Every finding on record at Medford Leas

Based on observation, interview and document review, it was determined that the facility failed to to maintain the kitchen environment and equipment in a sanitary manner and ensure all staff performed hand hygiene appropriately to prevent potential contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 02/20/25 at 12:01 PM, the surveyor conducted an initial tour of the kitchen with the Executive Chef (EC), Director of Dining (DD), and the Dining Manager (DM) and observed debris affixed to the ceiling tiles in the pot washing area. On 02/24/25 at 10:08 AM, the surveyor conducted a follow-up tour of the kitchen with the DD and the EC and observed the following: -In the presence of the DD, observed Dietary Staff (DS) come to the hand washing sink, turned the water on, applies soap to hands and rubbed hands together for less than 10 seconds before placing both hands under the running water and continued to rub hands together under the running water. The surveyor asked DS how many seconds she was supposed to wash hands together prior to rinsing and the DS stated 30 seconds. The DD interjected and stated 20-30 seconds. The surveyor asked the DD if the DS appropriately washed her hands and the DD stated, no, she needed education. -Debris was visible affixed to the ceiling tiles and fan in the pot area. -A large box of plastic wrap and a dispenser for labels was located on a metal table in the cooks area various food type debris on the exterior of the box and dispenser. -Two can openers that were affixed to tables had visibly dull blades, and one of the openers had various food debris affixed to the blade. The DD observed the debris and stated, looks like it needs attention. -Multiple sprinkler heads throughout the kitchen had visible dust type debris affixed to them. - The ice machine had debris in the channel by the opening. -The under counter freezer by cooks area with debris in channel of door. -The large grill had visible embedded grease in the lower drain and on the back of the grill. The EC stated it doesn't look like it was cleaned it over the weekend, and confirmed it was not clean. -There were four stacks of plate covers stored upright on top of the meal shelf where the resident meal trays were assembled and not protected from potential contamination. -A stack of resident meal trays was on a cart with visible debris under the cart. The Equipment Cleaning and Maintenance Guidelines effective September 2018 revealed under Procedure: 1. The Dining Services managers, supervisors and/or coordinators will develop, implement and manage protocols and schedules for cleaning equipment in their areas of responsibility. The Hand Washing Policy and Procedure Policy dated 3/2022 revealed: Procedure: .3. Rub hands together for 15 to 30 seconds: use friction on all surfaces of th hands-backs, palms, between the fingers and under the nails. (most bacteria on the hands live under the fingernails.) . NJAC 8:39-17.2(g)

Based on observation, interview and document review, it was determined that the facility failed to: a) ensure controlled drugs (narcotics) were stored in a permanently affixed compartment, and b) have a system in place to ensure that the emergency crash cart (a portable wheeled cabinet that contained emergency medical supplies and drugs) did not contain expired emergency supplies. This deficient practice was identified for 1 of 1 medication storage room, and for 1 of 1 emergency crash carts (ECC) reviewed for medication storage. The deficient practice was evidenced by the following: 1. On [DATE] at 9:30 AM, in the presence of the Registered Nurse (RN) the surveyor inspected the ECC and observed a mechanical suction machine and a Bag Valve Mask (BGM- a manual resuscitator device used in emergencies to provide breathing support to patients who are not breathing). The BGM had an expiration date of ,d+[DATE]. The surveyor asked the RN for the Cardiopulmonary Resuscitation (CPR) board (a flat, rigid surface that was used to position a patient to perform CPR). The RN was unable to locate the CPR board and at 9:37 AM, the RN opened a cabinet and observed the CPR Board, and an Emergency Bag (EB- a bag that contained emergency use items). The RN opened the EB and the following expired items were observed: 1. 4 -Suction catheter kits with expiration dates of ,d+[DATE]. 2. 4- Suction tubing kits with expiration dates of ,d+[DATE]. 3. 2- non-rebreather oxygen masks (a device that delivered high concentrations of oxygen) with a manufacture date of ,d+[DATE] and expiration date of [DATE]. The surveyor then asked the RN what was the process was to verify when the emergency items were not expired, and was there a checklist? The RN was unable to locate a checklist, and did not speak to a process that was in place to ensure that the emergency supplies were not expired. On [DATE] at 9:00 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) and inquired regarding the process for checking the emergency supplies. The UM/RN stated that the 11:00 PM- 7:00 AM staff were responsible to check the emergency supplies in the EB weekly, and would then remove all expired items from the EB. The surveyor asked for the emergency supplies checklist for [DATE] and February 2025. The UM/RN stated she did not have a checklist to provide. The surveyor then asked the UM/RN when was the last time that she had observed the checklist. The UM/RN stated, To tell you the truth, I have not seen a checklist for a while. The UM/RN then confirmed that staff had not been checking the emergency items to ensure there were no expired supplies in the EB. On [DATE] at 9:55 AM, the above concerns were discussed with the Director of Nursing (DON). The DON confirmed that staff failed to comply and based on the expired items that were observed inside the EB, and stated the emergency supplies had not been checked in a while. 2. On [DATE] at 10:20 AM, the surveyor observed the medication room refrigerator in the presence of the RN and another surveyor. Both surveyors observed the narcotic box was locked, and was located on a shelf inside the refrigerator. The surveyor then asked the RN to remove the narcotic box from the refrigerator. The RN lifted the narcotic box and removed it from the interior of the refrigerator, and then stated, that defeated the purpose. On [DATE] at 8:50 AM, both surveyors again, observed the medication room refrigerator with the Licensed Practical Nurse (LPN), and again observed that the narcotic box was not permanently affixed. The LPN was able to remove the narcotic box along with the shelf from the refrigerator. On [DATE] at 9:55 AM, both surveyors interviewed the Director of Nursing (DON) regarding the narcotic box not being permanently affixed. The DON stated that she was made aware the same day the surveyors identified it, and maintenance was supposed to address the issue. The DON stated she was made aware that morning that the narcotic box was still not permanently affixed. On [DATE] at 11:43 AM, the DON provided the surveyor with the facility policy titled, Medication Storage dated [DATE]. The policy revealed: It is the facility policy to store all medications in a safe, secure and orderly manner. The policy did not address narcotic storage. The DON stated that the policy would be reviewed to reflect narcotic storage. Purpose of the Policy: to outline guidelines, in accordance with state and federal regulations, for storage of medications. NJAC 8:,d+[DATE].4(a)(h)

