Every finding on record at Premier Cadbury of Cherry Hill

Complaint Intake # 2740465Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of food served to the residents. This deficient practice was identified during the lunchtime meal service on 3/13/26, on 1 of 2 nursing units ([NAME] 600) and was evidenced by the following:On 3/13/26 at 12:25 PM, in the presence of the Food Service Director (FSD), the surveyor conducted a test tray with a calibrated (calibration ensures that the thermometer is accurate and precise for the measurement of food temperatures) thermometer. The meal tray cart arrived on the unit at 12:20 PM. It was an open, not enclosed, cart. The surveyor tagged the bottom tray for temperature testing. When all the meal trays were delivered to the residents from that truck at 12:25 PM, the temperatures were checked for a regular consistency meal. The temperatures were as follows: Turkey Burger-95 degrees Fahrenheit 4-ounce milk carton: 46 degrees Fahrenheit The surveyor asked the FSD if the temperature of the turkey burger was adequate and he responded, no it is not. The plates did not have metal plate warmers (pellets) underneath the plates to help maintain heat. The FSD stated, We have no bottoms (meaning the plate warmers). The surveyor reviewed the policy titled Food Preparation and Service, dated 4/2019. The section titled cooking and holding time/temperatures revealed that the danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. Hazardous foods included but were not limited to meat, poultry and seafood. NJAC 8:39-17.4(a)

Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to a.) maintain clean kitchen equipment and b.) store foods in a manner intended to prevent the spread of food borne illness in resident pantries. This deficient practice was evidenced by the following:On 3/11/26 at 09:20 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. On a large open stainless-steel shelf, the surveyor observed stacks of stainless-steel pans. The surveyor observed eight stainless steel pans. When the surveyor separated the eight pains there was wet nesting within each pan. One of the pans had a dried yellow substance on the inside. The surveyor asked the FSD if they were clean pans and he stated yes, but he would rewash the pans. The FSD acknowledged the wet nesting within each pan and proceeded to remove them from the shelf. 2. The pellet warmer had paper stored inside the pellet warmer. The FSD said it had not worked for Close to a year. On 3/13/26 at 11:56 AM, the surveyor observed two pantries in the facility. 1. The pantry on the 500 unit had no paper towels at the sink. There was a resident refrigerator and freezer in the pantry. In the freezer the surveyor observed two opened 1/2 gallons of ice cream not labeled or dated. 2. The pantry on the 600 unit had a refrigerator and freezer. The freezer had one gallon of an opened container of ice cream that was not labeled or dated. The refrigerator had two clear plastic bags of food items. The items had a resident name on them but no dates. On 3/17/26 at 9:25 AM, during a meeting with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the LNHA acknowledged the wet nesting and the unlabeled items in the resident pantries. A review of the policy titled, Dining/Labeling of Food items, dated 1/2026 stated the facility adheres to a date marking system to ensure the safety of ready to eat, time/temperature control for food safety. Number two revealed that the food shall be clearly marked to indicate the day or date by which the food shall be consumed or discarded. A review of the policy titled Refrigerators and Freezers, dated 12/2014 stated that supervisors will be responsible for ensuring food items in pantries, refrigerators, and freezers are not expired or past the perish dates. NJAC 8:30-17.2 (g)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow a consultant physician's recommendations in a timely manner. This deficient practice was identified for 1 of 1 resident (Resident #47) reviewed for accommodation of needs and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/11/26 at 9:59 AM, the surveyor observed Resident #47 awake and alert sitting on the edge of the bed. The resident stated that they had eye surgery and were supposed to get eyeglasses but never received them. Resident #47 stated that they were informed by the previous unit manager that the eyeglasses were ordered but they were never received. On 3/13/26 at 8:54AM, the surveyor conducted a follow up interview with Resident #47 who again confirmed that they never received the eyeglasses and had not had a follow up visit scheduled with the eye doctor as recommended. The resident stated they still had double vision. The surveyor reviewed the electronic medical record and paper chart for Resident #47. