse Unit Manager (LPNUM) showed the surveyor Resident #13's EMAR that contained the EMAR Supplementary Documentation (SD), additional information in the EMAR, that revealed where the medication nurse should have documented the site (body part such as arm, abdomen, thigh) of the insulin injection, according to the LPNUM. The LPNUM stated that the medication nurse should have looked at the SD prior to entering a resident's room to verify the previous insulin injection site. She also stated that once the medication nurse selects YES to give the insulin, the SD area appears showing the previous site of the insulin injection. Furthermore, at that time, the LPNUM, in the presence of the surveyor, stated that the insulin injection sites should have been rotated and pointed to her left lower abdomen and then to her left upper abdomen as she demonstrated what injection site rotation within an area meant. On 4/12/18 at 8:52 AM, the Director of Nursing (DON) provided the Insulin Administration policy, dated 2/4/17, which revealed the following steps in the insulin administration procedure, 16b) Select an injection site; injection sites should be rotated preferably within the same general area (abdomen, thigh, upper arm). The DON further stated that the insulin injections should be rotated. On 4/12/18 at 11:36 AM, the Registered Nurse Supervisor stated that there was no current supervisory EMAR review [REDACTED]. On 4/13/18 at 9:56 AM, the DON stated that there was no monitoring of the rotation of insulin injection sites at the present time. The DON also stated that the insulin sites should have been with each insulin injection. NJAC: 8:39-29.2(d)

Based on observation and interview it was determined that the facility failed to store and date potentially hazardous foods (PHF) appropriately to prevent food borne illness as evidenced by the following: On 4/9/17 at 9:18 a.m., the surveyor began the tour of the kitchen with the Food Nutrition Director (FND) and observed the following in the walk in refrigerator: 1. One large container of opened ricotta cheese that was approximately half full. There was no label on the container indicating when the ricotta cheese was opened. The FND stated that all foods should be dated when they are opened. She added that she was unsure when it was opened and discarded it. 2. One large container of sour cream that was approximately half full. The container had a hand-written date of opened on 3/1/17 and expired on 4/14/17. There was a printed date by the manufacturer on the container of 4/14/17. The FND said that they will use the product until the date printed on the container by the manufacturer. The surveyor questioned the FND regarding the length of time the sour cream was stored in the refrigerator after it was opened. She stated she would check with the supplier. 3. One case of 12, 1 quart liquid eggs dated 3/22/17, two cases dated 3/29/17 and four cases dated 4/5/17. Each case indicated to store frozen at zero degrees Fahrenheit. The FND said that the product arrived frozen and that the facility stored the liquid eggs in the refrigerator once delivered. The hand-written date on the box indicated both the date the product was delivered as well as the date the product had been stored in the refrigerator. The FND said that the liquid eggs had a shelf life of one year when stored in the refrigerator. The surveyor then asked for the facility's policy for labeling and dating policy and storage of liquid eggs. 4. One - two-gallon stock pot of prepared chicken soup with a handwritten date of 4/8/17 and an expiration date of 4/11/17. The FND said the soup was made 4/8/17 to serve on 4/9/17. The surveyor asked the FND what the procedure was to cool foods. She stated that the product should be placed in smaller pans and cooled with an ice paddle. The FND was unsure if the soup had been cooled in that pot or transferred back into that pot for storage after the soup was cooled. The chef who made the soup was not available for interview at that time. The FND discarded the soup. On 4/9/17 at 10:00 a.m., the surveyor reviewed the facility's Safe Food Handling Policy. The Policy Statement indicated Leftover foods will be stored in shallow pans. Leftover food will be cooled to temperature of 45 degrees in no more than six hours. Leftover food stored past 72 hours will be discarded. On 4/11/17 at 9:30 a.m., the surveyor met with the Administrator and the Executive Director (ED). The ED said that the facility contacted the manufacturer of the liquid eggs on 4/9/17. They confirmed that the liquid eggs had a shelf life of one year when stored in the freezer, but only ten days once removed from the frozen state. The ED stated that she then informed the FND to discard the liquid eggs dated 3/22 and 3/29/17. The ED added that the sour cream was also discarded and they were revising the policies for storage of foods. NJAC 8:39-17.2(g)

Based on observation, interview, and record review it was determined that the facility failed to properly label and dispose of medications in 4 of 5 medication storage areas. The deficient practices were evidenced by the following: 1. On 4/9/17 at 10:00 a.m., the surveyor inspected the Subacute unit medication cart in the presence of Nurse #1. There was an unopened vial of Novolog Insulin that was stored in the cart. At that time, Nurse #1 stated that an unopened vial of Novolog Insulin should have been stored in the refrigerator. 2. On 4/9/17 at 10:10 a.m., the surveyor inspected the Subacute medication room refrigerator in the presence of Nurse #1. There was a vial of Acetylcysteine with an opened date of 4/1/17. At that time, Nurse #1 stated that the Acetylcysteine was good for four days (4/5/17) once opened and would discard it. 3. On 4/9/17 at 10:20 a.m., the surveyor inspected the 1st floor medication cart #2 in the presence of Nurse #2. There was an open package of Duo-Neb nebulizing solution that was dated 3/13/17. There was also an opened bottle of Xalatan eye drops that was not dated. At that time, Nurse #2 stated that an opened package of Duo-Neb had expired and that the opened bottle of Xalatan eye drops should have been dated. 