Based on observation, interview and document review, it was determined that the facility did not address the resident population, identify the specific care related to the type of diseases or conditions that were present in the resident population and did not identify the staff competencies and skill sets that were necessary to provide care for the specific resident population to the specific resident population and was evidenced by the following: On 02/20/25 at 1:30 PM, the facility provided the survey team with a copy of the Facility Assessment (FA), Updated 2/2024. The surveyor reviewed the FA which revealed: Facility Assessment and Overview: . There are three healthcare buildings . containing nursing care. Sub-acute Rehabilitation/ [Long Term Care] .Employee's licensure and certifications to manage resident care needs, physical, psychological, spiritual and social needs . Under Dining: Religious, ethnic, cultural considerations and preferences that may affect delivery of care and services, related to end of life care, can be managed through nurse on duty, social worker, resident services, and or unit resident care manager. Under QAPI [Quality Assurance and Performance Improvement]: .utilize the quality assurance performance improvement process (Reference QAPI written plan). The purpose of the quality assurance performance improvement program is designed to promote excellence in resident safety satisfaction choice, as well as high-quality programs and services in our facility .This program is designed to improve the lives of our residents in the areas of .skilled nursing. Under Admissions: .subacute rehabilitation/skilled nursing is a short stay unit .The facility serves residents who often have one or more chronic/co morbid conditions . The facility provides care services based on the needs of our resident population including the following: assistance with activities of daily living, mobility assistance, incontinence care, medication and medication management, fluid replacement, psychosocial support, wound care, competencies, infection control, physical therapy services, therapeutic recreation, nutrition, and respiratory therapy needs. Under Staff Education: .[Facility Name] currently utilizes in-house services and online training [online training company name redacted]. Prior to staff orienting there is a day one orientation in which the employee is trained on the following: assisted living in philosophy, resident rights, advanced directives, trauma informed care, risk and response, safe patient handling, hazardous wondering, an elopement, fire, safety, active shooters, abuse neglect exploitation, compliance code of mandatory reporting infection, control, workplace violence, attendance appearance, information system, social media, cell phone, substance free workplace, weapons, free workplace, smoke-free, workplace, infection, control practices, PPE (personal protective equipment] and respiratory protection plan. Under Infection Control: .conduct and infection control risk assessment, which is evaluated and determined potential vulnerabilities within the resident population and surrounding community, this process is integrated in the facility. It is part of the QAPI program. It is reviewed annually and or as needed. maintain a full-time infection preventionist on site. On 02/24/25 at 12:09 PM, the surveyor interviewed the Director of Nursing (DON) regarding the Facility Assessment (FA). The DON stated it was her responsibility to complete the FA and the surveyor asked the DON if the needs for staff education and competencies related to the care that was required for the residents. The DON stated that the facility used an online education program, and when asked if there were any educational needs identified in the FA, the DON stated, no. The surveyor asked the DON if the specific resident population was identified in the FA and the DON stated no that the specific types of residents were not identified in the FA. The DON stated, we have elders and there were no specifics included regarding the resident population. The surveyor asked the DON if there any competencies included in the FA regarding the competencies the staff would need to care for the residents. Upon inquiry, the DON confirmed that the facility has utilized mechanical lifts to transfer residents. The surveyor asked were competencies assessed to ensure the staff know how to use the mechanical lift. The DON stated, no, the staff would be shown but there would be no competencies. The DON stated that she had been unaware that the FA regulations had been revised 8/2024. On 02/24/25 at 1:17 PM, during the exit conference, the Licensed Nursing Home Administrator and Assistant Administrator confirmed that they were not aware of the updated FA requirements. NJAC 8:39-13.4(b)

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to identify and consistently implement an effective Quality Assurance and Performance Improvement (QAPI) program to: a)ensure medication carts and emergency carts for identified and monitored for expired supplies and medications, b) ensure secure storage of all narcotic medications, and c) ensure that competencies required for all staff who worked in resident care areas were identified and addressed. This deficient practice was evidenced by the following: 1. On 2/21/25 at 10:30 AM, two surveyors conducted an inspection of the nursing unit emergency cart and observed that the bag valve mask (an instrument to force air into the lungs) was expired in 7/2023; four suction catheters expired 4/2024; four suction tubing marked with an expiration date of 7/2023; and a non-rebreather mask (a device to provide oxygen) manufacturers date 5/2016 and expired 5/30/20. There was no emergency cart inspection check list. On 2/24/25 at 9:00 AM, the Registered Nurse Unit Manager RN/UM stated the process was for the 11:00 PM to 7:00 AM shift to inspect the emergency cart, but it was not being done. The RN/UM was unable to locate January 2025 and February 2025 emergency cart checklist. The RN/UM stated that the presence of expired items meant that the staff were signing off that the emergency cart had been inspected, but they were not actually inspecting it. 2. On 2/21/25 at 10:20 AM, the RN in the presence of two surveyors observed the medication refrigerator on the nursing unit. There was a locked narcotics box that was not permanently affixed and was easily removed from the refrigerator. At that time, the RN removed the narcotic box and stated, it defeated the purpose for being secured narcotic storage. On 2/24/25 at 8:50 AM, the Licensed Practical Nurse (LPN) and two surveyors again inspected the nursing unit medication refrigerator and observed that the locked narcotic box was still not permanently affixed and was easily removed. 