Every finding on record at New Jersey Veterans Memorial Vineland

Incident 2684633Based on interviews, review of the medical records, and review of other pertinent facility documentation, it was determined that the facility failed to properly administer tube feeding as ordered, and to monitor a severely cognitively impaired resident (Resident #2) on tube feeding; which caused the resident to receive 800 milliliters (ml) of tube feeding in 4 hours instead of the physician ordered 60ml per hour (which should be 240 ml in 4 hours). Nursing staff found Resident #2 with symptoms of respiratory distress on [DATE] at approximately 10:30 PM., and their oxygen saturation (the amount of oxygen circulating in the blood) reading at 63% (healthy levels 95 - 100%) on room air. At that time, the facility called 911 emergency to transport Resident #2 to the hospital. The resident was then sent to the hospital and was admitted with diagnosis of aspiration pneumonia (pneumonia caused by liquid in the lungs). The resident expired in the hospital on[DATE]. This deficient practice was identified for 1 of 5 residents reviewed for tube feeding management.The facility's failure to implement their tube feeding policy led to Resident #2's expiration. This posed the likelihood of serious physical harm and psychological, injury, impairment, or death which resulted in an Immediate Jeopardy (IJ) situation.The IJ began [DATE], when LPN#1 did not thread the feeding tube through the pump and monitor the feeding pump to ensure it functioned properly. The facility was notified of the IJ on [DATE] at 3:58 PM. The facility submitted an acceptable Removal Plan (RP) on [DATE] at 3:03 PM. The surveyor verified the implementation of the RP on-site survey and determined that the immediacy for F693 was removed as of [DATE] at 10:56 AM. The evidence was as follows:A review of the facility's policy titled, Tube Feedings Nasogastric, Gastrostomy, Duodenostomy, Jejunostomy revised [DATE], included I. Policy: All tube feedings will be administered by a Registered Nurse or a License Practical Nurse in accordance with the procedures of the [name redacted]. [.] III. Procedure: A. All feedings through a nasogastric, gastrostomy, duodenostomy, or jejunostomy tube must be ordered by the physician on the Physician's Order Sheet. B. The Physicians Order must, in addition to diagnosis and indication for use include: 1. Name of feeding 2. Amount of each feeding 3. Amount of flush. 4. Route. 5. Rate of flow. 6. Frequency of administration [.] IV. Responsibilities: Pump Feedings A. Check order for type, amount, and frequency of feedings. [.] F. Check to ensure tube is secure in nose or stomach. G. Set feeding pump to appropriate rate of flow. H. Aspirate using piston syringe to ascertain that tube is in appropriate position. I. Return aspirant to stomach, duodenum or jejunum. J. Place feeding liquid in feeding bag and run through tubing to expel air. K. Insert end of feeding tubing into nasogastric, gastrostomy, duodenostomy, or jejunostomy tube. L. Start Feeding pump. M. Observe that pump is functioning properly and that resident is tolerating the feeding.A review of the Facility Reported Event (FRE) dated [DATE], submitted to the New Jersey Department of Health (NJDOH) included the following:Nurse hung the prescribed enteral feeding at 5:00 pm as ordered. At 9:00 pm, the nurse noted that 800 ml of feeding had infused to the resident; and that the resident was supposed to receive 60ml/hr. Feeding was immediately stopped. Resident was assessed by Registered Nurse (RN) and oxygen applied, Medical Doctor (MD) notified. Resident sent to emergency room (ER) for evaluation.A further review of the FRE indicated that Resident #2 was totally dependent on staff for all ADL care and had care plan for total ADL care. The resident had physician's order for enteral feeding and for the resident to not receive Nothing by Mouth (NPO). The tube feeding order stated to deliver the enteral feeding through a tube feed machine at the rate of 60 ml/hour for 8 hours with 2 hours rest.The facility provided a summary of the investigation related to the FRE, which stated that the Licensed Practical Nurse (LPN#1) did not follow policy for administration of enteral feeding, resulting in Resident #2's hospitalization. The summary further stated that LPN#1 did not set the enteral feeding rate and that she may not have connected the tubing to the pump correctly.According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to: unspecified dementia (significant, progressive decline in memory) and malignant neoplasm of the larynx (cancerous tumor forming in the voice box tissue).According to the comprehensive Minimum Data Set (MDS), an assessment tool, dated [DATE], Resident #2's Cognitive Patterns under Section C indicated that the resident was severely cognitively impaired.A Plan of Care with an Original Date of [DATE] and an Effect. Date of [DATE] contained a Problems/Strengths of [Resident name] has feeding tube R/T [related to] NPO status/Dysphagia . The goals were that the resident will have no complications from the feeding tube, and the resident will have no s/s (signs and symptoms) of aspiration . Interventions included but was not limited to Ensure flow rate of feeding is per orders. Maintain pump. Alert supervisor/maintenance if problem with pump arises.A review of Resident #2's Physician's Telephone Order dated [DATE] revealed the following physician's orders (PO):-Twocal HN 2.0 through PEG Tube, infuse continuous at 60ml/hour over 8 hours or till Total Volume (TV) infused.-480 ml through peg tube, start at 5PM and stop the feeding at 1AM.- Twocal HN run continuous at 60ml/hour over 9 hours up at 3 am and take down at 12 pm or until TV infused 520 ml (Total amount to be infused 1000 ml/24 hours)-see flush order as directed.On [DATE] at 08:55 AM., during the entrance conference, the Director of Nursing (DON) informed the surveyor that Resident #2 had expired in the hospital.On [DATE] at 11:05 AM., LPN#1 was interviewed via a phone call by the surveyor. LPN#1 stated that she could not fully remember what happened with Resident #2 and that she had never had an issue with Resident #2's feeding before.On [DATE] at 11:14 AM., the surveyor called CNA #1 for an interview. CNA #1 did not pick up and a voice mail was left requesting a phone call back.On [DATE] at 11:32 AM., RN#1 was interviewed via a phone call. RN#1 stated that on [DATE], CNA#1 called her to Resident #2's room where CNA#1 and LPN#1 both were. LPN#1 informed RN#1 that Resident #2 had received their entire 24-hour worth of feed as a bolus because the tubing for the feed was not hooked on to the pump.On [DATE] at 12:27 PM., the DON was interviewed, and she stated that she was unable to observe the tubing hung up by LPN#1 on [DATE] because by the time she was informed of incident, the tubing had been taken down. She further stated that she did a test after the incident on [DATE], to recreate what could have occurred with Resident #2's feeding. The DON stated that her test consisted of hooking up Resident #2's tube feeding which came in a 1000 ml bottle; and that when she hung a full tube feed formula and let it free flow by gravity, the bottle emptied in about an hour.On [DATE] at 2:39 PM., the DON stated that she does not think that LPN#1 threaded the tubing through the pump and that she believes Resident #2's tube feeding was free flowing. She further stated, From what I believe and read, I don't think anyone checked on Resident #2 as frequently as I probably would have. I think if we had found it earlier, perhaps we could have done something to help Resident #2 before they got the to the point they did.On [DATE] at 2:44 PM., the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and DON together, and questioned them regarding the amount of tube feed that Resident #2 received. The LNHA stated that Resident received 800 ml of tube feeding instead of the amount the physician ordered. The DON stated that all staff who were interviewed related to this incident were checked for competency, by asking them to point out what they observed in Resident #2's room regarding their tube feeding and how much feed was left in the bottle. She stated that all staff stated that the 200 ml of the tube feed formular was remaining in the bottle, and confirmed that 800 ml had infused into Resident #2.On [DATE] at 2:48 PM., the LNHA stated that LPN#1 was inattentive to her duty regarding Resident #2's tube feeding. When asked if LPN#1 followed facility policy or procedure on tube feeding, the LNHA stated, No, not at all, she did not follow policy or procedure. She didn't thread it through, and she didn't check on Resident #2 properly or at all.On [DATE] at 3:25 PM., CNA #1 returned the surveyor's phone call, and a phone interview was conducted. CNA #1 stated that on [DATE], she heard Resident #2 gurgling and coughing which lead her to alert LPN#1. LPN#1 told CNA#1 she would assess Resident #2 when she got a chance. CNA #1 went back to Resident #2's room because she continued to hear Resident #2 gurgle and cough. CNA#1 further stated that when she went back to the Resident #2's room, she noticed that the tubing from the tube feeding set up was dangling while the feeding pump was flashing with no sound. At this time, she alerted LPN#1 again and LPN#1 went into the resident's room and noted that the tubing was not hooked up to the feeding pump.The surveyor verified the implementation of the RP on-site survey and determined that the immediacy for F693 was removed as of [DATE] at 10:56 AM.N.J.A.C. 8:39-13.2

Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 12/11/25, it was determined that the facility failed to ensure staff wore the appropriate Personal Protective Equipment (PPE) when providing care for patients on Enhanced Barrier Precautions (EBP) for a resident (Resident #4). The facility also failed to follow their policy titled Enhancer Barrier Precautions. This deficient practice was identified for 1of 5 residents reviewed for infection prevention and was evidenced by the following:According to Resident #4's admission Record (AR), the resident was admitted with diagnoses that included but were not limited to: cerebral infarction (the death of brain tissue due to a prolonged lack of blood flow) , aphasia (a language disorder, that affects your ability to communicate by impairing speech, writing, and understanding spoken or written language), and dysphagia (difficulty swallowing).According to the Minimum Data Set (MDS), an assessment tool dated 12/3/25, Resident #4's Cognitive Skills for Daily Decision Making was a 3 which indicated that Resident #4's ability to make decisions regarding tasks of daily life are severely impaired.According to Resident #4's Plan of Care (POC) with a last reviewed date of 12/9/25, under Problems/Strengths stated: Resident #4 has feeding tube. Size: 18 French (FR). Rev. #3, under Interventions: Enhanced barrier precautions Rev. #3.On 12/11/25 at 10:10 AM, the surveyor observed the Registered Nurse (RN) who was taking care of Resident #4 enter their room to flush their feeding tube and disconnect them from their feeding without a gown. As the surveyor and RN were leaving Resident #4's room, the surveyor observed the Certified Nursing Assistant (CNA) entering the room with the proper enhanced barrier precaution PPE.On 12/11/25 at 11:23 AM, the surveyor interviewed the CNA who stated that she wore gown and gloves when providing care to Resident #4 because Resident #4 has a tube feed and per facility policy that is protocol. She further stated that there is a sticker outside Resident #4's door to indicate that Resident #4 required enhanced barrier precautions.On 12/11/25 at 11:24 AM, the surveyor interviewed the RN who stated that Resident #4 is a tube feed resident who is on EBP, and confirmed that she did not put on appropriate PPE. The RN also stated that she could recall the CNA having her PPE on correctly earlier in the day when providing care for Resident #4 while she did not.Review of the facility policy titled, Enhanced Barrier Precautions with a revision date of 3/13/24 under Purpose states: to follow CDC guidance in implementing the use of additional personal protective equipment (PPE), when providing high contact resident care to residents who have infection or potential for colonization of bacteria or fungi that may be Multidrug-resistant Organisms (MDRO), to reduce the spread of the organisms to other individuals in the facility through contaminated hands and clothing. Under Hight-Contact Resident Care Activities: Staff should implement the use of Enhanced Barrier Precautions (use of gown and gloves) when providing high contact resident care activities. High contact care activities include: .providing tube feeding, injecting or infusing medications, indwelling medical device care or use. Under Facility Process for Implementing the Use of Enhancer Barrier Precautions: The facility will educate staff regarding the use of Enhanced Barrier Precautions, including the need to perform hand hygiene and change PPE when providing care.N.J.A.C. 8:39-19.4(n)