4. On 4/9/17 at 10:25 a.m., the surveyor inspected the 1st floor medication room refrigerator in the presence of Nurse #2. There was an opened bottle of Lorazepam oral solution that was not dated. At that time, Nurse #2 stated that the bottle of Lorazepam oral solution should have been dated when opened. A review of the manufacturer's specifications for the above medications revealed the following: 1. An unopened vial of Novolog Insulin, should be stored in a refrigerator. 2. Acetylcysteine solution, when opened had a 96 hour expiration date. 3. A package of Duo-Neb, when opened had a 14 day expiration date. 4. Xalatan eye drops, when opened had a 42 day expiration date. 5. Lorazepam oral solution, when opened had a 90 day expiration date. On 4/11/17 at 11:30 a.m., the surveyor received the facility policy for Storage of Medications, which indicated the following: 1. Under Temperature A: Medications and biologicals are stored at their appropriate temperature and humidity according to the United States Pharmacopedia guidelines for temperature ranges. 2. Under Expiration Dating C: Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. E: The nurse will check the expiration date of each medication before administering it. F: No expired medication will be administered to a resident. G: All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. NJAC 8:39-29.4(a), 29.4(3)g

Based on observation, interview and record review it was determined that the facility failed to a) maintain locked storage for 1 of 11 (Resident #11) resident's own medications, b) label blood glucose test strips (BGTS) according to the manufacturer's recommendation on 1 of 3 medication carts, c) provide limited access to refrigerated medications by authorized staff on 1 of 2 units and d) store a refrigerated medication correctly according to the manufacturer's recommendation. These deficient practices were evidenced by the following: 1. On 6/15/16 at 8:33 a.m., the surveyor observed Nurse #1 during the medication pass prepare medications to be administered to Resident #11. At this time, the surveyor, along with the nurse, reviewed the electronic Medication Administration Record (eMAR) which revealed an order for [REDACTED]. The nurse told the surveyor that this medication was not able to be supplied by the Pharmacy and the family member brought the medication in from home. The nurse also said that the resident kept the medication in their room. At this time, the surveyor observed the nurse remove a labeled medication bottle for Exemestane 25 mg from the resident's unlocked top drawer of the night stand next to the bed. On 6/15/16 at 8:48 a.m., the surveyor interviewed the nurse who said that the procedure for a resident who is alert and oriented to be able to have their own medication was being followed. The nurse added that the family member wanted the medication kept in the room. The nurse also said that the top drawer of the night stand does have a lock and thought it should have been locked. On 6/15/16 at 11:11 a.m., the surveyor reviewed the resident's medical record which revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Further review revealed the resident was alert and oriented with a Care Plan dated 6/8/16 with an intervention for the resident as receiving Exemestane may self administer. On 6/15/16 at 1:30 p.m., the surveyor reviewed facility policies for Medication brought into the facility by resident/family to be administered by residents and Storing Medications. The policy for Storing Medications states Medications are to be stored in a secure and orderly manner On 6/15/16 at 2:13 p.m., the surveyor interviewed the Director of Nurses (DON) who said that the current policy for Medication brought into the facility by resident/family to be administered by residents does not address the storage of the medication. In addition, the DON said that all medications are to be secured. 2. On 6/15/16 at 8:10 a.m. and 8:33 a.m., the surveyor observed the nurse during the medication pass obtain blood glucose results from two (2) residents consecutively using BGTS from the same bottle. On 6/15/16 at 8:48 a.m., the surveyor interviewed the nurse in reference to the BGTS bottle. The nurse said that the BGTS are kept locked in the medication cart and once the bottle is opened the BGTS will expire in 90 days. The nurse then said that the BGTS that were used for the two residents did not have a date when it was opened. In addition, the nurse said that it was the only bottle on the medication cart and should have been dated by the first nurse who opened it. At this time, the surveyor in the presence of the nurse reviewed the label on the BGTS which stated Date when open and Expires after 6 months. On 6/15/16 at 1:30 p.m., the surveyor reviewed the facility policy for Medication Administration which states All medications must be properly labeled There is no documented evidence this policy was consistently followed. 3. On 6/15/16 at 11:00 a.m., the surveyor in the presence of Nurse #2 went to the medication refrigerator located in an unlocked room located off an unlocked conference room containing the resident's charts and a copy machine. At this time, the surveyor observed the nurse open an unlocked refrigerator and said that this was the location for any medications that required refrigeration. The surveyor observed an empty locked affixed box in the refrigerator which the nurse said was for any narcotics that required refrigeration. The surveyor further observed in the refrigerator a vial of Insulin labeled for a resident. At this time, the nurse told the surveyor that the room where the medication refrigerator was located was an office for the Minimum Data Set nurse (MDSN) to input information into the computer at the desk located in the same room as the refrigerator. The MDS nurse was not in the office at that time. Upon leaving the office the nurse did not close or lock the door. On 