3. On 2/24/25 at 10:24 AM, a surveyor entered the kitchen for a follow-up inspection. During the inspection, a dietary staff member approached the sink next to the surveyor, turned on the water, applied soap, rub their hands together and placed both hands under the running water while applying friction. The surveyor requested a copy of the dietary staff members hand washing return demonstration competency. On 2/24/25 at 11:39 AM, the facility was unable to provide any return demonstration hand hygiene competencies. The RN Infection Preventionist RN/IP provided the hand hygiene policy, but acknowledged there were no documented return demonstration hand washing competencies for all the staff. On 2/24/25 at 12:09 PM, the Director of Nursing (DON) in the presence of two surveyors, stated that she was responsible for the Facility Assessment (FA) which included staff education. She stated the facility would use an outside service to provide online education, and that the facility would choose what topics were included from a database. The DON added there were no return demonstration competencies regarding staff education needs including the use of a mechanical lift, which the DON stated the facility utilized to transfer residents. The DON stated, it was the responsibility of whoever was training the Certified Nursing Aide (CNA) and it would be demonstrated and confirmed there was no documented evidence of a completed competency for the staff. On 2/25/25 at 9:07 AM, the RN/IP who was responsible for the QAPI program, stated that he was aware of some of the concerns identified by the survey team. He stated in September 2024, the pharmacy consultant identified a trend of expired medications. The RN/IP stated that the facility was conducting audits on expired medications but did not inspect any supplies, or the emergency cart. He next stated that a compliance company was at the facility 2/11, 2/12, and 2/13/25, for a mock survey and the facility was verbally told about a concern with narcotic storage not being secured in the cabinet. He specified that the DON and another nursing manager inspected the cabinet but did not inspect the narcotic storage in the medication refrigerator. The RN/IP revealed that the concern with performing competencies for the staff was identified, the middle of last year, but was not brought to QAPI, and the facilities efforts to use a computer program were not working, and the concern had not been addressed since. A review of the facility provided Quality Assurance Performance Improvement Plan Date: December 2023, next plan review due date December 2024, included but was not limited to; guiding values to improve the quality of care and quality of life of the residents, and focus on systems and processes. Scope included encompasses all areas of care and services that impact clinical care . Goals included the staff will receive up-to-date education on the best practice and clinical guidelines to promote highest level of clinical care. Trainings will be conducted . in multiple ways . Monitoring included to put in place systems to monitor care and services, drawing data from multiple sources. The QAPI team will decide what data to monitor routinely . areas may include . medications and medication compliance reports from the pharmacist (e.g. narcotics). On 2/25/25 at 9:59 AM, the facility administration was in the conference room with the survey team. The QAPI concerns were addressed. In reference to the competencies identified the middle of last year, the DON stated, I'll be honest we just started yesterday. Regarding the emergency cart inspections, the DON stated it fell off the kardex and had not been completed. NJAC 8:39-33.1; 33.2; 33.4

Based on observation, interview and document review, it was determined that the facility failed to ensure a system was in place, and consistently followed to incorporate feedback from all departments and direct care staff for their Quality Assurance Performance Improvement (QAPI) program. Refer to 761E, 812F This deficient practice was evidenced by the following: On [DATE] at 12:54 PM, during entrance conference the facility provided documentation which included their QAPI plan and three months of attendance sheets. A review of the attendance sheets documented no direct care staff or maintenance staff. On [DATE] between 9:30 AM to 10:20 AM, two surveyors identified concerns regarding expired supplies on the emergency cart, no inspections of the emergency cart, and a narcotic lock box which was not permanently affixed in the medication refrigerator. On [DATE] at 10:24 AM, a surveyor was inspecting the kitchen when a dietary aide approached the sink next to the surveyor. The dietary aide turned on the water, applied soap to their hands, rubbed their hands together, and then placed their hands under the running water while applying friction. On [DATE] during the Life Safety Code (LSC) inspection, the LSC surveyor identified concerns with the facility which included 14 of 14 resident rooms being accessible for instant use in case of emergencies; exit stair landings and handrails were not marked/identified; means of egress with no continuous illumination; emergency lighting not provided in various areas; areas with no protected self-closing doors; no automatic fire sprinkler protection to all areas of the facility; 12 of 14 resident rooms where the air conditioner was not maintained in a safe operating condition; and no inspection of the fire door assemblies. On [DATE] at 9:07 AM, the Registered Nurse Infection Preventionist RN/IP stated he was responsible for managing the QAPI program. The RN/IP stated that the QAPI team met monthly and recently changed to quarterly and a smaller group met at a subcommittee. He stated the attendees were the Medical Director, three nurse managers, the Minimum Data Set (MDS) nurse, admission staff, the Dining Services Director, the compliance staff member, the Chief Financial Officer and the Licensed Nursing Home Administrator (LNHA). When asked if the maintenance department, or any direct care staff such as a Certified Nursing Aide (CNA) were invited, the RN/ IP replied that maintenance was not invited. When inquired if there was a system for staff to report issues to QAPI, the RN/IP stated there was an email address where staff could report safety concerns but not necessarily for other quality related concerns. When asked if he spoke to staff or family for their input, he stated, Not really. We do not have an official way. On [DATE] at 9:31 AM, a CNA on the nursing unit stated she worked at the facility for 8 years and did not know what QAPI was but did know the facility had a safety meeting. She added she had never been to or invited to a QAPI meeting. On [DATE] at 9:59 AM, the facility administration was in the conference room with the survey team. The LNHA acknowledged he was ultimately responsible for the QAPI program. The Director of Nursing (DON) stated that CNAs and direct care nurses were only part of the falls QAPI committee. The LNHA added that QAPI was largely administrative. The surveyor asked if the falls committee was all encompassing such as the QAPI meeting, the Director of Health Services stated no. When asked about a comprehensive QAPI meeting to include staff and family input, the DON stated there was not a meeting that included all staff departments or family. A review of the facility provided Quality Assurance Performance Improvement Plan Date: [DATE], next plan review due date [DATE], included but was not limited to; Feedback, Data Systems and Monitoring: . will put in place systems to monitor care and services, drawing from multiple sources. Feedback systems will incorporate input from staff, families, and others as appropriate. NJAC 8:,d+[DATE].1(d); 33.2(b)(d); 33.3; 33.4; 34.1(a)(d)