Based on observation, interview, and document review, it was determined that the facility failed to consistently handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 08/19/2024 from 9:21 to 10:21 AM, the surveyors, accompanied by the Food Service Director (FSD), observed the following during the initial kitchen tour: 1. In the dry storage area, on the canned food rack, there was a dented 6-pound 10 oz can of tomato puree and a dented 46 fluid oz can of pineapple juice. There was a bin labeled dented cans in front of the canned food racks. The FSD stated that the expectation was that staff should have observed that cans were dented before putting it on the shelf. The FSD further stated that the expectation was that the cook should check the cans for dents prior to opening the cans. 2. In the dry storage area, on the top shelf of a five-tiered wire rack, there was an opened box of Styrofoam bowls that were not covered by clear plastic wrap and were exposed to the air. The FSD stated that Styrofoam products should have been covered. The FSD further stated that if the staff observed the Styrofoam to be opened, they would dispose of them. 3. In the bread storage area, there was a can opener laid on its side with unidentified debris on the tip of the blade. The FSD confirmed there was debris on the can opener blade used to open cans. The FSD stated he was unsure of when the can opener was last used. The FSD further stated after the can opener was used, it should have been cleaned. 4. In the bread storage area, on the third shelf from the top of a multi-tiered metal cart, there was an 18 oz opened bag of 16 count dinner rolls. The dinner rolls were exposed to the air. The FSD stated that all bread products should be sealed and not opened to air. The FSD stated that storeroom personnel and kitchen staff were responsible for discarding bread items. 5. In Walk-In Refrigerator #3/Produce Box, on the third shelf, there was a one-gallon jar of lite salad dressing that was previously opened and was undated. The FSD stated that the expectation was that salad dressing should have been dated when opened. 6. Observation of the reach-in/overflow ice cream freezer revealed there was no internal thermometer and no temperature log sheet. The Food Service Supervisor (FSS) confirmed that the reach in freezer did not have a thermometer in it. The FSD stated that there was no thermometer in the reach in freezer because ice cream mainly was stored in the walk-in freezer. 7. In the Walk-in Refrigerator #1, on the top shelf of a rolling rack, there was a black bag with a hole in it with meat exposed from the bag. The FSD stated there were approximately five pounds of ribs in the bag. The FSD stated that food should have been properly covered. 8. In the small storage room, on the second rack of a four-tiered wire rack, a one gallon previously opened jar of white vinegar had no dates. The FSD confirmed that the white vinegar jar was not dated. The FSD stated the expectation was that items should be dated when opened. 9. In the Food Prep Area, there was unidentified debris under the sink. The FSD stated debris should have been cleaned by staff. 10. In the Food Prep Area, there was an uncovered stand mixer that was in use. There were mixer parts stored inside the mixing bowl. The FSD stated the mixer had not been used yet for the day. 11. In the Food Prep Area, there was an uncovered deli slicer not being used with unidentified debris on the base of it. The FSD stated the deli slicer should be cleaned after each use. The FSD further stated that the deli slicer normally does not get covered since it is constantly being used. During a follow-up interview with the surveyors on 08/26/2024 at 9:44 AM, the FSD stated it was important to monitor canned goods for dents to prevent contamination. The FSD stated that it was important that meats and breads are covered so they do not become contaminated. The FSD further stated that it was important that all freezers have internal thermometers to ensure food was held at a proper temperature. The FSD stated that it was important for paper and Styrofoam products to be covered to prevent contamination. The FSD confirmed that the deli slicer was to be cleaned daily to prevent contamination. On 08/26/2024 at 11:16 AM, the surveyors, accompanied by the FSD, observed the following during the lunch tray meal line: 1. The Senior Food Service Handler (SFSH #1) was at the start of the lunch tray line with hair protruding out of the front and sides of their hairnet and was exposed. The FSD stated all hair should have been inside the hairnet, so that hair does not get into food. The FSD further stated that the supervisor was responsible for checking to ensure hair nets were being worn properly by staff. On 08/26/2024, the surveyors identified the following deficient practice for 2 out of 5 unit nourishment rooms where resident food was stored: At 10:38 AM, on the Liberty Unit in the presence of the Registered Nurse/Charge Nurse (RN/CN#1). There was an opened 48 fl. oz bottle of cranberry juice undated in the refrigerator. There were four unopened 48 fl. oz orange juice bottles with printed date of 8/7/2024 on top of lids in the nourishment room cabinets. The CN#1 stated she assumed date printed on lids were expiration dates. At 11:36 AM, on the Justice Court unit in the presence of CN #3, there was a 48 fl. oz orange juice bottle with a printed date of 8/7/2024 on the lid in the refrigerator. CN#3 stated the date printed on the lid indicated the expiration date. CN #3 further stated night shift was responsible for cleaning the nourishment room and the charge nurse was responsible for checking the dates on items. Review of facility food service policy titled, Handling of Damaged Food Products with a reviewed date of May 2019 revealed under Procedure, Generally, dented, bulging, or otherwise damaged canned products are included in the definition of damaged products. 1. whenever an item is discovered that is damaged, spoiled, or of question-able quality in the department, notify the Supervisor and manager in charge of the area, when applicable. Review of the undated facility food service policy titled, Infection Control revealed under Personnel, 6. Hair is effectively restrained. Revealed under Equipment Environment, Generally equipment and contact surfaces are cleaned and sanitized between uses. Review of the facility food service policy titled, Storage with a reviewed date of August 2005 revealed under Purpose, The objective is to maintain high quality food at approved temperature and conditions to ensure retention of quality, safe condition and nutritive value. Revealed under Philosophy, 3. Food is covered when stored on shelves and off floors. 4. Temperature records are maintained daily on refrigerators and freezers. Review of the facility food service policy titled, Storage of Meats with a reviewed date of August 2005 revealed under Purpose, The purpose of this procedure is to help provide safe, high-quality meats for use in hospital meals by ensuring proper storage of the raw meat products. Revealed under Procedure, Once issued, the production area wraps, labels, and dates any meat item for return to the storage area. Review of the facility checklist titled Cooks Main Kitchen Sanitation Inspection Checklist revealed under Description, 1. Kettles, Mixers, Braiser and Drain Trough are clean, sanitized. 3. Blenders, Food Processors, Slicers, and Chopper are clean and sanitized. 13. Can Openers, Base, and Blades are clean and good order. 15. Floor area and walls are clean and free of hazards. Review of the facility food service policy titled, Cleaning and Sanitizing the Slicer with a revised date of August 2005 revealed under Procedure, Note: Slicer should be cleansed after each use. Bacteria from raw meat could be transferred to cooked meat if slicer is not cleansed properly. Review of the undated facility nursing services policy titled Nourishment Room Maintenance Policy revealed under 6. Food Safety, Stock Rotation: Implement a first in, first-out (FIFO) system for all food items stored and ensure all food items are within use by dates. Labeling: Ensure all food items are clearly labeled with the use by dates and removed if out of date. NJAC 8:39-17.2(g)

Complaint #: NJ174817 Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to develop a comprehensive, person-centered care plan to include physician prescribed interventions for a wound treatment and oral antibiotic administration that were implemented after a resident-to-resident altercation. This deficient practice was identified for 1 of 12 residents (Resident #186) reviewed for abuse. This deficient practice was evidenced by the following: During the initial tour of the facility on 08/19/2024 at 11:52 AM, the surveyor observed Resident #186 in their room, who was being fed by a Certified Nursing Assistant (CNA) at the bedside. The resident closed their eyes and did not respond to the surveyor when spoken to A review of Resident #186's Face Sheet revealed that the resident had diagnosis which included but were not limited to: unspecified dementia, unspecified severity, with agitation, and Post-Traumatic Stress Disorder (PTSD). A review of Resident #186's Quarterly Minimum Data Set (MDS), an assessment tool dated 06/20/24, indicated that the resident's Brief Interview for Mental Status (BIMS) score of 03 out of 15, revealed that the resident was severely cognitively impaired. A review of the Interdisciplinary Progress Notes (IPN) revealed an entry dated 04/05/24 at 4:45 AM, indicated that .At approximately 03:26 AM heard commotion on couch in day room. This nurse and LPN (licensed practical nurse) went to resident and separated him/her from another resident. Upon skin assessment in his/her room noted skin tear to rt. (right) arm measuring 2.5 cm (centimeters) x 3.0 cm x 0.1 cm, 100% red tissue with scant serosanguineous drainage . A further review of Resident # 186's IPN revealed an entry dated 04/05/24 at 5:17 AM, Resident and another resident were sleeping against each other on couch appeared both residents startled each other upon waking up. Upon reviewing footage with supervisor and security both residents hit each other and other resident bit this pt.'s rt. (right) arm acquiring skin tear. On 04/05/24 at 2:42 PM, .Resident with a 6 cm round discoloration on right forearm with two skin tears with flaps in middle .No swelling and no pain noted. Skin tears associated with incident with another resident. Skin tears cleaned, ABT (antibiotic) applied and four steri strips applied and DSG (dressing) applied. New order for [sic.] days of oral ABT ordered . A review of Resident # 186's Physician's Orders revealed an order dated 04/05/24 at 4:58 AM, for Tx (treatment) to: right arm cleanse with NSS (normal saline solution) apply Triple Antibiotic Ointment cover up with foam dressing times 7 (seven) days Treatment once daily. A second order was reviewed dated 04/05/24 at 5:15 PM, for Augmentin (Amoxicillin/Clavulanate Potassium 875 mg (an oral antibiotic) (milligrams)-125 mg tablet 1 (one) tab oral for 7 (seven) days twice daily for prophylaxis (action taken to prevent disease) for skin tear. The medication was scheduled for administration at 9:00 AM and 9:00 PM. A review of Resident # 186's Medication Record revealed that Augmentin (Amoxicillin/Clavulanate Potassium 875 mg-125 mg tablet 1 (one) tablet oral for 7 (seven) days twice daily for prophylaxis for skin tear was documented that the medication was administered to the resident as ordered from 04/05/24 through the completion date of 04/12/24.A review of the resident's Treatment Record revealed that the entry for Tx to right arm cleanse with NSS apply Triple Antibiotic Ointment cover up with foam dressing times 7 (seven) days treatment once daily was administered to the resident as ordered from 04/05/24 through the completion date of 04/11/24. A review of Resident #186's Care Plan revealed that there was no documented evidence that the facility initiated a resident centered care plan that identified that the resident sustained a skin tear to their right arm because of a resident-to-resident altercation which resulted in the need for the resident to receive a physician prescribed oral antibiotic and wound treatment. A review of the Supervisory Nursing Services Twenty-Four Hour Report dated 04/05/24, revealed that Resident #186 was involved in a resident-to-resident altercation on 04/05/24 during the 11-7 shift. It detailed that the resident was asleep on the couch in the day room, startled and swung R (right) arm and resident grabbed and bit his/her R arm. The resident sustained ST (skin tear) on R arm 2.5 x 3 x 0.1 cm. Skin protocol in place . A review of the Nursing Services Twenty-Four Hour Report dated 04/06/24 revealed that Resident #186 was involved in a resident-to-resident altercation on 04/05/24 (11-7) ABT (antibiotic) for skin tear . On 08/22/2024 at 9:13 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that if any interventions were placed, or a new treatment was ordered as a result of a resident-to-resident altercation, it should be reflected on the Care Plan by the Registered Nurse Assessment Coordinator (RNAC). The ADON further stated that a nurse or a supervisor could type into the care plan and notify the RNAC that they made some adjustments to the Care Plan. On 08/22/2024 at 9:43 AM, the surveyor interviewed the Director of Nursing (DON) who stated that when a resident-to-resident incident occurred, if a wound treatment was required due to an injury, it should get carried over into the interdisciplinary progress notes and the RNAC then transcribed the occurrence into the Care Plan and included an antibiotic or treatment if they were ordered. On 08/22/2024 at 11:43 AM, the surveyor interviewed the RNAC who stated that if she were present in the facility, the nursing staff called her to alert her of a need to update the Care Plan. The RNAC stated she also reviewed the resident's Interdisciplinary Progress Notes to determine if there were changes. The RNAC reviewed Resident #186's Care Plan in the presence of the surveyor and stated that the only update that she saw in response to the resident's involvement in a resident-to-resident altercation was on 04/07/24, when the Pain Care Plan was updated to include, If resident becomes drowsy return him/her to his/her room. The RNAC stated that was a mistake and should have instead been included in the resident's behavioral care plan. The RNAC stated that she was aware that the resident did receive a bite and was getting an antibiotic. The RNAC stated that she would have thought that they would have added the antibiotic and treatment for the bite to the resident's Care Plan, but she just could not find it on there. The RNAC further stated, Honestly, we were never told that we had to put skin tears or wound treatments on the Care Plan. On 08/22/2024 at 1:03 PM, the surveyor interviewed the Chief Executive Officer (CEO) who stated that her expectation was for the Care Plan to be updated with new interventions or revisions soon after an occurrence. The CEO stated that in morning meeting we look at all new antibiotic starts, and make sure that it was care planned for. The CEO clarified that the process to include wound treatments and antibiotics on the Care Plan had only been in place for approximately three months or so and should have been reflected on the resident's Care Plan. On 08/27/2024 at 10:53 AM, the surveyor interviewed Licensed Practical Nurse (LPN #3) who stated that the Care Plan was updated by the Charge Nurse. LPN #3 stated that when she served as Charge Nurse, she reported any changes in resident status to the Nursing Supervisor, and then passed on the information on the 24-Hour Report, and at shift change. LPN #3 further stated that the Nursing Supervisor reported a change in resident status to the RNAC, who was responsible to update the Care Plan. On 08/27/2024 at 1:06 PM, the surveyor interviewed the CEO regarding Resident #186's Care Plan that was not updated to include both a physician prescribed antibiotic and wound treatment. The CEO stated that there was a lack of communication that did not occur. The CEO stated that any Registered Nurse could update the Care Plan. The CEO further stated that the portion of the Incident Case Report that prompted a conversation to be had between the Nursing Supervisor and the RNAC to update the care plan was missed. A review of the facility policy, Resident Care Planning-RAI (Resident Assessment Instrument) 27-37.3 (Revised September 2023) revealed the following: The care plan must describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The effectiveness of the care plan must be evaluated from its initiation and modified quarterly and as necessary; communication regarding care plan changes is ongoing among interdisciplinary team members. A review of the facility policy, Resident Accidents and Incidents Reporting (Revised: June 2024) revealed that Responsibilities of the Nursing Supervisor: .Review current care plan and indicate if any changes are needed to reduce the risk of the incident occurring in the future. Endorse Care Plan initiatives or changes to RNAC. NJAC 8:39-11.2

Based on record review, interviews, and facility policy review, the facility failed to ensure: 1. one resident (Residents (R) R82) and/or their representative out of a survey sample of 34 was invited to participate in their quarterly care plan meetings; and 2. the care plan policy included inviting residents/representatives to quarterly care plan meetings. This failure would affect all residents and/or representatives who are scheduled for quarterly care plan meetings. Findings include: Review of a document provided by the facility titled Resident Face Sheet, indicated R82 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R82's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/22 indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R82 was cognitively intact. During an interview on 01/02/23 at 10:45 AM, R82 stated he did not get invited to quarterly care conferences. Review of a document provided by the facility titled Department of Military and Veterans Affairs.New Jersey Veterans Memorial Home at Vineland, dated 03/28/22, indicated R82's representative was invited to his annual care conference which was scheduled on 04/28/22. Review of a document provided by the facility titled Interoffice Memorandum, dated 03/28/22, indicated R82 was invited to his annual care conference scheduled on 04/28/22. During an interview on 01/04/23 at 8:47 AM, Social Services stated families and residents were only invited to the care conferences on an annual basis and not quarterly. During an interview on 01/04/23 at 9:11 AM, the Administrator stated residents and representatives were invited during the annual or significant change care plan meetings and was not sure about being invited on a quarterly basis. During an interview on 01/04/23 at 9:41 AM, Medical Records confirmed she only sends out the invitations to residents and/or their representatives on an annual basis and has never sent out on a quarterly basis. During a subsequent interview on 01/04/23 at 10:31 AM, Medical Records brought in information regarding R82. Medical Records confirmed R82 was only invited to his annual care conference scheduled for 04/28/22. She confirmed there were a total of four care conferences held for the resident in 2022 and the resident and/or his representative were not invited to three of the four care conferences. Review of a document provided by the facility titled Resident Care Planning, dated 04/19, indicated .To assure [sic] each resident/family member/guardian an opportunity to participate in the development of the resident's individualized care plan. There was no information in the facility's policy which indicated the resident and/or the representative would be invited to the quarterly care plan conference. NJAC 8:39-13.2(a)