6/15/16 at 11:33 a.m., the surveyor interviewed the MDSN in the office with the unlocked medication refrigerator. The MDSN said that during the day when she is present in the building the door is left open. The MDSN said that the door to the office is locked when she leaves for the day. On 6/15/16 at 11:46 a.m., the surveyor with another surveyor observed the office door open and were able to open the unlocked medication refrigerator without the presence of any authorized staff member. On 6/15/16 at 2:13 p.m., the surveyor interviewed the DON who said that the office door should be locked when the MDSN is not in the office because the medication refrigerator does not have a lock. NJAC 8:39-29.2(c)(2), 29.4(a)(8), 29.4(c), 29.4(h) On 6/14/16 at 9:10 a.m., the unit manager stated that Resident #1 was alert, oriented and received an as needed medication for anxiety. On 6/14/16 at 11:30 a.m., the surveyor reviewed the record of Resident #1. The resident was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. The surveyor then reviewed the Controlled Medication Utilization Record (CMUR) along with the electronic Medication Administration Record (eMAR). On 6/1/16 at 9:30 a.m., the nurse signed on the CMUR that one tablet was taken out of inventory however, the nurse did not document on the MAR that the Ativan tablet was administered. On 6/15/16 at 2 p.m., the surveyor reviewed the eMAR and the CMUR with the medication nurse. She confirmed that she did not document on the eMAR that the dose was administered. The nurse then reviewed the Progress Notes. She stated that she wrote a note which documented that she gave the resident the Ativan, but did not sign for it on the eMAR. 3. On 6/14/16 at 11:30 a.m., the surveryor reviewed the record of Resident #7. The resident had a physician's orders [REDACTED]. The surveyor asked the nurse to see the resident's supply of the Ativan Liquid. The medication nurse opened the locked compartment of the cart and showed the surveyor two boxes of Ativan Intensol liquid. Each box had an label on it which indicated that they should be refrigerated. The nurse stated she would speak to the Provider Pharmacy and the Director of Nursing for further instructions. The surveyor then reviewed the Policy on Storing Medications. The policy indicated that, Medications and biologicals are to be stored in a secure and orderly manner, under proper temperatures and are to be accessible only to licensed nursing and pharmacy personnel. Under #6 , the policy indicated , Medications requiring refrigeration are to be stored at a temperature not less than 36 degrees Fahrenheit (F) or more than 46 degrees F.

Based on observation and interview, it was determined that the facility failed to: 1) ensure that dishwares were effectively sanitized to prevent bacterial growth and 2) label and date frozen foods when opened as evidenced by the following: On 5/19/15 at 8:15 a.m., in the presence of the Food Service Director (FSD), the surveyor observed a dishwasher in the dishwashing area. The surveyor asked the dishwasher to demonstrate how he washed dishes and what wash and final rinse temperatures were acceptable. He pointed to the sign on the dishwasher and stated, "150 degrees and 180 degrees." The dishwasher pushed the handle down of the single tank dishwasher and started the machine cycle. The wash temperature was 150 degrees Fahrenheit (F) and the final rinse was 163 degrees F. The manufacturer's specifications on the front of the dishwasher indicated that the wash temperature should be 150 degrees F and the final rinse temperature should be 180 degrees F. The dishwasher started the machine again and stated that it takes a few tries before it heats up. The wash temperature was 152 and the highest reading of the final rinse was 165. The dishwasher stated he would keep trying to get the temperature to rise. The FSD and the surveyor continued the tour of the kitchen. The walk in freezer had the following frozen foods that were not labeled and dated when opened and placed into the freezer: 1. 2 half bags of shredded cheddar cheese. 2. 1 quarter of a bag of riblets. 3. 1 half of a bag of stuffed flounder that was placed in a box of spinach stuffed flounder. The date on the box was 2/14/15. The FSD stated that this was the date it was delivered, because they had stuffed flounder on Friday of the week before. 4. 1 half bag of chicken cutlets. 5. 1 quarter of a bag of chocolate chip cookie dough. 6. 1 three-quarters full of a 3 gallon no sugar added mint chocolate chip ice cream bulk container that was opened and exposed to the circulating air. The FSD found the lid that was ripped along the edges. The portable ice cream freezer had an opened container of no sugar added mint chocolate chip ice cream with a lid that was partially closed and exposed with ice crystals forming on the top. The FSD and the surveyor returned to the dishwashing area. The Maintenance Director was inspecting the booster. He stated that the temperature was still not high enough. The surveyor observed the final rinse temperature to be 166 degrees F. The surveyor observed that the dishwasher had 10 white plate covers in his hands and was placing them on the lid rack. The surveyor asked him where they came from, and he stated they were from the upstairs unit and he had just washed them in the dishmachine. The surveyor asked the FSD if the machine was at the appropriate temperature. She said no, that it wasn't, and told the dishwasher to rewash everything and sanitize appropriately utilizing the three compartment sink. On 5/19/15 at 10:30 a.m., the surveyor received the policy on "Labeling", which indicated the following: "All food items should be labeled and dated upon receipt. Leftover cooked food items should be labeled and dated." The policy on "Safe Food Handling" indicated that, "All foods will be covered and labeled with the date and item description." The "Dishmachine Operation/Cleaning" policy indicated the following: "#2 Monitor wash tank temperature gauge. Wait for temperature reading to