Based on observation, interview, and document review, it was determined that the facility failed to follow appropriate hand hygiene during the meal service to prevent the potential spread of infection. This deficient practice was observed on 2/20/25 and 2/21/25, during the meal observation, as was evidenced by the following: On 2/20/25 at 12:40 PM, the surveyor observed Certified Nursing Aide (CNA #1) assisted Resident #60 to the Dining Room with the rolling walker. The resident sat at the table and proceeded to read the newspaper. At 12:48 the lunch cart arrived on the floor. The surveyor observed another resident along with Resident #60 at the table. The staff did not provide the residents with hand hygiene prior to the lunch meal. On 2/21/25 at 12:40 PM, the surveyor observed CNA #2 deliver the lunch tray to the a resident room, assisted the resident with the tray table, set the resident up for the meal and exited the room without performing hand hygiene. CNA #2 then returned to the cart picked up another meal tray, then delivered the tray to the room and exited without first performing hand hygiene. On 2/21/25 at 12:45 PM, the surveyor observed a Licensed Practical Nurse (LPN) picked up a tray on the meal cart, went to the room, assisted the resident to recline in the chair, set up the meal, then exited the room without first performing hand hygiene. On 2/21/25 at 12:52 PM, the LPN then went to the meal cart picked up another tray, went to another resident's room and assisted the resident with the lunch tray. The LPN then exited the room without first performing hand hygiene. The LPN was about to return to the cart when the surveyor inquired regarding hand hygiene not being observed after assisting each resident. The LPN stated to the surveyor, I was not aware that I must wash my hands after passing each tray. On 2/24/25 at 9:55 AM, the surveyor met with the Director of Nursing (DON) and informed her of the above-mentioned concerns. The DON stated that staff should wash their hands prior to meal tray delivery and perform hand hygiene after delivering each tray. The DON stated all residents should be provided with opportunity to wash their hands prior to their meals. On 2/24/25 at 12:15 PM, during an interview with the surveyor, the Infection Preventionist (IP) stated hand washing would be performed for 20-30 seconds with soap and warm water. The IP further stated hand hygiene was the best way to prevent infections. The IP confirmed that the staff should have performed hand hygiene during the meal delivery, and assisted residents with hand hygiene prior to their meals. On 2/24/25 at 1:10 PM, the survey team met with the Licensed Nursing Home Administrator and notified of the above-mentioned concerns. On 2/25/25 at 9:59 AM, the survey team met with the facility administration team for responses and no additional information was provided. A review of the facility's policy titled, Hand Washing Policy and Procedure dated 3/2022 revealed the following: Policy: It is a facility's policy to educate, promote, and enforce proper hand washing techniques throughout the facility in order to prevent and reduce the spread of infections. Purpose: All employees will receive proper hand washing technique education upon hiring, on an annual basis, and as needed to promote increased infection prevention and control. All residents will be encouraged and given opportunities to wash their hands. Hand washing should occur before and after eating meals, after using the bathroom . etc. NJAC 8:39-19.4 (a)(m)

Based on interviews, facility policy review, record review, and document review, it was determined that the facility failed to complete and transmit Minimum Data Set (MDS) assessments in a timely manner for 2 (Resident #6 and Resident #9) of 12 residents reviewed for MDS assessments. Findings included: Review of the facility's policy titled, MDS/PPS [prospective payment system] RAI [resident assessment instrument] Process, dated 10/2019, specified, RNAC [registered nurse assessment coordinator]/MDS Coordinator will transmit each resident's completed and signed MDS 3.0 within time frame required by OBRA [Omnibus Budget Reconciliation Act], MDS 3.0 and Medicare guidelines. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2019, specified, 5.2 Timeliness Criteria In accordance with the requirements at 42 CFR [code of federal regulation] S [section sign] 483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: Completion Timing: - For all non-Admission OBRA and PPS assessments, the MDS Completion Date must be no later than 14 days after the Assessment Reference Date. 1. A review of a Profile Face Sheet indicated the facility admitted Resident #6 with diagnoses that included dysphagia (difficulty swallowing) and dysarthria (slurred speech) following a cerebral infarction (stroke). A review of Resident #6's discharge MDS, with an assessment reference date of 07/19/2022, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was discharged to the community on 07/19/2022. Further review of the MDS, revealed the RNAC signed the MDS as being completed on 09/27/2022. 2. A review of a Profile Face Sheet indicated the facility admitted Resident #9 with diagnoses that included mild cognitive impairment and major depressive disorder. A review of Resident #9's discharge MDS, with an assessment reference date of 07/22/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was moderately impaired in cognitive skills. The MDS indicated the resident was discharged to the community on 07/22/2022. Further review of the MDS, revealed the RNAC signed the MDS as being completed on 09/26/2022. During an interview on 01/07/2023 at 9:23 AM, the Director of Nursing (DON) stated the MDS Supervisor had been out sick all week and was unavailable for an interview. During a follow-up interview on 01/07/2023 at 12:56 PM, the DON stated she had spoken with the MDS Supervisor and the MDS Supervisor stated he must have missed submitting the MDS assessments, but thought he had a year to submit. Per the DON, the MDS Supervisor oversaw all the facility's MDS process. During an interview on 01/07/2023 at 3:25 PM, the Administrator stated he was surprised that the MDS assessments had not been transmitted. He stated he thought it should have been caught during the facility's triple-check process. According to the Administrator, he expected MDS assessments to be transmitted in a timely manner according to the regulation. NJAC 8:39-11.1