Based on resident council interview, staff interview, and record review, the facility failed to obtain food preferences and provide menus for meal selection for five residents (Resident (R)185, R113, R68, R8, and R101) out of nine residents reviewed for food preferences in a total sample of 34 residents. These deficient practices resulted in the residents who prefer to eat in their rooms instead of the dining room not having the opportunity to choose foods from the menu but instead received the main course. Findings include: On 01/03/23 at 10:43 AM, R185 stated he has mentioned to the dietary department during food committee meetings that residents who prefer to eat in their rooms instead of the dining room do not choose other menu options. R185 stated no changes have been made to provide a way for the residents eating in their rooms to choose from the menu. Review of the Menu Planning Committee Meeting, dated 08/16/22, revealed [R185] stated the residents didn't have much a choice and it seemed to him that portions were smaller. During the Resident Council interview on 01/04/23 at 11:23 AM, R113, R68, R8, R101, and R185 stated how residents who prefer to eat in their rooms don't have many menu choices as they would if they ate in the dining room. The residents in the Resident Council interview agreed that during COVID it was nice when the staff would come by and provide menu options but since COVID restrictions have been lifted more menu options are given in the dining room. During an interview on 01/05/23 at 9:55 AM, the Food Service Supervisor (FSS) stated the menus are posted on the units and the nursing staff has menus available for the residents. The residents can ask for the alternate entree if they don't like what they are served. The residents can tell the nurses and then the nurses can call the kitchen. Some residents have the direct number to the dietary department. He also stated during COVID life enrichment staff would go to the resident rooms and review the menu with the residents but once the residents were able to return to the dining room they proceeded to continue like they had before COVID. NJAC 8:39-17.1(c) NJAC 8:39-17.2(b) NJAC 8:39-17.4(a)

Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to offer one (Resident (R) 82) of five residents (and/or their representatives) reviewed for flu/pneumonia vaccinations in a total sample of 34 residents, the opportunity to be vaccinated with the Prevnar (PVC20) in accordance with nationally recognized standards. The facility failed to update their most current policies to reflect current standards on pneumococcal vaccinations. This practice had the potential to increase the risk for residents over [AGE] years of age and/or with immunocompromising conditions who had not been vaccinated per CDC guidelines to contract pneumonia. Findings include: Review of a document provided by the facility titled Resident Face Sheet indicated R82 was admitted to the facility on [DATE]. R82 was [AGE] years or older at the time of admission. Review of an untitled document provided by the facility (lists vaccinations received), indicated R82 received PCV13 on 04/01/14. There was no other information that the resident had received PPSV23 or more recently PCV20. During an interview on 01/02/23 at 3:08 PM, the Infection Control Preventionist (ICP) stated she was unable to locate additional pneumococcal information for R82. During an interview on 01/02/23 at 3:42 PM, the ICP stated she was unaware of CDC's newest recommendations for the pneumococcal vaccines. Review of Center of Disease Control (CDC) website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, last reviewed 01/24/22, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older. The tables below provide detailed information . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults [AGE] years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended. For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete . The CDC guidelines went into effect on 10/21/21 per recommendations from the Advisory Committee on Immunization Practices (ACIP). Review of a document provided by the facility titled Immunization dated 02/21 indicated .Consent for preventable vaccine administration which encompasses both consent and refusal of influenza, pneumococcal vaccines will be obtained at the time of admission from the resident, guardian or power of attorney for healthcare.The seasonal influenza vaccine will be offered to all residents to all residents of the facility between October 1 through March 31 of the current year.The pneumococcal vaccination shall be offered to all residents [AGE] years of age or older and residents with high risk factors. The written consent from the resident. guardian or power of attorney for healthcare competed [sic] at the time of admission that reflects both consent and refusal of annual vaccination will be reviewed. There was no information on the facility's policy which would reflect current CDC recommendations on the pneumococcal vaccines. NJAC 8:39-19.4(i)

Based on observations, record review, interview with facility and audiology clinic staff and resident, and review of facility policies, the facility failed to ensure that one of two residents (Resident (R) 17) reviewed for hearing out of a total sample of 34 residents received proper treatment to maintain the use of hearing aids. This failure increased the risk of other residents' hearing aids not being maintained and functional. Findings include: Review of the medical record revealed a diagnosis on the Face Sheet tab for (R 17 of impacted cerumen (ear wax) bilaterally. Review of undated audiology notes titled Progress Notes found in medical records storage indicated a hearing aid evaluation/assessment was performed. R17 completed Hearing Handicap Inventory for Adults with a score of 32 indicating candidacy for hearing aids. Review of the section of Care Plan revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/22 and an MDS with an ARD of 11/28/22 revealed an admitted [DATE] and that R17 had moderate hearing difficulty that required the speaker to speak at a higher level and the use of a hearing aid. Further review of this MDS revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15 indicating R17 was cognitively intact. Review of the medical record under the Care Plan tab revealed there was no care plan for the use of the hearing aids. Review of the medical record under the Orders tab revealed physician orders initiated on 06/30/22 for insert bilateral hearing aids in the morning and remove at HS [bedtime] or 6:00 AM to 9:00 PM. Change hearing aid filters one time per month on the 30th. Review of the medical record under the Treatment Administration Record (TAR) revealed the hearing aid filters had not been changed for the time periods of 12/08/22 to 01/07/23, 11/18/22 to 12/07/22, 10/08/22 to 11/07/22, 09/08/22 to 10/07/22, 08/08/22 to 09/07/22 and 06/08/22 to 07/07/22. On 07/30/22 there is a notation of the filter change. Review of medical record under the Progress Notes tab revealed on 12/31/22 at 7:06 AM resident refused hearing aids. Not applied. Resident stated they haven't been working and that he has told his daughter and doctor already. Interview with R17 on 01/03/23 at 9:14 AM indicated when questioned why his left fist was clinched he stated he was holding the hearing aid in his left hand so he can hear the surveyor speak. R17 stated if both hearing aids are in his ears, he cannot hear, so he takes one out. R17 went on to indicate he received the hearing aids for free about six months ago. R17 stated its frustrating because the hearing aids don't work. Interview with Licensed Practical Nurse (LPN) 1 on 01/04/23 at 9:40 AM revealed we change the filters if we can, if not, we send them out. LPN 1 went on to state that she often worked with R17 and was not familiar with changing filters on the hearing aids each month on the 30th. Interview with the Medical Services Associate/Scheduler at the Audiologists office on 01/05/23 at 10:30 AM who had fitted and assessed R17 for hearing aids, indicated that not replacing the screens on the hearing aid would affect the function of the hearing aid. Interview with the Director of Nursing (DON) and Administrator on 01/05/23 at 11:40 AM revealed there is no policy or procedure for the care and maintenance of hearing aids at the facility. NJAC 8:39-27.5(a)(b)

Based on record review, observations, staff and resident interviews, review of Centers for Disease Control and Prevention (CDC) guidance, and facility policy review, the facility failed to ensure infection control measures were appropriately implemented and maintained for: 1. one resident (Resident (R62), who had a diagnosis of influenza A, out of four residents reviewed for Transmission Based Precautions (TBP) and 2. one resident (R55) out of two residents reviewed for respiratory care out of a total sample of 34 residents. Findings include: 1. Review of a document provided by the facility titled Resident Face Sheet, indicated R62 was admitted to the facility on [DATE]. Review of a document provided by the facility titled Interdisciplinary Progress Notes (IDT) for R62, dated 12/30/22, indicated the resident was sent to the hospital. The IDT notes dated 01/01/23 revealed R62 was readmitted back to the facility. Review of hospital documents provided by the facility titled Flowsheet Print Request, dated 01/01/23, indicated R62 had a diagnosis of influenza A. Review of a document provided by the facility titled Progress Notes Medical Provider Progress Note, dated 01/03/23, indicated R62 was positive for Influenza A on 12/30/22. Review of a document provided by the facility titled Physician Telephone Order, dated 01/03/23, directed the facility staff to place R62 under droplet precautions. During an observation conducted on 01/03/23 at 1:50 PM, a CDC poster was on the outside of R62's door which indicated R62 was on droplet precautions and directed staff to don (put on) eye protection and a face mask prior to entering into the resident's room. During an observation on 01/03/23 at 12:50 PM, the Speech/Language Pathologist (SLP) was observed in R62's room. The SLP was not wearing eye protection. She was observed wearing a gown, gloves, and a surgical mask. The SLP came to R62's door and confirmed she was to don eye protection but had not and had overlooked it. During an interview on 01/05/23 at 10:21 AM, the Director of Nursing (DON) stated she met with the SLP and notified the Rehabilitation Director the need for an inservice concerning TBP with the rehabilitation staff. 2. Review of a document provided by the facility titled Resident Face Sheet, indicated R55 was admitted to the facility on [DATE] with a diagnosis of anoxic brain injury (lack of oxygen to the brain) and use of a tracheostomy (trach-surgical opening in the windpipe to facilitate breathing). During an observation on 01/02/23 at 11:33 AM, R55's suctioning machine was sitting on his right side of his bed. Observed was an open package titled Suction Catheter 16 Fr (French) Mini Tray, which then had tubing inserted in the open package and the other end was connected to the suctioning machine. Suctioning removes thick mucus and secretions from the trachea and lower airway that cannot be cleared by coughing. During an observation on 01/03/23 at 9:59 AM, R55's suctioning machine was sitting on his right side of his bed. Observed was an open package titled Suction Catheter 16 Fr (French) Mini Tray, which then had tubing inserted in the open package and the other end was connected to the suctioning machine. An interview with R55's Family Member (FM)1 confirmed the tubing had been used to suction secretions from the trach During an observation on 01/03/23 at 10:45 AM, R55's used suctioning tubing was still connected to the suction machine and the other end was sitting in the same open package. During an interview on 01/03/23 at 1:48 PM, Licensed Practical Nurse (LPN) 2 stated he disposed of the tubing located in R55's room after FM1 asked him to throw it away. LPN 2 stated the tubing to the suction machine was considered one time use. During an interview on 01/03/23 at 2:09 PM, the Infection Control Preventionist (ICP) stated the used tubing connected to the suctioning machine was considered a potential infection control issue since the tubing was to be used one time and then thrown away. During an interview on 01/05/23 at 10:21 AM, the DON stated all nurses were aware to dispose of the suction machine tubing after one use. Review of the Centers for Disease Control (CDC) dated 05/22 indicated . Droplet transmission is, technically, a form of contact transmission, and some infectious agents transmitted by the droplet route also may be transmitted by the direct and indirect contact routes. However, in contrast to contact transmission, respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient, generally over short distances, necessitating facial protection. Respiratory droplets are generated when an infected person coughs, sneezes, or talks. Review of a document provided by the facility titled ISOLATION - CATEGORIES OF TRANSMISSION BASED PRECAUTIONS, dated 02/21, indicated .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection.ln addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets larger than 5 microns in size that can be generated by the individual coughing, sneezing, talking.Examples of infections requiring Droplet Precautions include.influenza. NJAC 8:39-19.4(a)(k)