reach minimum of 150 degrees F", and #6. During Final Rinse monitor rinse temperature gauge. Machine Final Rinse Cycle for 14 seconds. Temperature gauge must read 180-195 degrees F." The policy on "Daily Log Procedure" indicated the following: "Dishwashers are responsible for making sure appropriate sanitizing methods are followed by: 1) monitoring and recording daily log the temperature of the dishmachine wash and rinse cycles. and 2) notifying Food Service Supervisor and/or AFSS(Assistant Food Service Supervisor) when the temperatures are out of the appropriate range." The surveyor reviewed the "Assignment Sheet for Cooks" dated 5/19/15. The Breakfast Cook - 6 a.m. to 2 p.m., had placed their initials indicating that," Make sure all items in refrigerators have a label and is dated," was completed. On 5/19/15 at 12:30 p.m., the surveyor returned to the kitchen. The repairperson from the chemical supplier was in the dishwashing area. He stated that thermostat in the booster was not working properly and that he would order a new one. He added that he adjusted the thermostat and that the temperature reading was 177 degrees F. The surveyor asked the FSD to test the effectiveness of the temperatures in the dishwasher using the T-stick litmus strip. The repairperson placed it into the machine and ran the full cycle. The strip turned black indicating that the temperature was effective in sanitizing dishwares. NJAC 8:39-17.2(g)

Based on observation, interview and record review it was determined that the facility failed to administer medications in accordance with professional standards of practice. This deficient practice was evidenced for 2 of 11 residents, Resident's #6 and #11 observed during the morning medication pass of 6/13/14. The evidence was as follows: 1. On 6/13/14 at 9:11:00 a.m. during medication pass the surveyor observed Nurse #1 [MEDICATION NAME] milligrams (mg), [MEDICATION NAME] 10 mg and [MEDICATION NAME] 12.5 mg by mouth (po) to Resident #6. Nurse #1 did not obtain the resident's blood pressure (BP) and heart rate (HR) at that time. The surveyor reviewed the Medication Administration Record(MAR) and physician orders [REDACTED]. 2. On 6/13/14 at 9:23 a.m. during med pass the surveyor observed Nurse #1 administer [MEDICATION NAME] 5 mg, [MEDICATION NAME] 40 mg and [MEDICATION NAME] XL 25 mg by mouth (po) to Resident #11. Nurse #1 did not obtain the resident's BP and HR at that time. The surveyor reviewed the MAR and physician orders [REDACTED]. On 6/13/14 at 9:40 a.m. the surveyor interviewed Nurse #1 regarding when the blood pressure (BP) and heart rate (HR) for Residents # 6 and #11 were obtained. Nurse #1 stated that vital signs were done during rounds in the beginning of her shift. Nurse #1 further stated that the usual procedure is at the beginning of the shift in the morning around 7:30 a.m. to 7:45 a.m. The Director of Nursing (DON) provided a facility policy for "Medication Administration/blood pressure" which indicated "All Nurse administering medication shall adhere to the cautionaries and parameters specified prior to and after giving such medication." The facility policy further indicated, "Medication that require blood pressure before administering shall have blood pressure done and ensure that blood pressure taken is within range of parameter instructed by the prescribing Doctor before medication is given." On 6/13/14 at 12:45 p.m. during surveyor interview with the DON she stated that the standard of practice for a physician's orders [REDACTED]. The DON further stated that taking a BP and HR at 7:30 a.m. for administration of a medication with a hold order at 9:00 a.m. was unacceptable. N.J.A.C. 8:39-27.1(a)

Based on observation, interview and review of documentation provided by the facility it was determined that the facility failed to (a) maintain proper kitchen sanitation, (b) label, date and store open food items and (c) maintain food service areas and equipment in a safe and sanitary manner to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 6/24/13 at 9:40 a.m. during the initial tour of the kitchen, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. Fourteen tan colored plastic plate covers on the clean drying rack were wet nested. 2. Two green plate bases and one green plate cover located on the clean drying rack were soiled. At 9:45 a.m. during an interview with the FSD she stated all items on the drying rack were clean. 3. A large clear plastic container filled with a variety of cooking utensils was located on the bottom shelf of the clean drying rack. The white plastic cover of the container was soiled and there were clean meal service trays on the lid. 4. Multiple wet nested orange fiberglass trays were located on the bottom shelf of the drying rack. The trays were in poor repair with multiple stains, cracks and chipped areas and the metal interior of the trays was exposed. 5. A one gallon opened container of Golden Italian Dressing located in the walk-in refrigerator had a printed manufacturers date of 5/22/13 and had no date to indicate when it was opened. 6. A one gallon opened container of Cocktail Sauce located in the walk-in refrigerator had a printed manufacturers date of 10/23/12 and had no date to indicate when it was opened. 7. A second opened one gallon container of Golden Italian Dressing located in the walk-in refrigerator was opened on 6/3/13 had a printed manufacturers date of 4/23/13. 8. An opened one gallon jar of Maraschino Cherries located in the walk-in refrigerator had no date to when it was opened and the white plastic top contained multiple spots of black, fuzzy debris. At 10:10 a.m. during and interview with the FSD she stated that the black spots were mold. 9. Three, five pound (lb) containers of cottage cheese located in the walk-in refrigerator were expired and had best use by dates of 6/17/13, 6/9/13 and 3/25/13. 10. An opened five pound package of Parmesan cheese located in the walk-in refrigerator was wrapped in clear plastic wrap and had no date. 11. Two packages of cut red and green peppers and one package of cut celery were wrapped in clear plastic wrap and located in the walk-in refrigerator. The packages were not dated. 