Based on interviews, record review, and facility policy review, it was determined that the facility failed to include pertinent information on the baseline care plan for 1 (Resident #22) of 8 residents reviewed for care plans. Specifically, the facility failed to include the diagnosis and treatment of clostridium difficile (C-diff) on Resident #22's baseline care plan. Findings included: Review of the facility's Baseline Care Plan Policy, dated 11/2017, specified, The purpose of the policy is to assure that the residents immediate care needs are met through completion and implementation of the baseline care plan within 48 hours of a resident's admission. It is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative participate in the initial plan for delivery of care and are provided a written summary of the baseline care plan. The policy further specified, The baseline care plan will include conditions and risks affecting the resident's health and safety. A review of a Profile Face Sheet indicated the facility admitted Resident #22 on 01/02/2023, with a diagnosis that included enterocolitis due to clostridium difficile (C-diff). A review of Resident #22's baseline care plan, initiated 01/02/2023, revealed the resident did not have a care plan to address the resident's diagnosis of C-diff or the treatment plan for C-diff. A review of Resident #22's physician orders indicated on 01/03/2023, the resident had orders for Vancomycin (an antibiotic medication) 125 milligrams (mg) by mouth every 72 hours for C-diff colonization. During an interview on 01/07/2023 at 2:32 PM, Unit Manager (UM) #1 stated a resident that was being treated for C-diff with an antibiotic should have a care plan in place to guide the staff on how to care for the resident. UM #1 stated the admitting nurse should initiate the baseline care plan. Per UM #1, she did not realize Resident #22 did not have a care plan to address the diagnosis and treatment of C-diff until being interviewed by the surveyor. During an interview on 01/07/2023 at 2:47 PM, the Director of Nursing (DON) stated a diagnosis of C-diff with antibiotic treatment should be care planned, and the nurse who received the order from the physician was responsible for initiating the care plan. During an interview on 01/07/2023 at 3:25 PM, the Administrator stated the baseline care plan should include any pertinent diagnosis and treatment that the resident was to receive upon admission to the facility. NJAC 8:39-11.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On 8/22/19 from 8:18 to 9:54 AM, the surveyor, accompanied by the Lead Sanitation Coordinator (LSC), Sanitation Supervisor (SS), and Executive Chef (EC), observed the following in the kitchen: 1. In the downstairs walk-in freezer on an upper shelf, a plastic bag contained frozen 51% Whole Grain English Muffins and was removed from the original container. The package had no dates. The LSC stated, they should have been dated when removed from their original box. We just got them in the other day. 2. In the upstairs walk-in freezer on a rear shelf, an opened bag of cheese manicotti was removed from its original container and had no dates. The LSC stated, we opened them last week, they should be dated for opened and used by. 3. A package of frozen baby back ribs on a pan on a multi-tiered cart had no dates. The LSC stated, there should be a date for that. 4. In the kitchen entrance way, a wheeled storage cart contained 4 stacks of cleaned and sanitized bread plates/saucers. The saucers/plates were not inverted and were exposed. The cart was in close proximity to the dish machine. The LSC stated, we have a cover to protect them. The LSC proceeded to obtain a plastic cover for the storage cart. 5. The surveyor observed a Production Worker (PW) in the production area. The production worker had a lengthy beard. The production worker was not wearing a beard guard. The surveyor observed a Sanitation Attendant (SA) in the dish area. The SA had a lengthy beard and was not wearing a beard guard. 6. In the upstairs walk-in refrigerator on a lower shelf of a multi-tiered cart, a container of green onions was dated opened on 8/18 and had a use by date of 8/21. The LSC stated, they should be thrown away. On an upper rear shelf, a plastic wrapped package of green beans had an open date of 8-16-19 and a use by date of 8-18-19. The products were thrown in the trash by the SS. 7. A meat slicer was uncovered upon the surveyor's entrance to the kitchen at 8:18 AM. The surveyor interviewed the SS who stated that the meat slicer was cleaned and sanitized, and was not sure if the meat slicer was currently being used. The surveyor interviewed a PW at 9:32 AM who stated, I'm gonna use that to slice meat. The surveyor told the PW that the meat slicer had been uncovered for over an hour since the surveyor entered the kitchen. The PW stated, I don't know what you mean by it has been uncovered for an hour. The surveyor was approached by the EC who stated, I've been in kitchens for [AGE] years, I've never been told that I have to keep a meat slicer covered when it is not in use. 8. The surveyor was accompanied by the SS in the upstairs walk-in freezer. In the rear of the freezer on a multi-tired rack, multiple frozen packages of pork belly, rack of lamb, pork ribs and beef tenderloin had been removed from their original container. The products had no dates. The surveyor did not observe any visible signs of spoilage, freezer burn or discoloration of the products. The SS stated, We should label the product and date it once removed from the original container. On 8/22/19 from 11:50 to 11:58 AM, the surveyor observed the following in the kitchen in the presence of the cook: 9. The surveyor observed the cook donning a pair of disposable gloves. The cook proceeded to remove the disposable gloves and then throw them into the trash. The cook donned a new pair of gloves and proceeded to perform tray-line temperatures. The cook never performed handwashing between removing the gloves and donning new gloves. The surveyor reviewed the Medford Leas policy titled Food Storage Labeling Guidelines, effective date: (MONTH) (YEAR). Under the Procedure section, the policy revealed 7. The receiver and production staff, including the Sanitation-receiving Supervisor, Sous Chef and Executive Chef, will ensure that foods are rotated on a first in, first out (FIFO) basis and will ensure that outdated foods are discarded. The policy noted 9. Dining Services will utilize the food processor's date stamping and expiration dates as a guideline for food storage on pre-packaged items and dry goods. Items that are opened will be stored and utilized following the applicable storage and use-by rules and/or regulations. The surveyor reviewed the Medford Leas policy titled Handwashing and Glove Use, effective date: (MONTH) (YEAR). Under the Procedure section, the policy noted 5. Hands are to be washed and dried upon donning gloves or changing gloves and between glove use. Gloves are not to be reused. Once gloves are removed, they may not be reused and must be discarded. The surveyor reviewed the Medford Leas policy titled Dress Code and Uniform Policy, effective date: (MONTH) 2011. The policy noted in Procedure section: Facial hair must be neatly trimmed or shaved. Servers, Sanitation staff and food handlers with facial hair must wear a beard restraint. NJAC 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to practice transmission based precautions by not disinfecting a pulse oximeter after resident use. This deficient practice was observed for Resident #166, #168 and #169, 3 of 4 residents observed during medication pass and was evidenced by the following: On 8/22/19 at 8:34 AM, a Registered Nurse (RN #1 ) was observed as she applied a pulse oximeter (PO-an electronic device that measures the oxygen saturation in the blood) to Resident #169's finger. The RN then removed the PO without any disinfection observed. On 8/22/19 at 8:47 AM, Unit RN #1 applied the previously non-disinfected PO to Resident 166's finger and then removed it without any disinfection observed. On 8/22/19 at 9:00 AM, Unit RN #2 was observed as she applied the same non-disinfected PO, which was used on Resident #166's and 169's finger, to Resident #168's finger. She then removed the PO without any disinfection observed. During an interview with RN #1 on 8/22/19 at 9:30 AM, she stated that after a PO was used on a resident, it should have been wiped with a disinfectant. She further stated that the PO should have been wiped to have avoided cross contamination. During an interview of RN#2 on 8/22/19 at 9:32 AM, she stated that she honestly had not practiced disinfecting the PO between resident use, but that she probably should have wiped it after she had removed it from Resident #168's finger. During an interview with the DON on 8/22/19 at 2:10 PM, she stated that the PO should have been disinfected after any resident contact. Review of the Resident Equipment Cleaning Policy and Procedure revealed: #14- Clean pulse oximeters with alcohol swab after each use. NJAC: 8:39-19.4(a)(l)

Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous foods in a safe manner. This deficient practice was evidenced by the following: On 9/18/18 from 8:16 AM to 8:41 AM the surveyor, who was accompanied by the Dining Health Services Coordinator (DHSC), observed the following in the kitchen: 1. In the dry storage room, a bag of sesame seeds wrapped in plastic was opened and undated. When interviewed, the DHSC stated that the sesame seeds should have been dated. The DHSC further stated that items are supposed to be dated when opened 2. In the walk-in freezer, a bag of potato cakes had a use-by date of 9/17/18. When interviewed, the DHSC confirmed the date and discarded the bag of potato cakes. 3. In the walk-in freezer, a second bag of potato cakes was opened and undated. 4. In the walk-in freezer, a bag of chicken patties was opened and undated. 5. In the walk-in freezer, a bag of potato fries was opened and undated 6. In the walk-in freezer, a bag of sweet potato fries was opened and undated. 7. In the walk-in freezer, an opened box of beef patties was stored on a shelf. The surveyor observed that the plastic packaging inside of the box was opened and was exposing the beef patties that were inside of the box. When interviewed, the DHSC confirmed that the beef patties were exposed to the air. The DHSC stated that the beef patties should have been completely covered and should not have been opened like that. 8. In the walk-in freezer, a bag of chicken tenders was opened and undated. 9. In the walk-in refrigerator, a carton of heavy cream was opened and undated 10. In the walk-in refrigerator, a bag of parmesan cheese was opened and undated 11. In the downstairs freezer, two packages of scones were opened and undated. The surveyor reviewed the facility's Food Storage Labeling Guidelines policy with the effective date of (MONTH) (YEAR), provided by the DHSC. The policy reflected that it was the policy of Dining Services to follow recognized guidelines and regulations for food storage and food labeling. The policy revealed that staff would rotate foods on a first in, first out basis and ensure that outdated foods were discarded. The policy further revealed that the label would include the name of the food item, the production date, and the discard date. NJAC 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to follow physician's orders for oxygen equipment care for 1 of 2 residents reviewed for respiratory care (Resident #5). This deficient practice was evidenced by the following: Resident #5 had [DIAGNOSES REDACTED]. On 9/18/18 at 10 AM the surveyor observed the room of Resident #5. The resident was not present in the room at that time. The surveyor observed a bag dated 9/9/18 hanging on the wall by the oxygen connection tubing. The surveyor reviewed the physician's orders in the medical record which noted Change O2 tubing and humidifiers weekly 1 time per week: Times 7p-7a. On 9/19/18 at 11:30 AM the surveyor interviewed the Director of Nursing (DON) about the oxygen tubing for the resident. The DON reviewed the Physician's Orders (PO) in the medical record which noted Change O2 tubing and humidifiers weekly 1 time per week: Times 7p-7a. The DON then reviewed the Electronic Medication Administration Record [REDACTED]. The surveyor and the DON went into the resident's room and observed the O2 tubing bag dated 9/9. The humidifier was dated 9/16. At that time, the DON stated everything should be changed at the same time and have the same dates for both. The DON stated The dates should typically match. The surveyor asked the DON which shift was responsible for changing the tubing. The DON said the facility divided it among the shifts. After further review of the physician's order, the DON stated It's done by the night shift. The surveyor then inquired if the tubing was changed by the night shift and the DON stated I cannot say whether it was done or not. We stress to our staff, if it's not signed out, it's not done. The staff member who signed off on this is relatively new here. When asked if a staff member missed changing the tubing, the DON Yes, it should've been done on the 10th. NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to ensure that all Certified Nursing Assistants (CNA) received 12 hours of annual inservice training as required. This deficient practice was identified for 2 of 5 CNA files reviewed and was evidenced by the following: On 9/19/18 the surveyor reviewed a list of the facility's CNAs that was provided by the facility administrative staff and randomly selected 5 CNA files for review of performance evaluations and inservice training. When interviewed at 10:28 AM the Director of Nursing said the facility used the calendar year for tracking the 12 hours of annual inservice training. The surveyor reviewed the 5 CNA files for the 12 hours of annual inservice training for the calendar year (YEAR). The surveyor observed that 3 of the 5 CNAs had less than 12 hours. When interviewed about the lack of inservices at 9/19/18 at 12:30 PM, the Director of Health Services said some CNAs were from Assisted Living and had been pulled to Long Term Care. During an exit meeting on 9/19/18 at 2:00 PM the Director of Health Services said they actually tracked the 12 hours of annual inservices from (MONTH) to April. She then provided the surveyor with additional print-outs that included more inservices. The surveyor reviewed the additional information in order to make a total number of inservices between (MONTH) 1, (YEAR) and (MONTH) 1, (YEAR). Of the three CNAs previously found to be deficient of the 12 hours, there was documentation that one had received enough hours. The other two still did not have the 12 hours as follows: CNA #2 had 5 hours of inservice training during (YEAR). The additional documentation showed no further training until 7/6/18. CNA #5 had 1.75 hours of inservice training during (YEAR). The additional documentation showed an inservice completed on 4/1/18 for 0.5 hours. The only other inservices noted were completed in (MONTH) (YEAR). NJAC 8:39-43.17(b)