Based on observation, interview, review of medical records, and other facility documentation, it was determined that the facility failed to maintain a medication error rate of less than 5%. This deficient practice was identified for 1 of 2 nurses observed administering medications to 2 of 6 residents (Resident #112 and #225) on 1 of 2 units, totaling 2 errors out of 33 medication opportunities that resulted in a medication error rate of 6% and was evidenced by the following: On 04/06/21 at 9:10 AM, the surveyor observed a Registered Nurse (RN #1) administering medications to Resident #112. Resident #112 had finished eating breakfast before the surveyor and the RN entered the room. The RN proceeded to administer Resident #112 all of their medications, including [MEDICATION(S)] (a diabetes medication); Resident #112 took all of the medications. The RN left the room and signed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] The surveyor obtained and reviewed the April 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor also obtained and reviewed the MAR, which additionally noted, Caution: take 15 minutes before meals. The medication was scheduled for administration on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 04/06/21 at 9:20 AM, the surveyor observed the RN administer medications to Resident #225. When the surveyor and RN entered the resident's room, the resident was eating breakfast and had completed 85% of his/her meal. The RN administered all medications to the resident, including one tablet of [MEDICATION(S)] (an antacid); Resident #225 took all the medications together. The RN left the room and signed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] The surveyor obtained and reviewed the April 2021 POS for Resident #225, which included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor obtained and reviewed the MAR, which additionally noted, Caution: Take on an empty stomach. Avoid antacids for 30 minutes. Take 2 hours after other medications. The medication was scheduled for 7:30 AM. During an interview with the RN on 04/06/21 at 9:34 AM, the surveyor inquired if the medication [MEDICATION(S)] was appropriately given to Resident #112. The RN replied, It was given after breakfast, and it should be given before breakfast. It was not given properly. During the same interview, the surveyor also inquired about when the medication [MEDICATION(S)] for Resident #225 should be given. The RN stated, It should be given before breakfast, but the meal was already here. It should be given at 7:30 AM. During an interview with the surveyor on 04/07/21 at 12:41 PM, the Director of Nursing Services stated if the RN gave the medications late or not as ordered, the RN should've notified the physician and obtained an order to either hold (the medication) or give it at another time. If the medication should be given on an empty stomach, it should be given on an empty stomach. The RN should've notified the physician for orders. A review of the facility's Medication/Treatment Administration policy with a revised date of January 2020 indicated 5. Medications must be given within one-hour before/after the time ordered. You MUST adhere to AC [before meals] and PC [after meals] times. If the time you are administering this medication is beyond the hour before or after, call the physician before administering for further orders. NJAC 8:39 - 29.2(d)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to: a.) ensure that the urinary catheter drainage bag (drainage bag) was correctly stored to prevent the spread of infection for Resident #75, 1 of 4 resident's reviewed for the use of an indwelling urinary catheter; and, b.) follow proper hand hygiene practices during a tube feeding administration for Resident #187, 1 of 1 resident reviewed for tube feeding. This deficient practice was evidenced by the following: Reference: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers for Hand Hygiene and COVID-19, updated 5/17/2020 included, Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. It further specified the procedure for hand hygiene which included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. 1. On 04/05/21 at 9:34 AM, the surveyor, observed Resident #75 lying in bed. The resident's drainage bag, which was not contained in a privacy bag, and tubing were lying on the floor next to the side of the bed that faced the door. When interviewed at that time, Resident #75 did not respond to any of the surveyor's questions. On 04/06/21 at 9:01 AM, the surveyor observed Resident #75 lying in bed. The resident's drainage bag, which was not contained in a privacy bag, and tubing were lying on the floor next to the side of the bed that faced the door. The surveyor made the same observations later on at 10:09 AM. According to the Resident Face Sheet, Resident #75 was admitted to the facility with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS), an assessment tool, dated 1/28/21, revealed Resident #75 was identified as severely cognitively impaired, required use of an indwelling catheter, and was dependent on staff for activities of daily living. The MDS further revealed that Resident #75 had impaired use of the upper extremity on one side and impaired use of the bilateral lower extremities. During an interview with the surveyor on 04/07/21 at 9:28 AM, the Certified Nursing Assistant (CNA #1), responsible for caring for Resident #75, stated that she provided incontinent care to the resident and changed the drainage bag as needed. CNA #1 further stated that the resident's drainage bag was attached to the bed and should not touch the floor for infection control. During an interview with the surveyor on 04/07/21 at 11:44 AM, the Licensed Practical Nurse (LPN #1) stated the CNA was responsible for emptying the drainage bag and recording the amount in the medical record. LPN #1 further stated that the resident's drainage bag should be kept below the bladder and off the floor at all times. During an interview with the surveyor on 04/07/21 at 12:39 PM, the Director of Nursing (DON) stated the resident's Foley drainage bag should be covered and kept off the floor. A review of the facility's Indwelling Catheter Care policy, dated February 2020, indicated positioning the drainage bag below the level of the bladder and off of the floor. The surveyor reviewed the facility's undated Infection Control Guidelines for the Prevention of Indwelling Catheter-Associated Urinary Tract Infections provided by the Chief Executive Officer (CEO). The policy reflected under the Closed Sterile Drainage section that the collection bag or tubing should not be allowed to touch the floor or other contaminated objects. 2. On 04/07/21 at 11:03 AM, the surveyor, observed LPN #2 administer a tube feeding (liquid form of nourishment delivered directly into the stomach through a flexible tube) to Resident #187. The surveyor observed that the LPN gathered the tube feeding supplies and then washed her hands at the resident's sink for 12 seconds before putting on gloves. The surveyor further observed that after the LPN administered the tube feeding, she disposed of her gloves and washed her hands for seven seconds. During an interview with the surveyor on 04/07/21 at 11:16 AM, LPN #2 stated the process for handwashing included applying friction with soapy hands for 30 seconds. LPN #2 further stated that the importance of proper handwashing was to prevent infections. During an interview with the surveyor on 04/08/21 at 9:28 AM, the Registered Nurse (RN) Charge Nurse stated the handwashing process included lathering soapy hands together for 30 seconds. The RN Charge Nurse further noted that the importance of proper handwashing was to prevent the spread of germs between staff and residents. During an interview with the surveyor on 04/08/21 at 9:49 AM, the DON stated the handwashing process included scrubbing hands together with soap for no less than 15 seconds. The DON further noted the importance of proper handwashing was to prevent the spread of infection. During an interview with the surveyor on 04/08/2021 at 12:50 PM, the CEO stated that the LPN should have either washed her hands for 15 seconds or used alcohol-based hand sanitizer. A review of the LPN's Infection Prevention Hand Washing Competency, dated 03/11/2020, included Scrubs hands vigorously for at least 30 seconds, with an evaluation result of YES. A review of the facility's Hand Hygiene Guidelines policy, with a reviewed date of February 2021, included under the Hand Washing Procedure section, Moisten the hands and wrists, apply a heavy lather of soap and Use friction, rubbing one hand upon the other for 15 seconds. NJAC 8:39-19.4(a)(1)(5)

Based on observation, interview, and record review, it was determined that the facility failed to prepare and administer medications in accordance with professional standards of clinical practice. This deficient practice was identified for 1 of 38 residents (#181) reviewed and was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practiceof 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 caresupportive 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, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practiceof nursing as a licensed practical nurse is defined as performing task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorativecare, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 5/28/19 at 10:42 a.m., the surveyor observed pills in the medication cup on Resident #181's dresser. The medications consisted of three white oval pills, one white round pill, and one brown oval capsule. Resident #181 verbalized that the medication was his/her 12 o'clock pills. A review of the Minimum Data Set, an assessment tool used to facilitate the management of care dated 4/22/2019, revealed that the resident's cognition was intact. The surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the resident at 10:50 a.m. on 5/28/19. The LPN identified the pills in the medication cup as three [MEDICATION NAME] tablets (an over the counter medication used to treat an intolerance to dairy products), one [MEDICATION NAME] tablet (a medication used to promote digestion), and one Immodium tablet (an over the counter medication used to treat diarrhea). The LPN continued to mention that the medications were scheduled to be administered at 11:30 a.m., acknowledged that he had pulled the medications prior to the scheduled administration time and stated that he should not have left them at the bedside. The Physician Orders, dated and time stamped 5/13/19 at 1:00 p.m., reflected that the resident was to receive [MEDICATION NAME] 5 mg tablet, one tablet oral half hour before meals for Gastro-[MEDICAL CONDITION] Reflux Disease (a digestive disorder); [MEDICATION NAME] HCL (Immodium) 2 mg capsule, one capsule oral before meals for diarrhea; and [MEDICATION NAME] Original 9000 unit tablet, three tablets oral three times a day with meals for lactose intolerance. On 5/28/19 at 12:12 p.m., the LPN and the surveyor reviewed the Medication Administration Record [REDACTED]. On 6/04/19 at 01:47 p.m., the surveyor reviewed the LPN's Medication Pass Observation checklist dated 1/28/19 and 1/29/19 that indicated medications were to be prepared as they were administered and the patient was to be watched until all medications were swallowed. The facility's Drug Administration Procedures indicated that medications were not to be pre-poured and were to be administered promptly after being prepared. On 6/04/19 at 2:00 p.m., the surveyor reviewed the facility's Medication Pass Protocol that specified that the nurse was to never leave medications next to or with a resident, was to always administer medications himself/herself, and was to make sure the resident had swallowed the medications before leaving the resident. NJAC 8:39-11.2(b)

Based on observation and record review, it was determined that the facility failed to provide an environment that enhanced the self esteem and self worth of residents during dining. This deficient practice occurred with 2 of 5 residents (Residents #65 and #188) observed during meals and who resided on 1 of 6 units and was evidenced by the following: 1) On 4/6/18 at 12:19 p.m., the surveyor observed Resident #65 seated in a chair at the table in the dining room. There was a Certified Nursing Assistant (CNA) seated at the same table assisting another resident. Resident #65, who was holding a spoon in his/her right hand, used the spoon to scoop up food that had dropped onto the table. On 4/9/18 at 12:05 p.m., the surveyor observed Resident #65 seated at the table in the same dining room. The resident had a plate of food in front of him/her. There was a can of soda on top of the food on the plate. The resident lifted the can of soda off of the plate. There was food on the bottom of the can. Resident #65 raised the can to his/her lips and licked the food from the bottom of the can. There were no staff seated at the table but there were staff in the room collecting the trays from other residents. According to the care plan for the potential for nutritional deficit, Resident #65 may need reminders often throughout the meal. 2) On 4/9/18 at 11:55 a.m., the surveyor observed Resident #188 seated at the table in the dining room. The resident's lunch was on the table. The resident's eyes were closed. There was a CNA seated at the same table assisting another resident with their meal. At 11:58 a.m., Resident #188 was awake and attempting to cut the sandwich with a spoon. The same CNA was at the table, with her back to Resident #188 while she was assisting another resident with their meal. At 11:59 a.m., Resident #188's eyes were closed and his/her fingers were on the plate, in the food. At 12:07 p.m., the resident dropped part of a sandwich onto his/her pants. The resident scooped up the sandwich from his pants and began eating it. From 12:10 p.m. to 12:14 p.m., Resident #188 unsuccessfully attempted to pick up a large piece of sandwich with the spoon three times. The staff member that was seated at the same table at this time, observed two of the resident's attempts to eat the sandwich with the spoon but did not assist the resident. At 12:20 p.m., Resident #188 was still trying to cut the sandwich with a spoon. On 4/9/18 at 12:27 p.m., Resident #188 was seated at the table with his/her eyes closed. At 12:28 p.m., the resident opened his/her eyes then closed them again. At 12:32 p.m., a staff member came to the table and woke up the resident who still had approximately half of the meal left to eat. At 12:34 p.m., the same staff member asked the resident if he/she was ok as the resident touched the spoon to the top of a roll on the plate then put the empty spoon in his/her mouth. At 12:35 p.m., a Licensed Practical Nurse (LPN) asked Resident #188 if he/she wanted the sandwich cut. The resident agreed. Once the LPN cut the sandwich, Resident #188 began eating the food. At 12:44 p.m., the resident had consumed the sandwich and was holding the cup of ice cream to his/her mouth before the resident found the spoon and used it to eat the ice cream. According to the most recent quarterly Resident Assessment Instrument (RAI) dated 2/22/18, Resident #188 was cognitively impaired and required supervision with eating. According to the care plan for the history of/potential for weight loss, Resident #188 was on aspiration precautions and should be supervised during meals. NJAC 8:39-4.1(a)(12)

Based on observation, interview and record review, it was determined that the facility failed to offer a substitute meal to a resident who refused the lunch meal that was served. This deficient practice occurred to 1 of 5 residents (Resident #177) observed during meals and who resided on 1 of 6 nursing units and was evidenced by the following: On 4/06/18 11:47 a.m., the surveyor observed that Resident # 177 was seated in a recliner in the dining room. A companion served and prepared the resident's meal which included pureed beef stew and pureed bread. At 11:53 a.m., the companion fed the resident a spoonful of the pureed beef stew. When the resident tasted it he stated, EWW. The resident continued to refuse the pureed beef stew. When interviewed by the surveyor at 11:57 AM, the companion stated that the resident does not like the pureed beef stew or the pureed bread. The companion stated that the resident's family picked this meal from two choices. The companion also stated that she didn't know if there was anything else they could send as a substitute for the pureed stew. She stated that the resident had a big breakfast and that he will be receiving a boost drink that she will mix with a magic cup to make a shake. When interviewed by the surveyor on the same day at 1:13 p.m., the FSD stated that there were substitutes for the pureed beef stew and pureed bread. The FSD stated that there was pureed ravioli and pureed chicken available for that meal. The FSD stated that there was either pureed chicken or turkey available at each lunch in addition to the main pureed entree and the substitute pureed entree. A review of the lunch meal menu for 4/06/18 revealed that pureed cheese ravioli with tomato sauce was the substitute entree for the pureed beef stew. When interviewed on 4/06/18 at 1:45 p.m., the Director of Nurses and the Chief Executive Officer (CEO) stated that the companion should have reported the resident's refusal to the nurse and not assume that there was no alternate meal to substitute for the meal that Resident #177. According to data provided by the facility, the training of the companion assisting the residents at mealtime did not include what the companion should do if the resident expressed a dislike of the meal that they were provided. NJAC 8:39-27.1(a)

Based on observations, interview, and policy review on 4/11/18 in the presence of facility management, it was determined that the facility failed to maintain commercial clothes dryers in safe operating condition from fire by maintaining the dryers free from excessive lint accumulation. This deficient practice was evidenced by the following: At 12:00 p.m., the surveyor observed that 3 of 5 commercial clothes dryers in the main laundry had an excessive accumulation of lint in the lower lint clean-out chambers. These dryers were identified as #6, #7, and #8. The lint accumulation consisted of several sheets of lint the had accumulated on the lint screen and fallen to the bottom due to weight. In an interview, at the time, the laundry attendant stated that she cleans the chambers out 3 times each day but does not maintain a log to show compliance. A review of the facility's Housekeeping/Laundry policy for cleaning and sanitizing washers and dryers stated that all dryers were to be cleaned of lint daily and that the RSW worker shall document completion of the task on the Log Sheet. NJAC 8:39-31.2(e), 31.7(e)