12. A soiled, gray colored garbage pail filled with dirty, nonfood items and cardboard debris from cases of soda was located in the back of the walk-in refrigerator. At 10:10 a.m. during an interview with the FSD she stated that the garbage pail was used in the past to store lettuce before the facility got produce bins back in the Winter of 2012. 13. Multiple sized, clean, wet-nested food service pans were located on a shelf in the Cook's area. Two of the pans were soiled. 14. Four closed 1 liter hot beverage air pumps were located on a shelf in the Cook's area and contained between 1/4 to 1/2 inch of pooled water. At 10:15 a.m. during an interview with the FSD she stated that when service items are cleaned they are placed on the shelf in the Cook's area and the four air pumps were no longer being used. 15. Three opened 2.5 lb clear plastic containers of thyme, paprika and bay leaves located in the dry storage room were heavily soiled with dried food debris on the inside and outside of the containers and were not dated. 16. A 24 ounce (oz) opened container of "Chef Magic Seasoning Blend" located in the dry storage room was heavily soiled on the outside with dried food debris and was not dated. 17. A 20 oz opened container of salt located in the dry storage room was heavily soiled with dried caked on food debris and was not dated. During surveyor interview at 10:25 a.m. the FSD stated that the above mentioned items were soiled because the cooks used their soiled hands to handle the containers. 18. Two opened boxes of "Fish Fry Seasoning" located in the dry storage room were inside a clear plastic bag and not dated. 19. An opened and undated 11 lb container of "Gold Metal Ready to use Chocolate Frosting" was located in the dry storage room. Review of the manufacturers instructions printed on the container stated "Once icing container has been opened the icing can be stored covered at room temperature for one week. After this period store covered in cooler." 20. Two 50 lb portable containers located under a utility table contained rice and flour. Neither of the containers were dated and both the inside and outside of each container was soiled. The inside of the rice container had black debris mixed in with the raw rice. The inside of the flour container had clumps of soiled, discolored flour. The inside of both containers was not lined with any protective bags/plastic wrap. On 6/25/13 during an interview with the Registered Dietitian (RD) at 3:00 p.m. she stated that the facility uses a general computer program for all mandatory in-services for about the past one and a half years. Before the program was introduced the RD used to do monthly in-services with the dietary staff. The RD also stated that the FSD does impromptu staff meetings but they're not documented. On 6/25/13 at 12:00 p.m. the surveyor reviewed the mandatory computerized program used by the facility titled "Silver Alert." The program failed to include any food service related in-services. On 6/25/13 at 12:00 p.m. the surveyor reviewed the facility's Policy and Procedure (P&P) for "Food Storage" dated 1/1/2011 which stated that "Leftover food is stored in covered containers or wrapped carefully and securely, clearly labeled, and dated before being refrigerated and all non-perishable food items must be dated and labeled." On 6/25/13 at 12:00 p.m. the surveyor reviewed the facility's P&P for "Refrigeration: Refrigerator/Freezer" dated 6/1/2009 which indicated that "the cooks are responsible for removing expired foods and discarding them every three days." On 6/25/13 at 12:00 p.m. the surveyor reviewed the facility's P&P for "Pot Washing" which indicated "store pots and pans in like sized stacks and upside down in designated pot and pan racks." The P&P failed to include any information about air-drying to prevent wet-nesting. N.J.A.C. 8:39-17.2(g)

Based on observation, interview and record review it was determined that the facility failed to provide a safe environment and protect resident's from injury with a hot water dispenser. This deficient practice was identified for 2 of 7 alert, oriented and ambulatory residents located on the sub-acute unit, Resident #'s 6 and 9 and was evidenced by the following: On 6/26/13 at 9:50 a.m. the surveyor observed an automatic water dispenser in the right corner of the common area on the sub-acute unit, across from the Nurses station. The unit had 2 dispensers, one for hot water and one for cold water. The hot water dispenser had a red tab on top that had the word "lift" printed on it. When the surveyor lifted the tab and pushed down on a gray button located just under the red tab, hot water was dispensed with steam. The surveyor obtained a plastic cup and in the presence of another surveyor and the unit clerk, filled the cup with about 4 ounces (oz) of hot water. The surveyor placed a calibrated thermometer inside the cup and after 30 seconds the water temperature registered 178 degrees Farenheit (F). At 10:00 a.m. the surveyor notified the team leader of the observation and at 10:10 a.m. the surveyor re-tested the hot water a second time using the surveyor's calibrated thermometer, in the presence of the unit clerk and the Director of Maintenance. After 1 minute the water temperature registered 178 degrees F. At 10:10 a.m. after the surveyor tested the hot water for the second time the Director of Maintenance disconnected the unit. At 10:15 a.m. the surveyor interviewed the unit clerk and she stated that the hot water dispenser was mostly used by the staff. According to surveyor interview with the facility Administrator at 10:20 a.m. current census on the sub-acute unit was seven. At 10:25 a.m. the surveyor team conducted interviews with facility staff, a family member, and residents to ascertain the level of orientation and safety awareness of each of the seven residents. Two of seven residents were alert, oriented and ambulatory, Resident #6 and Resident #9. Both resident's stated they used the water dispenser for cold water. Later at 10:26 a.m. during an interview with the Director of Maintenance he stated that the facility rented the unit, does not record the temperatures and the facility does not have a Policy & Procedure (P&P) for the care and use of the unit. He also provided the surveyor with a copy of the rental agreement which indicated that the unit had been in the facility from 9/8/11. At 11:40 a.m. the surveyor reviewed the manufacturers specifications for the "Free-Standing Water Cooler" which failed to provide any information about maintenance or water temperature guidelines. N.J.A.C. 8:39 31.7(h)