Based on observation, interview and record review it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 7/8/16 from 7:15 a.m. to 9:30 a.m., the surveyor observed the following in the kitchen in the presence of the Dining Health Attendant (DHA): 1. In the walk-in refrigerator, a small pan with a half piece of cooked roast beef with drippings, dated 6/27/16, was on a shelf. When interviewed by the surveyor, the cook said the item was to be used for deli roast beef and had passed the 3-day shelf life. 2. In the walk-in refrigerator, a pan that contained sliced pieces of beef tenderloin was stored in small pan directly on top of multiple packages of lunch meat on the top shelf. When interviewed by the surveyor, the cook stated the beef tenderloin was raw and was improperly stored. 3. In the walk-in refrigerator, a large pan that contained a raw, whole piece of beef tenderloin was not labeled or dated and was stored directly on top of a box of cooked duck halves. 4. In the walk-in refrigerator, 2 pans of raw catfish fillets were being stored directly on top of pre-cooked duck breast halves. 5. In the walk-in refrigerator, a small metal pan that contained sliced raw beef tenderloin was dated 7/3/16. When interviewed by the surveyor, the cook confirmed that the beef tenderloin was both raw and had passed the 3-day shelf life. 6. In the walk-in refrigerator, a large container of smoked white fish was dated 6/15/16 by the facility and had already been opened and used. The manufacturer's sticker had a use-by date of 7/15/16. When interviewed by the surveyor, the cook was unable to identify the use-by date for the white fish once it had been opened. 7. In the walk-in refrigerator, raw sausage links were stored over 2 cases of cooked dried chipped beef. 8. In the walk-in refrigerator, there was a multi-tiered cart that contained a pan of raw flounder that was stored directly over a pan of green beans. Beneath the green beans there was a pan of cooked stuffed cabbage. The pan of cooked stuffed cabbage was not fully covered as the overlay had been pulled back. 9. When the surveyor inspected the ice machine, a blue opaque container was lying on its side on top of the ice machine and contained 2 metal ice scoops. A clear plastic ice scoop was stored on top of the blue opaque container. The surveyor asked the DHA to pull the 2 metal ice scoops out of the blue opaque container. Once the ice scoops were removed a puddle of water was observed in the bottom of the container. 10. The ice machine drain lines were in direct contact with the open floor drain. 11. In the chemical closet in the main kitchen, multiple brooms and dust pans were stored with the heads resting on the floor. 12. In a kitchen storage area on the lower level, multiple brooms and mops were being stored with the heads resting on the floor. When interviewed on 7/7/16 at 12:20 p.m., the Food Service Director (FSD) said raw foods should be stored on the bottom shelf below cooked and ready to eat items. The FSD also said the smoked fish should have had an open date and had a 3-day shelf life once opened. When reviewed, the facility's policy indicated potentially hazardous foods have a 3-day shelf life, the label will indicate the name of the food, the production date and the discard date. NJAC 8:39 - 17.2 (g)

Based on observation and record review, it was determined that the facility failed to use proper hand washing technique during administration of wound treatments. This deficient practice was observed for 1 nurse during a wound treatment observation for Resident #1, and was evidenced by the following: On 7/8/16 at 9:10 a.m., the surveyor observed the Nurse wash her hands in Resident #1's room [ROOM NUMBER] times during the administration of treatment to 3 wounds. With each observation, the Nurse turned on the warm water, wet her hands, applied soap to her hands and washed her hands for less than 15 seconds. The handwashings ranged in duration from 5 seconds to 12 seconds. The Nurse then rinsed and dried her hands. The surveyor reviewed the facility's Hand Washing Policy and Procedure which revealed that, The use of proper hand washing techniques has been noted to be the single most important procedure for preventing the spread of infections. The policy's handwashing procedure revealed that hands should be washed for 15-30 seconds. NJAC 8:39 - 19.4 - 1

Based on observation, interview and record review, it was determined that the facility failed to discard opened vials of medication in accordance with the manufacturer's specification. This deficient practice was identified in 1 of 1 medication rooms inspected and was evidenced by the following: On 7/16/15 at 2:30 p.m. in the presence of the Registered Nurse Unit manager (RN/UM), the surveyor inspected the medication room on the Estaugh Unit. The surveyor observed 1 vial of Purified Protein Derivative (PPD), a medication used to test for [DIAGNOSES REDACTED]. The vial was opened but was not dated as to when it was opened. The surveyor asked the RN/UM if she knew when the vial was opened. She stated that she did not know. The surveyor observed another vial with an open date of 4/21/15. The surveyor asked the RN/UM how long the medication was kept after it was opened. She told the surveyor that she thought it was good for ninety days. When the surveyor asked what she was going to do with the PPD vials, she told the surveyor that she would discard the vial that had no date and keep the one that was dated. The surveyor reviewed the package information from the manufacturer regarding storage of the PPD. This indicated that PPD should be discarded thirty days after it was opened because of possible degradation which could affect the effectiveness of the medication. The surveyor reviewed the facility's Medication storage policy on 7/22/15. This showed that deteriorated drugs should be removed but the policy did not address medications with limited shelf life once opened. NJAC 8:39 - 29.4 (f)

C# NJ Based on interviews, review of the medical records, and review of pertinent facility documents, it was determined that the facility failed to follow physician orders [REDACTED].#5). This deficient practice is evidenced by the following: Reference: New Jersey Statutes Annotated Title 45: 11-23 definition: "The practice of nursing as registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems,...and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist." Reference: New Jersey Statutes Annotated Title 45: Chapter 11-23 definition: "The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities..., under the direction of a registered nurse or licensed or otherwise legally authorized physician." The surveyor reviewed the medical records on 3/30/15 and 3/31/15. 1. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), an assessment tool dated 12/22/14, indicated that the resident was alert, oriented, and required assistance with activities of daily (ADLs). The Physician order [REDACTED]. The "Weight Tracking Form" indicated that on 1/1/15, the resident weighed 100.1 lbs, on 1/3/15, the weight was documented as 98.5, and on 1/4/15, the resident weighed 96.9 lbs. There was no documentation indicating that the physician was made aware of the aforementioned weights. An interview was conducted by the surveyor on 3/31/15, at 11:00 a.m., with the Unit Manager (UM). The UM explained that the doctor was aware of the resident's weight loss, therefore did not need to be notified when the resident lost more weight. The facility did not have a policy on physician notification. An interview was conducted by the surveyor on 3/31/15, at 12:30 p.m., with the doctor that wrote the order on 12/29/14. The doctor stated that she wanted to be notified daily if the resident weighed less than 105 lbs. NJAC 8:39-27.1(a)