Based on observation, interview and record review, it was determined that the facility failed to follow a physician's order for the provision of oxygen to a resident. This deficient practice occurred to 1 of 27 residents whose physicians' orders were reviewed and was evidenced by the following: According to the medical record, Resident #6 had a physician's order dated 3/9/17 to receive Oxygen at 3 liters per minute through a nasal cannula. This physician's order also indicated that the Oxygen could be increased to a maximum of 10 liters per minute to keep the resident's oxygen saturation level at 90% to 95% for episodes of Shortness of Breath. The medical record also revealed that Resident #6 was receiving Hospice services since being readmitted to the facility on [DATE]. On 4/20/17 at 10:10 a.m., the surveyor observed that Resident #6 in bed and receiving oxygen through a nasal cannula. The surveyor also observed that the oxygen concentrator was set to deliver 2 liters of oxygen per minute to the resident. When interviewed by the surveyor on 4/20/17 at 10:23 a.m., the Licensed Practical Nurse (LPN) assigned to care for this resident stated that he thought that the resident was ordered to receive 2 liters of oxygen per minute. This LPN stated that he was not sure if the resident was supposed to receive oxygen all of the time or only when necessary (PRN). This LPN stated that he would have to look up the resident's oxygen order in the Medication Administration record (MAR) but thought that the oxygen was to be provided PRN. At 10:24 a.m., the LPN stated that he could not find an oxygen order for Resident #6 in the MAR and added that he would have to look it up in the physician's orders. After reviewing the resident's physician's orders, the LPN told the surveyor that Resident #6 should be receiving 3 liters per minute of oxygen. The surveyor then requested that the LPN observe the resident and the amount of oxygen that the resident was receiving at that time. At 10:25 a.m., the surveyor and the LPN entered the resident's room. The surveyor observed that Resident #6 was in bed with oxygen being delivered at 2 liters per minute through a nasal cannula. The LPN stated that the oxygen was set on 2 liters per minute instead of 3 liters per minute. The surveyor then observed the LPN turn a dial on the oxygen concentrator. When interviewed at that time, the LPN stated that he turned the resident's oxygen up to 3 liters per minute then left the room. At 10:27 a.m., the surveyor observed the LPN standing at the nurses station looking through a binder. The observed that this LPN did not obtain the oxygen saturation level on Resident #6, who had received the incorrect amount of oxygen. When interviewed by the surveyor in the presence of the Director of Nurses (DON) at 1:23 p.m. on 4/20/17, the LPN stated that Resident #6's oxygen had been set at 2 liters per minute and it should have been at 3 liters per minute. This LPN also stated that he would have applied a mask to deliver oxygen to Resident #6 if the resident's oxygen saturation level was less than 93%. The LPN then stated that he had not checked the oxygen saturation level on Resident #6 earlier that day when it was discovered that the resident had been receiving 2 liters of oxygen instead of 3 liters, as ordered by the physician. When interviewed by the surveyor on 4/20/17 at 1:28 p.m., the DON stated that the professional staff should be monitoring to ensure that Resident #6 was receiving 3 liters of oxygen as ordered by the physician. The DON also stated that the professional staff should be checking and documenting the resident's oxygen saturation every shift. According to the resident's Treatment Administration Record (TAR) for 2/27/17 through 3/14/17, the professional staff were documenting their [DIAGNOSES REDACTED]ils every shift from 3/9/17 through 3/14/17 indicating that Resident #6 was receiving 3 liters of oxygen per minute. There was only one entry of the resident's oxygen saturation level documented on the 3:00 p.m. to 11:00 p.m. shift on 3/10/17. There was no documentation in the TARs from 3/15/17 through 4/20/17 to indicate that the professional staff ensured that Resident #6 was receiving the physician ordered amount of oxygen and that the resident's oxygen saturation levels have been maintained at 90% to 95%. NJAC 8:39-27.1

Based on observation, interview and record review it was determined that the facility failed to administer medications in accordance with acceptable standards of clinical practice. This deficient practice was identified for 2 of 4 nurses who administered a total of 30 medications to 6 residents on 2 of 3 observed units. There were 3 errors which resulted in a medication error rate of 10% and was evidenced by the following: 1) On 4/17/17 at 8:55 a.m., the surveyor observed a Licensed Practical Nurse (LPN) administer medications to Resident #18. At that time, the LPN stated I'm a little behind on the [MEDICATION NAME] (a medications used to lower blood sugar). According to the Medication Administration Record, [REDACTED]. The medication was scheduled to be administered at 7:30 a.m. and contained additional instructions for the resident to take the medication 15 minutes prior to the meal. At the time of the observation, the resident had completed the breakfast meal. (Error #1) 2) On 4/17/17 at 9:10 a.m., the surveyor observed the same LPN administer medications to Resident #31. The LPN poured 15 cubic centimeters (cc) of [MEDICATION NAME] (a laxative) 10 Grams/15 cc into the resident's open can of orange soda. The resident swirled the can of soda, took a sip and put the can down on the bedside cabinet. At that time, the LPN asked the resident You're going to finish that, right? The resident responded yes. The LPN then left the room without waiting until the resident had consumed the full dose of medication which had been diluted in the soda. According to the MAR, the [MEDICATION NAME] was permitted to be mixed in a full glass of water or juice to improve its flavor. (Error #2) 3) On 4/17/17 at 9:20 a.m., the surveyor observed a second LPN administer medications to Resident #12. The LPN crushed the resident's scheduled medications which included a Calcium 600 mg/Vitamin D 400 mg dietary supplement tablet. The LPN mixed the crushed medications in approximately 2 Tablespoons of pudding and administered it to the resident. Following the administration, the LPN did not offer any additional fluids to the resident. According to the MAR indicated [REDACTED]. The facility's Medication/Treatment Administration Policy also indicated that when a cautionary statement instructed that a medication was to be given with food, the nurse was to offer the resident four crackers and four ounces of milk or pudding. (Error #3) NJAC 8:39-29.2(d)

Based on observation, interview and record review, it was determined that the facility failed to consistently provide a resident with a nutritional intervention that had been initiated to address weight and nutritional concerns. This deficient practice was identified for Resident #25, 1 of 3 residents reviewed for weight and nutritional concerns, and was evidenced by the following: According to the medical record, Resident #25 had [DIAGNOSES REDACTED]. Resident #25 had an order to receive double portions of pureed foods and honey thickened liquids. According to the care plan developed by the staff for a history of weight loss and the potential for further weight loss and dehydration related to [MEDICAL CONDITION]'s disease and swallowing impairment, Resident #25 was to be offered extra fluids snacks and snacks throughout the day. On 4/20/17 from 9:31 a.m. through 10:30 a.m., the surveyor observed Resident # 25 seated in a Broda chair in the solarium of the Honor's Circle nursing unit. The surveyor observed that the resident's arms, legs and torso were in constant motion. During this observation period, activities were being provided to the resident however, no snacks or beverages were offered to the resident. The refrigerator located in the pantry of the Honor's Circle nursing unit contained multiple containers of apple sauce, Boost pudding, Boost Plus shakes, Boost Glucose Control shakes, sugar free pudding, regular pudding, pitchers of juice as well as honey and nectar thickened dairy product. In addition to those items, there were five bowls labeled pureed sandwiches for Resident #25. The date of 4/19/17 was written on the lids of each bowl as well as the time of day that the pureed sandwiches should have been offered. At approximately 12:15 p.m. on 4/20/17, the surveyor observed Resident #25 seated in a Broda chair. The resident was awake and all of the his/her extremities and torso were in constant motion. When interviewed by the surveyor at this time, the Certified Nursing Assistant (CNA #1) who was assigned to provide care and services to Resident #25, stated that she did not provide the resident with any snacks that day. CNA #1 stated that although she was assigned to provide care to the resident, CNA #2 was assigned to feed him. CNA #1 added that because CNA #2 was assigned to feed the resident, then CNA #2 should have provided snacks to the resident. When interviewed by the surveyor at 12:25 p.m., CNA #2 stated that she was assigned to feed breakfast and lunch to Resident #25, it was the responsible of CNA #1 to provide snacks to the resident. When interviewed by the surveyor on 4/20/17 at 12:33 p.m., the Director of Nursing (DON) stated that it was the responsibility of the assigned CNA, which would be CNA #1, to provide snacks to Resident #25. On 4/20/17 at 2:00 p.m., the surveyor observed Resident #25 seated in a Broda chair in his/her room. The resident was being fed a pureed sandwich by CNA #3. When interviewed at this time, CNA #3 stated that the resident will receive a can of Boost pudding after the sandwich. According to data provided by the facility, Resident #25 was to receive a pureed sandwich from the kitchen at 2:00 p.m., 8:00 p.m. and on the 11:00 p.m. to 7:00 a.m. shift. Another snack sheet indicated that Resident #25 received a pudding in the evening. The Nutritional Supplement List indicated that Resident #25 was to receive one can of Boost pudding four times a day and two cans of Boost pudding on the 11:00 p.m. to 7:00 a.m. shift. When interviewed by the surveyor on 4/20/17 at 2:35 p.m., the facility's Administrator (LNHA) stated that there was no order for Resident #25 to receive pureed sandwiches. The LNHA stated that there were too many systems being used by the staff to track and provide snacks to the residents. The LNHA stated that the system for tracking which residents get snacks and the time that the snacks should be provided needs to be streamlined. When interviewed at 2:50 p.m., the LNHA stated that Resident #25 used to be able to ambulate and would go into the pantry to get his/her own food from the refrigerator. The LNHA stated that Resident #25 receives double portions now and no longer needs between meal snacks. NJAC 8:39-27.1

Based on observation, interview and record review, it was determined that the facility failed to follow infection prevention precautions for the appropriate care of residents' respiratory equipment. In addition, the facility did not follow appropriate hand hygiene procedures after having direct resident contact. This deficient practice occurred to 1 out of 2 residents (Resident #15) reviewed that had respiratory equipment and 1 out of 4 nurses observed on the medication pass observation and was evidenced by the following: 1) According to the facility's policy titled Care of Respiratory Equipment, under the paragraph of Trach Aerosol/Nebulizer Equipment, the facility staff should change all nebulizer unit tubing weekly or PRN (as needed). This policy also reflected that after administering a nebulizer treatment to the resident, the nebulizer fluid chamber must be disassembled, rinsed with sterile water and allowed to dry thoroughly between treatments. On 4/12/17 at 8:15 a.m., 10:02 a.m., and 1:25 p.m., the surveyor observed that a piece of white tape on Resident #15's nebulizer unit tubing was dated 4/2/17, ten days prior to this observation. On 4/13/17 at 8:15 a.m., 8:50 a.m., and 9:50 a.m., the surveyor made subsequent observations of the nebulizer unit tubing with the same tape and the same date of 4/2/17. In addition, on 4/18/17 at 1:20 p.m. and on 4/20/17 at 9:05 a.m. and 2:15 p.m., the surveyor observed that Resident #15's nebulizer machine had not been disassembled and there was a small amount of clear fluid and droplets present in the nebulizer fluid chamber. A review of the medical record revealed that Resident #15 had a physician's orders [REDACTED]. In addition, there was an order for [REDACTED]. When interviewed by the surveyor on 4/18/17 at 1:20 p.m., the Licensed Practical Nurse (LPN #1) stated that Resident #15's [MEDICATION NAME] nebulizer times were 9:00 a.m., 2:00 p.m., and 9:00 p.m. and that the [MEDICATION NAME] nebulizer were scheduled for 9:00 a.m. and 9:00 p.m. When interviewed by the surveyor on 4/20/17 at 2:10 p.m., LPN #1 stated that nebulizer fluid chambers are rinsed out at the sink, dried, and placed in a labeled bag after each use. LPN #1 added that the nebulizer unit tubing was to be replaced every week and the nebulizer fluid chambers were to be cleaned after each use. LPN #1 then stated to the surveyor, You just reminded me that I have to clean the resident's nebulizer. 2) On 4/17/17 at 9:15 a.m., during medication administration, the surveyor observed a Licensed Practical Nurse (LPN) pause to wash her hands. After applying the soap, the LPN proceeded to wash her hands under the stream of running water for 13 seconds. The LPN then dried her hands and turned off the faucet with a paper towel. According to the facility's Infection Control Handwashing Competency, the handwashing procedure to be followed was to first apply soap, then scrub both hands for a minimum of 30 seconds, followed by rinsing both hands thoroughly under running water. In a follow up interview on 4/18/17 at 3:30 p.m., the Assistant Chief Executive Officer confirmed that staff should wash their hands vigorously for at least 30 seconds away from the stream of running water. NJAC 8:39-19.4(k)

Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a consistent manner. This deficient practice was evidenced by the following: On 4/18/16 from 9:36 a.m. to 11:15 a.m. the surveyor observed the following in the presence of the Food Service Director (FSD): 1. The 3 compartment sink was in use. The surveyor asked the Food Service Worker (FSW) to check the concentration of sanitizer in the 3 compartment sink. The FSW dipped a test strip into the sanitizing solution. When compared to the color grid on the test strip container, the test strip color indicated the concentration of sanitizer was less than 200 ppm. The manufacturer's sanitizer specifications for adequate sanitization was a range from 200 ppm to 400 ppm. When interviewed, the FSW stated the color on the test strip was okay for adequate sanitization. The FSD who stated the color on the test strip was lighter than 200 ppm told the FSW to empty the sanitizing compartment and refill it. The directions for the mixing of the sanitizer was approximately 8 ounces into 32 gallon of water. The FSW later brought a new test strip over to the surveyor who was in a different area of the kitchen. The FSW stated that she had refilled the sanitizing compartment of the 3 compartment sink and tested the concentration of the sanitizer. When observed by the surveyor, the color of that test strip appeared to be in the color range between 200 ppm to 400 ppm. The surveyor walked back over to the sanitizing compartment of the 3 compartment sink. The surveyor observed 1 side of the solution in the sanitizing compartment was clear and the other side appeared to be a pink color. The surveyor asked for a test strip and dipped it into the clear part of the sanitizing solution. The test strip indicated the concentration of the solution was less than 200 ppm. The surveyor asked if the solution had been stirred after adding the sanitizer into the water. The FSD stirred the solution and retested the concentration. The sanitizing strip indicated the concentration was less than 200 ppm and not adequate for sanitization. 2. In the walk-in refrigerator, a roast turkey breast was in a pan on a shelf covered with plastic wrap. There were 2 facility labels on the plastic wrap. The first label was dated on 4/14/16 and had a use by date of 6/14/16. The second facility label was dated 4/17/16 and had a use by date of 4/24/16. When interviewed, the FSD stated the turkey breast had been roasted on 4/14/16 and was a leftover. The FSD said he told a cook to freeze the roasted turkey breast on 4/17/16 after it had been in the refrigerator for 3 days. The FSD stated the facility policy for ready to eat foods and leftovers was 7 days. The FSD stated the use by date of 4/24/16 exceeded the use by day of 7 days. On 4/19/16 from 9:45 a.m. to 9:55 a.m. the surveyor observed the following in the presence of the Food Service Director (FSD) in the main dining room kitchen: 1. The dish machine was in use for breakfast clean-up in the main dining room kitchen. The dish machine was a single tank stationary dish machine that relied on hot water temperatures for adequate sanitization. During the first 2 observations of the dish machine running, the final rinse temperature gauge reached 180 degrees Fahrenheit and immediately shut off. During the third observation the dish machine rinse cycle began at 180 degrees Fahrenheit and immediately dropped to 160 degrees. The dish machine specification for adequate sanitization indicated during the final rinse, the final rinse temperature gauge must read 180 degrees to 195 degrees Fahrenheit for 10 seconds. On 4/19/16 at 1:10 p.m. the surveyor observed the following in the presence of the FSD in the upper dining room kitchen: 1. The dish machine was in use for clean-up of the lunch meal. The surveyor observed 2 FSWs on the clean side of the dish machine. When asked by the surveyor who was working on the soiled side of the dish machine, FSW #1 stated that the FSW #2 was assigned to the soiled side of the dish machine. FSW #2, who was wearing an ace bandage under a glove, was unloading clean items from a dish machine rack on the clean end table of the dish machine onto a cart. When interviewed at that time, FSW #2 stated he had washed his hands and put clean gloves on prior to the surveyor entering the kitchen. When asked how he washed his hands, FSW #2 stated he had washed his hands while wearing the ace bandage. The FSD told FSW#2 to take off his gloves and ace bandage and wash his hands. FSW #2 unwrapped the ace bandage and tucked it under his armpit while washing his hands. On 4/20/16 at 12:50 p.m. the surveyor observed a residents' lunch tray cart outside the dayroom on Honor Circle. Facility staff members removed 2 resident lunch trays to serve to residents from this cart. When the doors to this lunch tray cart were opened, the surveyor observed multiple lunch trays from residents that had already been eaten. NJAC 8:39 -17.2(g)

Complaint #: NJ 617 Based on interview and record review, it was determined that the facility failed to thoroughly investigate an allegation of abuse, and failed to protect residents from potential future abuse while an investigation was in process. The facility risked further abuse of the involved resident and to care-resistive residents on 1 of 6 nursing units for a period of 121 days. This was identified for Resident #30 for an incident that occurred on [DATE]. This deficient practice was identified for 1 of 3 closed records reviewed and was evidenced by the following: The surveyor reviewed a facility Progress Note (PN) dated [DATE] and a continuation of the note on [DATE] (date discrepancy), that stated the Charge Nurse (CN) was alerted to go to the resident's room by the Hospice Aide. The CN found the resident spitting and being combative with care and attempts to redirect the resident were unsuccessful. A 1x1 cm skin tear was documented to the right forearm and a 4.2 x 1.5 cm skin tear was documented to the left forearm. The CN "noted what appeared to be blood on the bedsheets." The CN note revealed the resident "continued to be aggressive and wrists/arms had to be held in order to be cleansed and dressed." The CN note revealed "it took 3 caregivers to apply dressings to arms." The surveyor reviewed offsite records and a statement from the Food Service Director (FSD) that stated Resident #30 was held down by 2 staff members on [DATE] while wound care was being provided. The FSD, who was an eyewitness to the incident, reported the observation to the Unit Manager (UM) and the Director of Nursing (DON) on the day of the incident. On [DATE] at 9:51 a.m. the surveyor interviewed the DON. The DON at the time of the survey had been the FSD at the time of the incident and was the witness to the occurrence. Also present in the room was the current Assistant Director of Nursing (ADON) who was the DON at the time of the incident on [DATE]. They said the FSD/current DON had reported the incident to the UM and DON/current ADON on the day it occurred, including a written statement. The FSD/current DON said that after the incident occurred she went on leave and returned in August and observed that the 3 staff members involved in the [DATE] incident with Resident #30 were still working on the same nursing unit. She said she questioned this and was told the nursing staff was still following up on the incident. The FSD/current DON said she returned to the nursing department as the DON in [DATE] and discovered that the [DATE] incident had not been fully investigated or reported; all the paperwork had not been completed; the staff had not been removed from the unit; and no disciplinary actions had been processed for the involved staff. The DON said she immediately investigated the incident, removed the staff from the unit, filled out all the proper forms and notified the administrative staff. The staff member who was the DON at the time of the incident (now the ADON) said she had spoken with the UM and told her to process administrative actions for the 3 involved employees. She said no immediate action had been taken against the staff except for inservice training. When asked what should have happened at that time, the ADON said the staff should have been removed from the unit which was the facility protocol during an investigation. The ADON said she had not reviewed the resident's medical record as part of her investigation. She said the involved staff told her the resident was bleeding onto the bedding and staff were trying to clean up the resident's skin tears. The DON, who was the witness to the event, said she did not see blood on or around the resident and that the resident calmed as soon as the staff left him/her alone. According to a "Staff Meeting Roster," there was an inservice conducted by the UM titled "Combative Residents: Nurse to be informed of a combative resident to ensure safe care." The Certified Nusing Assistant (CNA) involved in the incident signed the inservice form on [DATE], the Charge Nurse (CN) and the Hospice aide signed on [DATE], and the medication nurse Registered Nurse (RN) signed on [DATE] or [DATE] (unclear handwritten documentation.) At the bottom of the form was a handwritten notation "sensitivity training will be set-up on dealing with difficult residents and sensitivity" to be conducted by the Staff Development RN. When interviewed on [DATE] at 9:55 a.m., the UM said all staff were inserviced on [DATE]. The UM could not provide an explanation why the sign-in forms were not consistent with this statement. The UM said the inservice consisted of the following: with an aggressive resident the staff should not intervene due to the risk of escalation or injury; staff should walk away after ensuring resident was safe and come back later; go to the supervisor if resident was soiled or bleeding; may need to go to the doctor if necessary. The UM said the facility policy was to leave a resident alone if combative/resistive to care. The UM provided the surveyor with the handout she went over with the staff titled "Aggressive/Agitated/Difficult People" that had been developed by the staff development nurse. Included was the following: do not crowd or corner resident; avoid touching a resident in crisis; do not restrain, force or rush the resident. An inservice was held with the involved RNs on [DATE] by the staff development nurse titled "Aggressive Behavior; Elder Sexuality" and also included a review of "How to handle the aggressive resident." An inservice was held by the staff development nurse with the involved CNA on [DATE] titled "Dealing with Aggressive/Agitated Residents." On [DATE] the (current) DON completed the "Unusual Incident-Sentinel Event Report" form which indicated an internal investigation was to be conducted for the [DATE] incident with a report to be submitted to administration (as this had not been done until the November date.) The "Preliminary Conclusion" section stated the following: "Incident of inappropriate physical contact involving nursing staff to resident. Incident to be investigated and report to follow." Statements following this report included the following: a. The UM indicated she was instructed on [DATE] to conduct inservice training on the 2 RNs involved in the incident. The UM indicated the "impromptu" inservice was conducted on [DATE]. (The inservice records were in conflict with this statement.) The UM said the DON did not instruct her further. The UM said the FSD directed her to complete administrative action on the "employees mentioned." (The 2 RNs were mentioned in the statement but not the CNA.) This statement was written on [DATE]. b. The Hospice aide statement was dated [DATE] and indicated she rolled the resident over on [DATE] to provide pericare on the resident's buttock, which was sore and red. The aide indicated that when she began to wash the resident's buttocks, Resident #30 became agitated, started scratching and became combative. There was no description of how the resident's agitation/combativeness manifested itself or what the resident was scratching. The aide indicated that when she rolled the resident back, she noticed a skin tear and believed the resident had hit the siderail. The aide indicated she received an inservice on [DATE] that indicated staff were to obtain the help of another staff member when the resident became agitated. On [DATE] a "Narrative Report" was completed for the [DATE] incident involving Resident #30. This narrative was completed by the Assistant Chief Executive Officer (ACEO) for Clinical Services. The report indicated the ACEO was informed of the request for administrative action for the 3 involved employees on [DATE] at approximately 10:30 a.m. The ACEO then requested information regarding the incident and the staff were "immediately reassigned from the nursing unit and an investigation initiated." Included as part of the report were interviews with staff which revealed the following: a. The CN said she was the first person to assess the resident's wounds and that due to the resident's resistance, she requested assistance from the medication nurse RN and the CNA. The CN said she had to "hold (his/her) arms" to bandage the resident. b. The medication nurse RN said the CN asked for her help with Resident #30 as the resident would not let the CN bandage the skin tears on the arms. (Note the medication nurse RN statement dated [DATE] indicated she had been the first nurse to assess the residents wounds and it was she who requested help from the CN and the CNA. These 2 statements did not match.) This staff member denied anyone placing the towel over the resident's mouth. c. The CNA said she was asked by the CN to help her and the medication nurse RN with caring for the resident's skin tears. The CNA said she was asked by the CN to hold the resident's right arm down as the CN attempted to bandage it. The CNA said the resident continued to resist the staff and was kicking, spitting and hitting and dug his/her fingernails into her arm and she called for help. The CNA said the resident was thrashing and moving his/her head back and forth in bed. This staff member denied anyone placing the towel over the resident's mouth. d. The UM said she immediately inserviced all 3 employees on dealing with combative/resistive residents and informed the DON of the incident. The UM said she was directed to submit a request for administrative action on all 3 employees. e. The ADON said she directed the UM to complete the request for administrative action for the 3 involved employees and submit this to the nursing office. f. The DON said she received "the incident report with the statement and following review forwarded the report to administration." g. The Hospice aide said the resident was cooperative until she turned the resident over and began washing the buttocks. The aide said the resident became "highly agitated and began flailing (his/her) hands and arms." The aide said she noticed a skin tear on the hand and wrist area. (Note: no skin tear was identified on the hand area in the medical record, employee statements or incident investigation.) An interview with the resident was attempted by staff at that time but the resident was not able to participate "related to (his/her) cognitive impairment and memory recall deficit" per the narrative report. The [DATE] report indicated the 3 involved staff members remained re-assigned off the nursing unit where this incident occurred and were being monitored as per facility policy. Administrative action was submitted for all 3 employees involved in the incident. Administrative action was also submitted for the DON and ADON for failure to report the incident per facility protocol and the UM for "excessive delay in carrying out an order" for the administrative actions on the 3 involved employees. A Facility Reporting Incident Date & Analysis Yield (FRIDAY) form, a State-required form sent to inform the State Agency (SA) of potential CNA abuse of a resident, was completed (but not sent to the SA) on [DATE] by the DON who was in place at the time of the incident. The DON stated she had reminded the UM "several times over the last few months" to process the administrative actions for the involved staff members of the [DATE] incident with Resident #30. On [DATE] at 11:17 a.m. the current DON said the involved staff members were reassigned to other nursing units beginning on [DATE]. The facility "Resident Safety Policy and Procedure-Resident Abuse" indicated the following: a. Employees would receive initial and annual training on abuse prohibition practices. According to inservice records, the 2 involved RNs received annual training on [DATE] and the CNA received training on [DATE] and additional training on abuse on [DATE]. b. The facility "will investigate all alleged and/or suspected events that may constitute abuse and an investigative report of the finding, disposition of the victim, conclusions and subsequent administrative actions filed as a matter of record." c. "Investigations pertaining to employee to resident require the resident be protected from further harm. Incidents involving employees shall require the employee be reassigned to another work area. The employee shall not have contact with the resident throughout the course of the Administrative Investigation." The 3 involved staff were not reassigned until [DATE]. d. "Employees administratively reassigned shall have their performance monitored by the respective shift charge nurse, impromptu via observation of the employee's interactions with those cognitively impaired residents assigned and conduct discreet inquiries with those deemed capable and note for the record weekly, or as needed, whether any concerns were presented. Monitoring shall continue throughout the period of the employee's reassignment and for two weeks following their return to their original assignment." Staff were not reassigned until [DATE]. e. "The Supervisor on Duty will initiate an investigation of all reported incidents of alleged or suspected abuse, conducting inquiry and soliciting written statements of anyone having, or thought to have, knowledge of the occurrences or who may have been in the vicinity at the time of the incident. The Supervisor on Duty shall reference the Unusual Incident-Sentinel Event procedure to guide the investigative/reporting process." The Unusual Incident-Sentinel Event form was not completed until [DATE] and the employee statements were incomplete. f. "Alleged violations/substantiated unusual incidents" should be reported to Administration and notification via a "Reportable Event Record" should be completed/forwarded to the Department of Health. This incident was not reported to the state agency. The facility policy titled "Resident Incident Case Reporting Form" indicated the following: a. A "Preliminary Unusual Incident-Sentinel Even Report" form should be completed with 24 hours of any incident which is deemed reportable. This completed form should be "forwarded to the Office of Administration by 10 a.m. on the first business day following the incident." This form was not found. b. "A written Final Investigative Narrative, including employee statements utilizing the FRIDAY form, must be forwarded to Administration within 72 hours of the incident." The final narrative was not completed until [DATE]. Due to the facilitiy's failure to thoroughly investigate the above incident and follow established protocols immediately following the incident, the residents were placed at risk for further abuse and an Immediate Jeopardy was identified. The Immediate Jeopardy began on [DATE] when the facility failed to investigate an allegation of abuse and follow the regulation and facility protocol to protect all residents from further abuse. The Administrator, Assistant Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 11:50 a.m. The Immediate Jeopardy was removed and the deficient practice corrected on [DATE], after the facility removed the accused staff from access to Resident #30 and other residents with resistive behavior, and conducted a thorough investigation of the incident and took appropriate action per facility policy. The Plan of Correction (POC) submitted by the facility on [DATE] at 1:50 p.m. included the following actions: a. Corrective actions for Resident #30: at the time of the survey the resident was deceased . Inservicing was conducted in [DATE] with all involved staff members; in [DATE] with the 2 RNs and in [DATE] with the CNA. Disciplinary actions were processed for the 3 involved staff members (in [DATE]) and staff were removed from the nursing unit on [DATE]. b. Identification of other residents having the potential to be affected by the same deficient practice: All residents with documented behaviors were reviewed and combative/resistant to care were identified. Their care plans were reviewed and interventions identified. c. Measures put into place/systemic changes made to ensure the deficient practice does not recur: Inservice training on abuse/neglect with emphasis placed on prompt reporting of incidents. Nursing supervisors and nursing administration re-educated on abuse/neglect policies and procedure for reassignment of personnel and mandatory reporting protocols. All abuse/neglect allegations will be investigated immediately and reviewed by facility administration referencing compliance with mandatory abuse reporting guidelines. d. How the corrective actions will be monitored to ensure the deficient practice will not recur: All abuse/neglect investigations will be reviewed by the Quality Improvement Coordinator for adherence to mandatory reporting guidelines and facility abuse/neglect policy. Additionally the allegation of abuse/neglect will be analyzed to identify any trends. This data will be reported to facility administration monthly. The nurses and CNA involved will be retrained in accordance with the POC. The POC completion date was [DATE]. The surveyors verified the POC was carried out via observation of the inservice training on [DATE] and interview with staff members on [DATE]. Post-survey on [DATE], the surveyor learned that while the facility completed documents regarding reporting to the allegations of abuse on [DATE], they were not sent to the responsible agencies / Boards. Refer to F223 NJAC 8:39 - 4.1 (a) 5