Based on observation, interview and record review, it was determined that the facility failed to administer all medications without an error rate of less than 5%. This was observed on the afternoon medication pass of 6/24/13 and the morning medication pass of 6/25/13 for 4 nurses, 9 residents, 27 medications and 3 errors observed. This deficient practice resulted in a medication administration error rate of 11.1%. The evidence was as follows: 1. On 6/24/13 at 1:10 p.m. during the medication pass, the surveyor observed Nurse #1 administer [MEDICATION NAME] 800 milligrams (mg) by mouth (po) to Resident #3 who was in bed. The resident was not eating and at that time, and the surveyor interviewed Nurse #1 who stated that Resident #3 had eaten lunch at 12:00 Noon. On 6/25/13 the surveyor reviewed the facility policy titled "Medication Administration" which indicated that medications will be administered at the times as stated in our medication pass policy. Further review indicated that medications may be given up to one hour before and up to one hour after stated time, with the exception of those that are to be given before or with meals. On 6/24/13 at 1:31 p.m. the surveyor reviewed the Medication Administration Record (MAR) which indicated the Times OF Administration (TOA) set for [MEDICATION NAME] was 12:00 Noon. Further review of the MAR and review of physician orders [REDACTED]. Also the Nurse initialed the MAR which indicated that she administered the medication with the meal during the above observation. On 6/25/13 at 10:29 a.m. the surveyor interviewed the Consultant Pharmacist (CRPh) who stated that the [MEDICATION NAME] should have been administered with the lunch meal and not after the resident finished eating lunch. On 6/24/13 the surveyor reviewed manufacturer specifications which indicated that [MEDICATION NAME] should be administered with meals. 2. On 6/25/13 at 7:39 a.m. during the medication pass, the surveyor observed Nurse #2 administer an Aspirin [MEDICATION NAME] Coated 325 mg tablet po to Resident #11. On 6/25/13 at 9:30 a.m. the surveyor reviewed the MAR and physician orders [REDACTED]. Also the Nurse initialed the MAR which indicated that she administered the 81 mg dose during the above observation. On 6/25/13 at 9:36 a.m. the surveyor interviewed Nurse #2 who acknowledged that she administered Aspirin [MEDICATION NAME] Coated 325 mg instead of the physician ordered 81 mg tablet. On 6/25/13 at 10:29 a.m. the surveyor interviewed the CRPh who stated that the Nurse should have administered the 81 mg dose as ordered by the physician during the above observation. 3. On 6/25/13 at 8:30 a.m. during the medication pass, the surveyor observed Resident #9 who was seated in a wheel chair eating breakfast in a dining area on the second floor. Resident #9 had [DIAGNOSES REDACTED]. The resident was eating scrambled eggs and had consumed approximately half the portion at that time. At that time, Nurse #3 wheeled Resident #9 to his/her bedroom and injected 28 units of [MEDICATION NAME] Mix 70/30 Insulin subcutaneously (sc) to the left arm of the resident. Nurse #3 then wheeled Resident #9 back to the dining area where his/her breakfast was still on the table and Resident #9 resumed eating. The Nurse initialed the MAR which indicated that she administered the insulin before breakfast during the above observation. On 6/25/13 at 9:12 a.m. the surveyor reviewed the MAR and physician orders [REDACTED]. On 6/25/13 at 10:09 a.m. the surveyor interviewed Nurse #3 who agreed that she should have administered the above dose of Insulin before Resident #9 started to eat breakfast as ordered by the physician. On 6/25/13 at 10:29 a.m. the surveyor interviewed the CRPh who stated that Nurse #3 should have administered the above dose of the insulin before Resident #9 started to eat breakfast during the above observation. Refer to Example 1. N.J.A.C. 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to provide appropriate pharmaceutical services with respect to medication labeling, disposal and storage. This deficient practice was observed for 2 of 2 nursing units of the facility. The evidence was as follows: 1. On 6/24/13 at 10:55 a.m. the surveyor in the presence of Nurse #2 inspected the first floor medication refrigerator and observed bags of syringes for external use of Lorazepam gel, 0.5 milligrams (mg) per milliliter (ml) for Resident #3. On each bag there was a dispensing pharmacy label which indicated to refrigerate there was also a use by or expiration date. In addition, each syringe in each bag was labeled by the pharmacy when the medication expired. In one of the bags, the pharmacy label on the bag indicated to use the syringes (there were 2 syringes left in this bag) by 4/18/13. The 2 syringes were each labeled as expired on 9/1/13. In another one of these bags, the pharmacy label on the bag indicated to use by 6/3/13 but each of the 10 syringes left in the bag were labeled as expired on 10/26/13. Nurse #2 stated that there was a current "as needed" (prn) order for the above Lorazepam to be administered to Resident #3 for agitation. She further stated that the pharmacy told her that the expiration date on the label on the bag was in effect if the medication was not stored under refrigeration and the expiration date on each syringe was in effect if the medication was