Based on observation and interview, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 7/9/13 from 9:30 a.m. to 10 a.m., the surveyor observed the following in the presence of the Director of Dining Services (DDS): 1. The 3-compartment sink was in use. The surveyor asked for a test strip to check the concentration of sanitizing solution. The test strip did not detect the presence of sanitizing agent. When checked by the surveyor, the test strips had an expiration date of 6/15/13. The surveyor asked to see any other containers of test strips. When observed by the surveyor, the other 2 containers of test strips also expired on 6/15/13. No system was in place to verify an adequate concentration of sanitizer. 2. A Food Service Worker (FSW) was at a food preparation table. The FSW wiped the table top with a cleaning rag and then picked up a plate of cut-up pound cake. When interviewed, the DDS stated the pound cake was to be pureed for meal service. 3. The area surrounding a sink built into the end of the food preparation table was wet. A can of thickener and 2 boxes of gloves were observed on the table top near the sink. When observed by the surveyor, the bottom of the box of gloves was wet. 4. Open containers (2), 1 which contained soapy water for cleaning and 1 which contained a sanitizing solution, were on the shelf below the food preparation table within splashing distance to containers of food. 5. Multiple boxes of plastic wrap (a food contact surface) were on food preparation tables. The boxes were visibly soiled with a substance of unknown origin. 6. The wall behind a clean pot storage rack had a piece of paint dangling from the wall and multiple areas of chipped paint. On 7/10/13 from 9:30 a.m. to 10:30 a.m. the surveyor observed the following in the presence of the Director of Dining Services (DDS): 1. In the walk-in refrigerator, a pan which contained a piece of cooked roast beef was labeled opened on Monday 7/1 with an expiration date of Wednesday, 2 days later. The DDS stated the roast beef should be discarded. 2. In the walk-in refrigerator, multiple sheet pans which contained raw meats that had been pulled to thaw or received unfrozen were on sheet pans as opposed to deep bins. The sheet pan which contained 6 bags of thawed raw pork had a puddle of raw pork drippings approaching the top of the sheet pan. This sheet pan was on the 2nd shelf from the bottom next to and within splashing distance of the milk containers. 3. A FSW was at a food preparation table adjacent to the built-in food preparation sink preparing egg salad sandwiches. A pan of egg salad was inside a pan which contained ice cubes. The ice cubes were melting and water was overflowing on to and over the countertop. A squeegee was on the sink surround. A food covered immersion blender was inside the food preparation sink with the water running on it which then splashed onto the food preparation table. 4. A drawer below the food preparation table contained a hair net and unsealed disposable cup lids. The drawer was visibly soiled with food debris. 5. A stack of sheet pans was stored on the shelf below the food preparation table. The shelf and the sheet pans were visibly soiled with dried food debris. 6. Open containers (2), 1 which contained soapy water for cleaning and 1 which contained a sanitizing solution were observed on the shelf below the food preparation table. These containers were within splashing distance of containers of food. The concentration of the sanitizing solution was tested with a test strip and found to be greater than 400 ppm, a concentration which was toxic. The DDS stated she did not know who had filled the container of sanitizing solution. NJAC 8:39 - 17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to have an effective system in place to ensure that the prescribed amount of nutritional formula was provided to a resident who was dependent on a Gastrostomy Tube (GT) for nourishment. This deficient practice was identified for Resident #9, 1 of 1 residents reviewed for GT feedings, and was evidenced by the following: During the initial tour on 7/9/13 at 10:15 a.m., the Unit Manager (UM) said Resident #9 received GT feedings for nourishment. The surveyor observed Resident #9 in bed at that time. At the bedside, the surveyor observed a GT feeding pump with a 1000 ml bottle of Two Cal HN infusing. Approximately 200 mls of formula were left in the bottle. On 7/9/13 at 1:15 p.m. the surveyor observed the resident in bed with the GT feeding infusing at 90 ml/hr. A 1000 ml bottle was dated 7/9/13 at 11:15 a.m. which indicated the time this particular bottle of Two Cal HN was started. The 1000 ml bottle had approximately 800 ml of formula remaining. The 6/13 physician's orders [REDACTED]. On 7/3/13 the physician changed the tube feeding order to Two Cal HN 90 ml/hr from 6 a.m. to 6 p.m. In order for the total volume of 1080 ml to infuse in 24 hr or 12 hrs, the pump could not be shut off for any reason. Therefore, it would not be possible for the resident to receive the total volume as there would be occasions during the day when the pump would have to be shut off, such as during care. When interviewed on 7/10/13 at 2 p.m., the nurse stated the tube feeding was started at 6 a.m. and taken down at 6 p.m. daily, not when the total volume of formula had infused. On 7/10/13 at 2:05 p.m. the UM stated the nurses recorded the volume of tube feeding formula infused at the end of each shift onto the Medication Administration Records (MAR). The surveyor reviewed the 6/13 and 7/13 Enteral Protocol forms in the MAR indicated [REDACTED]. Documentation on the 6/13 Enteral Protocol form indicated the tube feeding formula was scheduled to run at 45 ml/hr continuously, with a total volume of 1080 ml per 24 hours. When reviewed, documentation on the 6/13 Enteral Protocol form indicated the total volume of tube feeding formula infused ranged from 672 ml to 1010 ml on 27 days during the month of 6/13. No documentation was found to indicate the the tube feeding had been turned off during the 27 days reviewed. (The total volume of tube feeding infused was not recorded on 6/29/13 and 6/30/13.) As of 7/9/13, the total volume of tube feeding documented as infused on the 7/13 Enteral Protocol form ranged from 650 ml to 1040 ml. There was no documentation found to indicate the tube feeding was held. Therefore, the resident was not receiving the total volume of feeding daily as ordered. When interviewed on 7/11/13 at 9:30 a.m., the Director of Nursing (DON) confirmed that the resident had not been receiving the total volume of tube feeding as ordered. The DON stated the 24 hour feeding rate in 6/13 and the 12 hour tube feeding schedule ordered on [DATE] did not account for times the tube feeding would be turned off as needed for care. Although the nurses had recorded the volume of tube feeding formula infused each shift, no one had added the volumes to see if the resident was receiving the prescribed 1080 ml/24 hrs. When interviewed on 7/11/13 at 11:40 a.m., the Registered Dietitian (RD) could not explain how they compensated for the additional formula needed to make up the volume not infused when the tube feeding was being turned off for care. The RD stated she had no knowledge that the amount of tube feeding formula infused was recorded each shift by the nursing staff and thought the nurses used the pump to account for the volume infused. NJAC 8:39 - 27.1(a)