Complaint #NJ 617 Based on interview and record review, it was determined that the facility failed to protect a resident from abuse. Resident #30 was forcibly held down by 2 staff members while yelling and thrashing around in bed while a third staff member applied a dressing to the resident's arm. This deficient practice was identified for 1 of 3 closed records reviewed and was evidenced by the following: The surveyor reviewed a facility Progress Note (PN) dated [DATE] and a continuation of the note on [DATE] (date discrepancy), that stated the Charge Nurse (CN) was alerted to go to the resident's room by the Hospice Aide. The CN found the resident spitting and being combative with care and attempts to redirect the resident were unsuccessful. A 1x1 cm skin tear was documented to the right forearm and a 4.2 x 1.5 cm skin tear was documented to the left forearm. The CN "noted what appeared to be blood on the bedsheets." The CN note revealed the resident "continued to be aggressive and wrists/arms had to be held in order to be cleansed and dressed." The CN note revealed "it took 3 caregivers to apply dressings to arms." The surveyor reviewed offsite information of a statement from the Food Service Director (FSD). This indicated that on [DATE], the FSD was coming down a resident hall asking who was calling out. The FSD went into the room of Resident #30 and the following was reported: the FSD told the staff to remove their hands from the resident; that they were nurses and this should never be done to a resident; that at no time should a towel be placed over a resident's face; that this was unacceptable. The offsite records stated the resident stopped yelling and 3 staff members exited the resident's room. There were 2 Registered Nurses (RNs) and a Certified Nursing Assistant (CNA) who emerged from the room. The staff were identified by first names. The surveyor reviewed the medical record which indicated Resident #30 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment completed on [DATE] indicated the resident had long and short-term memory deficits and moderate cognitive impairment. The corresponding "Inter-Disciplinary Care Plan Note," dated [DATE], indicated the resident could be physically aggressive and resistive to daily care. No episodes of these behaviors had been noted. The resident was receiving Hospice care. At the time of the survey Resident #30 was deceased . The surveyor reviewed physician's orders [REDACTED].#30 was receiving the anti-psychotic drug, [MEDICATION NAME], the mood stabilizer medication, [MEDICATION NAME], and the anti-anxiety medication, [MEDICATION NAME], every 8 hours as needed. These medications were being used for [MEDICAL CONDITION] Affective Disorder and dementia with behavior disturbances. The [DATE] "Quarterly Psychopharmacological Medication Monitoring Review," completed by the physician, indicated Resident #30 would "continue to occasionally grab at staff breasts or try to hit them." The [DATE] "Resident Summary" completed on [DATE], indicated the resident was confused, resisted care and had dry and fragile skin in fair condition. The summary indicated treatments had been ordered to the resident's left and right arms on [DATE]. The [DATE] "Resident Care Cardex" indicated Resident #30 was resistive to care at times. The plan of care for Resident #30 was initiated on [DATE] and included the following issues under "mood and behavior": can be verbally and physically aggressive with staff; resistive to daily care; and had grabbed at staff member's wrists at times. Interventions listed included the following: try to redirect by putting favorite channel on TV or favorite music on; "if unable to redirect then leave the room and report to the nurse. Caregiver to return when calm to complete care." In the evaluation section of the care plan, it indicated the resident had no behavioral issues for the periods ending February and [DATE]. The surveyor requested the investigation of the [DATE] incident. The "Resident Accident Incident Report" indicated the incident occurred on [DATE] at 10:30 a.m. as documented by the Hospice aide. The Hospice aide documented Resident #30 was combative, kicking and scratching during morning care. The statement indicated "when I rolled (him/her) back, noticed scratch on left arm." There was no further statement clarifying what had transpired during care or what "rolled back" meant. In the "Describe Injuries Sustained" section, the CN indicated a 1x1 cm injury was on the right forearm and a 4.2 x 1.5 cm injury was on the left forearm. The CN statement on this report indicated the Hospice aide had told her the resident had sustained skin tears to both arms. There was no explanation as to the origin of the right arm injury. The injury had not been documented by the Hospice aide in her explanation of what had occurred. The CN indicated the resident was swinging his/her arms and spitting during the injury assessment. Employee statements were obtained from the RN CN, the other RN who was in the room (medication nurse), the staff CNA and the FSD who witnessed the incident. No formal statement was obtained from the Hospice aide other than the information contained on the first page of the "Resident Accident Incident Report." The statements revealed the following: a. The CNA statement was not dated as to when it was written. The CNA indicated she was asked to assist with the resident as he/she had been combative with the Hospice aide and nurse. The CNA indicated she and the CN went into the resident's room to assist with treatments. The CNA did not include information regarding how the resident was held down or by whom. b. The RN medication nurse statement, written on [DATE], indicated Resident #30 sustained "multiple" skin tears to both arms during morning care. There was documented evidence of 2 skin tears so this information was unsupported. The medication nurse indicated she went to the resident's room to assess and dress the wounds and the resident was agitated and grabbed her arm. The nurse left the room and asked for the help of another nurse and a CNA. The resident continued to be combative by swinging, hitting and spitting at the staff members during the treatment. The statement did not include information regarding how the resident was held down or by whom. c. The CN statement was not dated as to when it was written. The CN indicated the Hospice aide approached her, said the resident was combative with care and sustained a skin tear to each arm. This was in conflict with the Hospice aide's statement on the "Resident Accident Incident Report" that the resident sustained [REDACTED]. The CN indicated blood was observed on the resident's abdomen and tip of the nose upon entering the room. The CN Progress Notes indicated blood was on the bedsheets only. The CN indicated the resident continued to be combative while staff attempted to dress the wound (singular) and the resident's CNA was asked to help because the "resident was so uncooperative and was actively bleeding from open areas (plural.)" The CN indicated "We then held resident's arms in order to dress wounds. Resident continued to pinch and dig fingernails into skin of nurse and aide in which aide let out a 'yelp.' At this point (the FSD) was outside room, entered and noted what was occurring." The statement did not include information regarding how the resident was held down or by whom. d. The FSD statement was written the day of the incident, [DATE]. (Note that the FSD was also a RN.) The FSD stated the following: "At 11:15 a.m. this nurse was on (unit name) making diet kitchen rounds and delivery of juice order on the unit. As I proceeded down wing 2 of (unit name) about midway I heard someone calling out for help-the sound was clear and loud and intermittently was muffled. I continued down the corridor and noted the call for help coming from (the resident's room.) I entered the room and asked who is calling for help-at this time I observed (the resident) lying supine in bed-with a folded terry cloth towel over resident's lower face-(medication nurse RN) was holding (his/her) left forearm tightly and bracing her right elbow against (the resident's) left upper arm-(the CNA) was at the upper right side of resident's bed holding (his/her) right forearm and pressing her arms against resident's shoulder area to hold (him/her) down. (The CN) was attempting to wrap a dressing around resident's right arm. The resident was able to move (his/her) head and remove the towel from (his/her) face. I immediately directed the staff to let the resident be and informed them their actions were inappropriate. Resident was observed to have reddened areas on both wrists and superficial skin tear on left wrist. This nurse informed both RNs and the CNA that there was no reason for the resident to be held in that manner and under no circumstances should a towel be placed over (his/her) face. (The CN) stated the resident had been combative and was spitting at staff. I informed (the CN) and the other two employees to leave the resident-(he/she) was now calm-and to complete an incident report and chart in the resident's progress notes-should (he/she) develop bruising. The staff left the room-resident was resting. This nurse then reported the incident to (the UM) nursing supervisor and (the Director of Nursing.) It should be noted that all three of these employees have had inservice on dealing with difficult and combative residents. This incident should not have occurred. (The UM) advised she would be inservicing them again." On [DATE] at 11:21 a.m. the surveyor interviewed the UM. The UM said the facility's typical routine was to leave a resident alone if they became combative with care. The UM said that when she observed the resident after the incident, he/she was not receiving care and was calm. The UM said Resident #30 had fragile skin and padded siderails secondary to aggression as the resident was known to be combative with care "since day one." There was no information in the statements about whether the resident's padded siderails were in use at the time of the incident. On [DATE] at 11:57 a.m. the surveyor interviewed the CNA. The CNA said the resident "always" had a history of [REDACTED]. When asked how she rendered care for this resident, the CNA said she would take a step back and talk to the resident and he/she would nod his/her head in agreement for care to be given. On [DATE] at 12:40 p.m. the surveyor interviewed the medication nurse RN. The RN said Resident #30 could be cooperative with care versus resistive to care. The RN said she would give the resident time to calm down if resistive. The RN said the resident had "blood all over the face and body" and a nurse was attempting to wrap each arm while the CNA was trying to calm the resident by holding his hand. Note there was no documentation that blood was observed "all over the face and body" of Resident #30. On [DATE] at 12:53 p.m. the surveyor interviewed the CN via telephone. The CN said the resident sustained [REDACTED]. The CN said the resident was being combative during the wound assessment and had a history of [REDACTED]. The CN said the staff CNA usually had a good rapport with Resident #30 but the resident would not calm for her this day. The CN said they gave the resident some time to calm down but he/she did not. Resident #30 had been given [MEDICATION NAME] and [MEDICATION NAME] earlier in the day. The CN said there was blood on the resident's gown and sheet. (The CN and medication nurse RN statements were conflicting as to where blood was observed. In addition, the CN Progress Note did not mention blood on the resident's gown.) The CN said the [MEDICATION NAME] had not worked to calm the resident and it was now lunchtime and she wanted to wrap the resident's wounds and did not want anyone to see the resident in his/her current condition because of a potential accusation of neglect of the resident. The CN said a family member of the resident's roommate visited daily around that time and she did not want the family member to see Resident #30 in that condition. The CN said she informed the UM about the resident's behaviors and asked the medication nurse RN and the CNA to help dress the resident's wounds. The CN said she held one of the resident's arms and the CNA held the resident's other hand. The CN said the resident dug his/her fingernails into the CNA's wrist and the CNA yelped and that was when the FSD walked into the room. The CN said the FSD told them to stop and they did. The CN was not sure where the RN was standing or what the RN was doing at that point. The CN said the [MEDICATION NAME] and [MEDICATION NAME] had not worked so she said "let's go in and get this done, ladies." The CN then said she held the resident at the wrist and below the elbow. The surveyor reviewed the Medication Administration Record [REDACTED]. Refer to F225, F282 NJAC 8:39 - 4.1 (a) 5