stored under refrigeration. The surveyor then asked Nurse #2 where that information was documented. Nurse #2 then agreed with the surveyor that this information was not documented. She further agreed that the use by date indicated on the labels on the above two bags indicated that the medication had already expired, also the word "refrigerate" which was also indicated on the same labels, contradicted what the pharmacy told her. On 6/24/13 at 12:30 p.m. the surveyor interviewed a representative of the dispensing pharmacy who stated that the above medication expired on the date indicated on the syringe if the medication was kept under refrigeration and it expired on the date indicated on the label on the bag if not stored under refrigeration. She then stated that the pharmacy in-serviced staff on this. The surveyor then asked the representative why this information was not indicated on the label. She then stated that the pharmacy could not ensure where the facility would store the medication and they felt the way it was indicated was appropriate. On 6/25/13 at 12:09 p.m. the surveyor continued the interview with Nurse #2 who agreed that Nurses, for example per-diem staff not familiar with the storage requirements, would not know the storage requirements of the above medication as the labeling for when the medication expired was conflicting and confusing. On 6/25/13 the surveyor reviewed the facility policy titled "Medication Administration" which indicated that all medications must be properly labeled. 2. On 6/25/13 at 8:12 a.m. during the medication pass, Nurse #2 of the first floor administered an Acetaminophen 325 mg tablet, a Senna 8.6 mg tablet and a Dyazide capsule (a prescription medication) po to Resident #8. The resident immediately spit all three medications out of his/her mouth and stated that he/she wanted these medications in apple sauce. Nurse #2 then placed the spit out medications whole into a medication cup, put apple sauce in the cup and threw the mixture into the open garbage bag that hung on the side of the medication cart. There was no Nurse or Pharmacist that witnessed the disposal. Nurse #2 went into and out of resident rooms leaving the medication cart with the garbage bag in the common corridor out of her eyesight. On 6/25/13 at 10:26 a.m. the surveyor interviewed Nurse #2 who stated that she followed facility policy by disposing the medications as observed above. On 6/25/13 at 10:29 a.m. the surveyor interviewed the Consultant Pharmacist (CRPh) who stated that he trained the Nurses to dispose of medications by crushing the medications then put into kitty litter and never just throw the unwanted medications into the trash. On 6/25/13 the surveyor reviewed the facility policy titled "Disposal of Medications" which indicated that to dispose of prescription medications not labeled to be flushed, Nurses can either crush in apple sauce or dilute the medication with water and take the mixture bagged to the dumpster for disposal. Further review indicated that all medication destruction in the facility should be witnessed by 2 licensed Nurses or the Pharmacist. 3. On 6/25/13 at 8:44 a.m. during the medication pass, the surveyor observed Nurse #3 of the second floor put a loose Furosemide 40 mg tablet into a medication cup in preparation for administration to a resident. The Nurse then stated that she was not going to administer the Furosemide at that time so she then put it whole into a medication cup and threw it directly into the open garbage bag that hung on the side of the medication cart. There was no Nurse or Pharmacist that witnessed the disposal. Nurse #3 went into and out of resident rooms leaving the medication cart with the garbage bag in the common corridor out of her eyesight. On 6/25/13 at 10:09 a.m. the surveyor interviewed Nurse #3 who stated that the facility policy was to throw unwanted medications down the toilet. She added that she should not have thrown the Furosemide into the open garbage bag as observed above because anyone in the common corridor had access to it. Refer to Example 2. 4. On 6/25/13 at 11:35 a.m. and again on 6/26/13 at 9:34 a.m. the surveyor observed an open container that had packets of Vitamin A & D ointment and packets of Calmoseptine Ointment in it on the desk of the First Floor Nurses' Station. There was access from the common corridor to where this container was stored and on each of the above observations, there was no Nurse in direct eyesight of these medications. On 6/25/13 the surveyor reviewed the facility policy titled "Medication Administration" which indicated that all medications must be stored in a locked cart at the Nurses' station. 5. On 6/26/13 at 11:31 a.m. the surveyor observed a Cymbalta 20 mg capsule wrapped in unit dose wrapper on the floor in the common corridor of the second floor near the parked medication cart. The surveyor then showed this medication to Nurse #3 and told her where the medication was found. Nurse #3 stated that it must have fallen out of the medication cart. She further stated that the medication belonged to Resident #7. The Nurse then returned the medication to Resident #7 stock in the medication cart. The Nurse also stated that this medication should have been locked up in the medication cart as anyone in the common corridor had access to it. Refer to Example 4. N.J.A.C. 8:39-29.6(a), 29.4(f)(g)(h)