COMPLAINT #NJ 617 Based on record review, it was determined that the facility failed to follow the established plan of care for Resident #30 who was held down by staff when being combative during care. This deficient practice was identified for #30, 1 of 30 residents reviewed, and was evidenced by the following: The plan of care for Resident #30 was initiated on 7/20/10 and included the following issues under "mood and behavior": can be verbally and physically aggressive with staff; resistive to daily care; and had grabbed at staff member's wrists at times. Interventions listed included the following: try to redirect by putting favorite channel on TV or favorite music on; "if unable to redirect then leave the room and report to the nurse. Caregiver to return when calm to complete care." The surveyor reviewed the evaluation section of the care plan that indicated the resident had no behavioral issues for the period ending February and May 2013. The surveyor reviewed offsite records and staff statements that indicated Resident #30 was forcibly held down by 2 staff members while calling out for help and thrashing about in bed during skin tear treatment. Refer to F223 NJAC 8:39 - 4.1 (a) 5 11.2 (f)

Complaint #NJ 712 Based on observation, interview and record review, it was determined that the facility failed to accurately administer medications to the residents for whom the the medications were prescribed. In addition, the facility failed to report a significant medication administration error immediately after the error occurred. Resident #23 was hospitalized with a [DIAGNOSES REDACTED]. This deficient practice was identified for Residents #23 and #32, 2 of 2 residents reviewed for medication administration errors, and was evidenced by the following: Resident #23 had [DIAGNOSES REDACTED]. According to the 3/28/13 Resident Assessment Instrument (RAI) the resident was alert and oriented. Resident #32 had [DIAGNOSES REDACTED]. The resident's 5/16/13 RAI identified the resident as alert and oriented. According to a reportable provided to the Department of Health a nurse gave Resident #23 the wrong medication. Residents #23 and #32 reside in the same room. It was alleged that the nurse gave Resident #32's medications to Resident #23. On 5/30/13 at 2:15 p.m. the surveyor observed Resident #23 in his/her room playing solitaire on a personal desktop computer. When interviewed at this time, Resident #23 said the nurse had given him/her Resident #32's medications which was discovered by Resident #32 shortly later. Resident #23 said Resident #32 reported this to the nurse who asked Resident #32 not to say anything and that Resident #23 would be all right. Resident #23 said the next morning Resident #32 "could not wake me up, I was sent to the hospital and I didn't wake up for 24 hours. When I did wake up, I was really in a state of confusion." Resident #23 said "the nurse didn't go to the charge nurse, (he/she) hid it." Resident #23 told the surveyor to speak to Resident #32, who was not present in the room, for more details. On 5/30/13 at 2:45 p.m. Resident #32 returned to the room. When interviewed at this time, Resident #32 told the surveyor the following regarding the medication incident of 2/9/13: "About 9 p.m. (nurse's name) put them (the meds) down on our tables. He/she (Resident #23) took his/hers, (the nurse) and I chatted." Resident #32 said after the nurse left the room, he/she went to take his/her medications and saw they were not right. Resident #32 said "I know the name, strength and what each pill is for." Resident #32 said "I went to (nurse's name) and told him/her there was a problem. Resident #32 said the nurse said "that's no big deal, we'll switch them." Resident #32 told the nurse that Resident #23 "took them already." Resident #32 said the nurse then said "promise me you won't tell anyone; if you tell, it will be my job. There's no harm in it, he'll/she'll be all right." Resident #32 said the nurse said "at least (Resident#23) will get a good night's sleep" and laughed. Resident #32 then said "I should have known better but I promised not to tell." According to the 2/13 physician's orders [REDACTED].#32's medications. The medications of Resident #32 that were consumed by Resident #23 included Klonopin 0.5 mg (a medication used to treat anxiety which can cause sedation), [MEDICATION NAME] 100 mg (an anti-depressant medication which can cause drowsiness) and [MEDICATION NAME] mg ( a narcotic pain reliever, [MEDICATION NAME]). The surveyor reviewed the facility's Narrative Report regarding the incident which stated that on the morning of 2/10/13, Resident #23 was found to be lethargic, with slurred speech and a low blood pressure (80/53). At that time Resident #32 reported the medication error from the previous evening. The physician was called and the resident was sent to the emergency room and subsequently admitted to the hospital with [REDACTED]." NJAC 8:39 - 29.2 (d)

NJ Based on interview and review of medical records and facility documents, it was determined that the facility failed to assure that an identified safety intervention was in place to prevent falls for 1 of 3 sampled residents (Resident #1). The resident, whose Plan of Care specified transfers with assistance of at least 2 staff, sustained an incident while being transferred by one staff working alone. The incident resulted in bilateral spiral femur fractures which required hospitalization and surgical repair. This deficient practice is evidenced by the following: Medical records and facility documents were reviewed and interviews conducted on 4/4/13 unless otherwise noted. Hospital records were also reviewed on this date. 1. Resident #1 was originally admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident had a significant history of falls, including a left hip fracture in 2010. According to the 1/8/13 Minimum Data Set (MDS), an assessment tool, the resident scored 8 out of a possible 15 points on the Brief Interview for Mental Status (BIMS) evaluation, indicating moderate cognitive impairment. The resident was non-ambulatory and totally dependent upon staff for all transfers and locomotion. The Plan of Care since 4/4/10 specified the resident to be transferred with assist of at least 2 staff, with a mechanical lift to be used as needed. An undated Resident Care Cardex indicated the resident transfer needs were sit to stand lift with 2 assist. Review of associated facility investigative documents revealed that a fall/incident occurred on 3/26/13 at 9 a.m. as the CNA attempted to transfer the resident from his bed to his wheelchair, and the resident's knees buckled, causing the resident to begin to fall. The CNA reportedly lowered the resident to the floor onto the bedside mat, however, the resident's knees bent under the weight of his upper torso as he slid down the side of the bed, and he landed on his buttocks. It was noted that the CNA "straightened his legs out" after he was on the floor. A nursing assessment was completed by a unit Licensed Practical Nurse (LPN,) at which time the resident denied pain and showed no facial grimacing. The resident was manually "lifted" back to bed by the CNA and LPN. No Incident Report was completed at that time, and no investigation was initiated. The facility summary indicated routine care continued to be provided to the resident, and no pain was noted throughout the following night. On the morning, of 3/27/13 just prior to 10 a.m., the resident complained of pain and a CNA noted swelling of his knees. The physician was notified and examined the resident. Bilateral knee X-rays were ordered. A nursing entry of 3/28/13 at 1 a.m. indicated a phone call was received from radiology advising limited results from the left knee X-ray, with strong suspicion of a distal femoral fracture. The right knee X-ray was unable to be completed due to the resident's complaint of pain. On 3/28/13 at 7 a.m. the physician was notified of the left knee X-ray results and an order was received to transfer the resident to the hospital for evaluation. At that time the resident's responsible party was initially notified of the incident, the X-ray results and the pending transfer. At 8:15 a.m. the resident left the facility via transport, and was subsequently admitted to the hospital with [REDACTED]. On 3/28/13 an Incident Report was completed, and a facility investigation was initiated regarding the injury. The investigation revealed that the involved CNA and the LPN who initially assessed the resident had reported the incident to the unit charge nurse. Based on the CNA's report that the resident did not fall but was lowered to the floor, the Registered Nurse (RN) Senior Charge Nurse directed that an incident report was not required as a fall did not occur. No evidence was found that the RN Senior Charge Nurse personally examined the resident or reported the incident to her immediate supervisor, both of which are required by facility policy. The RN Senior Charge Nurse's statement indicated the physician was notified on 3/26/13 that the resident was lowered to the floor and a post survey telephone interview with the physician on 4/11/13 at 12:20 p.m. verified this. Statements by nursing staff on the subsequent 11 p.m.-7 a.m. and 3-11 p.m. shifts reflected that they were not aware or informed of the incident during shift report. However, the statements indicated that the resident was not experiencing any stress or discomfort until day shift on 3/27/13. Review of hospital records from South Jersey Hospital Regional Medical Center revealed the following: CT of right lower extremity 3/28/13 12:48:00 Right Femur "A comminuted, spiral fracture is noted through the distal right femur, which is laterally displaced by 1 cm and posteriorly displaced by 1.3 cm. The fracture line extends into the patellofemoral compartment and through the medial epicondyle. Extensive hemorrhage is noted within the major fracture line." Left Femur "A spiral fracture is noted through the distal left femur, which is laterally displaced by 1.1 cm and posteriorly displaced by 2.3 cm. Hemorrhage and small air pockets are noted within the major fracture line, which may be from an open fracture." Impression: Spiral fractures of both distal femurs, as described. On 4/3/13 the resident underwent [REDACTED]." In a telephone interview with the surveyor on 4/5/13 at 12:05 p.m., the involved CNA stated that she had been Resident #1's full-time primary 7 a.m. to 3 p.m. shift caregiver for approximately one year. She had always transferred the resident by herself in the same manner, without assist from other staff. Typically, the resident was able to stand and "move his feet enough" that she could pivot him from bed to wheelchair, however on 3/26/13, "his legs just buckled under him and he went down." The CNA further stated that she had checked the resident's Care Card regarding transfer assistance "maybe once, just in the beginning (of her assignment to him) and it just said pivot." She denied rechecking the Care Card for updates to the resident's care needs since that time, or hearing of care status changes during shift report. In a telephone interview with the surveyor on 4/16/13 at 12:30 p.m., the Unit Manager stated that CNA's were included in shift rounds daily, and any changes in resident status were discussed. Additionally, facility protocol required that CNA's check their residents' Care Cardex every day, regardless of whether changes were discussed in shift rounds. In a telephone interview on 4/16/13 at 1:25 p.m. the RN Senior Charge Nurse stated that she did not personally assess the resident but relied upon information provided to her by the CNA and LPN, who indicated that the resident was lowered to the floor and exhibited no signs of pain. According to the facility policy entitled: Nursing Services 25-39, Resident Accident/Incident Reporting Form (#NUR-1193-019), Section III. Specifics: "Any accident or incident, regardless of whether an injury is present, involving a resident requires the completion of a Resident Accident/Incident Report Form, #NUR-1193-019." and Section IV. Procedure: A. It is the responsibility of all employees to report to their immediate supervisor any accident or incident, or observation of a probable incident, involving a resident and initiate nursing form (NUR#1193-019) immediately. NJAC 8:39-27.1(a&b)

C# NJ C# NJ Based on interview and review of medical records and hospital documentation, it was determined that the facility failed to implement an identified safety intervention; wheelchair alarm, for 1 of 3 sampled residents, Resident #1, who had a history of [REDACTED]. This deficient practice is evidenced by the following: Medical records were reviewed and interviews conducted on day of survey, unless otherwise noted. 1. According to the Minimum Data Set, an assessment tool, dated 10/06/11, Resident #1 had [DIAGNOSES REDACTED]. The resident was alert and oriented and required assistance with transfer and ambulation. His balance was noted as "not steady." A review of the resident's Interdisciplinary Plan of Care initiated 7/18/11 identified the resident as having a history of falls due to rigidity and gait dysfunction. Identified interventions included assistance with wheelchair transfer, reminders to ask for assistance and use of call light, and use of a Posey (safety) alarm at all times. A facility Reportable Event Record/Report faxed to the Department of Health and Senior Services indicated that on 10/25/11 at 11:16 a.m., Resident #1 was in his room with the Speech Therapist (ST), who seated the resident in his wheelchair. The ST then left the room and heard a noise. She returned to find Resident #1 lying on the floor and bleeding from the left side of his head. The ST called for assistance. A physician responded and the resident was stabilized for transfer to the hospital. At that time, the resident was noted to be "unresponsive and breathing in a snoring manner." The resident was subsequently admitted for a cardiac workup. An accompanying written statement by the ST indicated the resident's alarm was on the chair but did not sound. On a tour of the Freedom Unit at 10:15 a.m., the Unit Manager (UM) identified Resident #1 as being alert and oriented. The UM then said that the resident did not like having the alarm and was known to dismantle the alarm on occasion. When asked why the facility continues to use the alarm the UM replied because sometimes it works and staff are able to get to the resident before he falls. An Interdisciplinary Progress Note dated 10/28/11 8:00 p.m., indicated the resident was readmitted to the facility with four sutures on the left forehead. Ecchymosis around the sutured laceration and left eye were also noted. On interview at 11:30 a.m., the Certified Nursing Assistant (CNA), assigned to the resident the day of the incident, stated she assisted the resident with transfer that morning and tested his wheelchair alarm. It was working. The resident went to the dining room for breakfast. Afterward, she escorted him back to his room and the resident requested to get back into bed. The CNA assisted him to bed and turned off his wheelchair alarm so it would not keep sounding. Later, before lunchtime, the CNA heard some commotion and observed Resident #1 on the floor near his wheelchair. No alarm was sounding. On interview at 11:10 a.m., the ST stated she went to the resident's room for a therapy session. The resident was sitting up in the bed for the session. Before leaving, the resident requested to sit in his wheelchair. The ST assisted the resident into the chair. She observed the pad alarm was in place and assumed the alarm was turned on. When asked if she ever had any in-service on alarms or knew how to check the alarms for function, she replied, "No one ever told her to check alarm function." On interview at 11:40 a.m., the newly hired Director of Therapy stated she was not sure if staff ever received any formal in-service on alarms or if it was just a standard of practice to check alarm function. She went on to say that she did have a discussion with the ST on safety issues after this incident. On interview at 11:45 a.m., the physical therapist working with Resident #1 stated he always checks to make sure any alarms are in place and working. When asked how he knew to check alarms, he said other staff in the therapy department are always reminding each other and the CNAs on the floors always ask if the alarms are working. On interview at 1:00 p.m., the Director of Nursing stated that the therapy department is a contracted service. They do receive a basic orientation like on fire safety, etc., but the orientation does not include safety alarms. Since the incident the facility is expanding the orientation process. According to a follow-up investigation summary faxed to the DHSS on 11/02/11, all therapists are required to review the residents care plan prior to providing care to the residents. Resident #1's care plan does document that the Posey alarm should be used at all times. NJAC 8:39-27.1(a)