Based on observation, interview and record review it was determined that the facility failed to perform a dressing change using adequate infection control measures for 1 of 1 residents reviewed for pressure sores, Resident #4. The deficient practice was observed as follows: Resident #4 was readmitted to the facility in November of 2012 with an unstageable left heel pressure sore. On 6/25/13 beginning at 9:30 a.m. the surveyor, in the presence of another surveyor, observed a facility Nurse perform a pressure sore dressing change on Resident #4. The treatment Nurse was assisted by another facility Nurse. The treatment Nurse rolled the treatment cart into Resident #4's room and began to remove supplies from the cart and placed them onto the over bed table which she had already covered with a plastic backed field. The Nurse then removed the Treatment Administration Record from the binder and placed it onto the clean field. As the treatment Nurse prepared to cleanse the wound she picked up the gauze and handled the gauze in areas that were to touch the wound with her gloved hands. She then poured the Normal Saline Solution onto the gauze and began to cleanse the wound. The treatment Nurse started in the center of the wound and went outward in a circular motion. Instead of throwing away the gauze after doing that process once, she started again with the same gauze in the center and went outward in a circular motion and then threw the gauze away. The treatment Nurse did this same process several times. On 6/26/13 at 11:40 a.m. during surveyor interview with the Director of Nurses (DON), in the presence of facility administration and other surveyors, the DON stated that the treatment cart should not have been taken into the resident's room and it was not what the facility usually does. The DON also agreed that it was professional standards of practice to throw away the gauze after one full circular motion. The surveyor reviewed the "Wound Care" policy and procedure provided on 6/26/13 at 11:50 a.m. which indicated under the area "Steps in the Procedure" to "Assemble the equipment and supplies necessary to perform the procedure and take them to the resident's room." N.J.A.C. 8:39-19.4 (a)

Based on observation, interview and review of documentation provided by the facility it was determined that the facility failed to maintain the kitchen equipment in a sanitary and functional manner. This deficient practice was evidenced by the following: On 6/24/13 at 9:40 a.m. during the initial tour of the kitchen in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. There was a build up of black, charred food debris on the three racks located inside the top convection oven and the four racks located inside the bottom convection oven. 2. The interior and exterior sides of the fryer were heavily soiled with caked on food debris and non-food debris. 3. A pipe located inside the bottom section of the fryer had a soiled white cloth towel wrapped around it. At 10:05 a.m. during an interview with the FSD she stated that the towel is there to catch drips after the inside is cleaned. The FSD acknowledged that she was not aware of the potential fire hazard due to location of the cloth towel. 4. The garbage disposal located next to a three compartment sink in the cooks area and adjacent to the toaster was heavily soiled on the top, sides interior and exterior of the unit. At 10:20 a.m. the FSD stated that the three compartment sink and the garbage disposal are no longer used. 5. The four light fixture covers located under the front and back hoods were soiled with dried and splattered food debris. On 6/24/13 at 11:00 a.m. and 6/25/13 at 11:30 a.m. the surveyor reviewed the facility's signed "Assignment Sheets" for the Pot Washer, Dishwasher, Utility Person, Cooks and Servers. The assignment sheets failed to include the above mentioned items and/or other specific maintenance or cleaning schedules for large pieces of kitchen equipment. N.J.A.C. 8:39 31.4 (a)

Based on observation and interview on 6/25/13 it was determined that the facility failed to ensure that handrails were securely attached to corridor walls and free of splinters as evidenced by the following: At 10:15 a.m. a small section of wooden handrail between resident room #111 and the stairway exit was not securely attached to the wall. The handrail felt very loose when body weight was applied. There was also another small section of handrail by resident room #102 that had 4 gouges with micro-splinters protruding. During surveyor interview with the Maintenance Director at 12:15 p.m. he stated that the facility did not have a routine maintenance program for monitoring handrails. N.J.A.C. 8:39-31.2(e)

Based on observation, interview and record review, it was determined that the facility failed to ensure that the physician orders [REDACTED]. This deficient practice was observed for 1 of 11 residents reviewed, Resident #8 and was evidenced as follows: On 4/10/12 at 10:30 a.m. the surveyor reviewed 5 monthly Physician order [REDACTED].#8. The POSs contained medication orders, diet orders, treatment orders and supplement orders. Surveyor review revealed that the physician had not signed the POSs. During the above observation the surveyor also reviewed the "Doctor's Progress Notes" which indicated that the last note the physician entered and signed was 8/10/11. On 4/10/12 at 11:19 a.m. during surveyor interview with Resident #8's physician, he stated that he should have signed all the above POSs at the time that they were dated. The physician then showed the surveyor that he signed the POS dated 3/24/12. Further interview revealed that the physician had just signed the POS. The surveyor reviewed the remainder of the above POSs, which were for the months of 11/2011 through February 2011. Each of the POSs were signed by the physician on 4/10/2012 but were dated as though they were signed during the respective months the POSs were dated. The physician added that even though the last "Doctor's Progress Note" that he documented and signed was 8/10/11, he had examined Resident #8 in the months of 10/2011 and 11/2011. The surveyor then observed the physician document on and sign the "Doctor's Progress Notes" dated 10/5/11 and 11/11/11, however he dated the notes as though they were documented in the medical record on the respective dates. On 4/10/12 at 1:28 p.m. the surveyor interviewed the Director Of Nurses (DON), the Assistant Director Of Nurses (ADON), the Administrator and the Executive Director. It was agreed that without physician signature on the POSs, all the orders on the POS were not currently active, even though medications were currently being administered to Resident #8. N.J.A.C. 8:39-35.1(d)6