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to: combined forms of age-related cataract, bilateral (a clouding of the lens of the eye). A review of the resident's quarterly/comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/10/26, included the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) did not include a focus area for cataracts or eyeglasses. A review of the progress notes and paper chart revealed that Resident #47 had left eye cataract surgery on 9/18/25 and right eye cataract surgery on 10/24/25. A review of the consultation form, dated 11/20/25, revealed that Resident #47 was stable after cataract surgery with intermittent diplopia (double vision). Recommendations included a prescription for eyeglasses, to follow up in 2 months, and will consider PRISM glasses (specialized prescription lenses designed to correct double vision) if still has diplopia. A review of a nurse's note, dated 11/21/25 at 1:39 PM, revealed that the prescription was given to the ophthalmologist and the resident and doctor were made aware. Further review of the progress notes and the paper chart from 11/21/25 to present did not reveal any documentation that the residents' eyeglasses were ordered or received. There was no documentation that a follow-up visit with the eye doctor was scheduled. On 3/13/26 at 10:52 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that when a resident returned from an outside physician's visit with recommendations, the nurse would contact the attending doctor and get a physicians order for the recommendations. The nurse would then write a progress note and notify the family. LPN #1 further stated that it was the responsibility of the resident's nurse to notify the unit secretary that a follow up visit needed to be scheduled. When asked what happened to Resident #47's prescription for the eyeglasses, LPN #1 stated I don't know. On 3/13/26 at 10:53 AM, the surveyor interviewed the Director of Nursing (DON) who stated that when a resident returned from a doctor's appointment, the paperwork would be given to the nurse or unit clerk. The cart nurse would then call the attending doctor and obtain physician orders per the recommendations. The DON further stated that she did not know about the resident eyeglasses or the follow up appointment. On 3/16/26 at 1:18 PM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), and the survey team, acknowledged that the eyeglass prescription should have been completed and a follow up visit with the eye doctor should have been scheduled.A review of the facility's Consultation policy, undated, included that upon completion of the consultation, recommendations from the consulting practitioner will be communicated to the attending physician for review and implemented as appropriate. Consultation finding and related care interventions will be documented in the medical record and incorporated into the president's plan of care as indicated. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 1of 2 units ([NAME] 6 Unit). This deficient practice was evidenced by the following: On 3/11/26 at 10:10 AM, in room [ROOM NUMBER]B on the [NAME] 6 Unit, the surveyor observed a personal refrigerator. Inside the refrigerator door, there was an unlabeled, open container of food. [NAME] and red debris were identified on the bottom of the refrigerator, along with a loose piece of a blue paper label. The freezer compartment did not contain a thermometer, and the floor of the freezer was covered in ice. [NAME] and red debris were also visible on the bedroom floor. The wall had areas of missing white paint, exposing the paper layer of the drywall. In the bathroom, black scuff marks appeared on the walls, and the wall trim was hanging adjacent to the toilet, with black residue on the wall behind the trim. On 3/13/26 at 10:59 AM, during an interview with the surveyor, the Director of Maintenance (DOM) stated that the maintenance department was not responsible for cleaning residents' personal refrigerators and was unsure why the freezer compartment did not have a thermometer. The DOM explained that a thermometer should be present to ensure food stored in the freezer was maintained at the proper temperature. The DOM further stated that the wall in room [ROOM NUMBER]B should not have areas of missing paint exposing the paper layer of the drywall, and that the wall trim should not be hanging loose adjacent to the toilet, with black residue visible on the wall behind the trim. He added that the damage may have occurred when a hand sanitizer dispenser was removed a while ago, but he could not confirm the exact time. The DOM reported that the facility had hired a private contractor to complete the repairs but did not know when the repairs would begin. On 3/13/26 at 11:03 AM, during an interview with the surveyor, the Director of Housekeeping and Laundry ([NAME]) stated that housekeepers clean rooms daily and as needed, based on residents' needs. She reported that housekeeping was not routinely responsible for cleaning residents' personal refrigerators but would do so upon request. She further stated that bedroom floors and personal refrigerators should be kept clean to maintain a homelike environment. On 3/13/26 at 11:03 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that residents' personal refrigerators were cleaned daily by housekeeping and should not contain open, unlabeled, or undated food, debris, or loose trash. These practices were important to maintain a homelike environment and for infection control purposes. On 3/13/26 at 11:03 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the refrigerator and freezer compartment in room [ROOM NUMBER]B on the [NAME] 6 Unit should have been cleaned and the freezer defrosted by housekeeping, as this was a housekeeping responsibility. Additionally, she reported that maintenance should have ensured a thermometer was present in the freezer compartment for infection control purposes. A review of the facility's undated policy titled Homelike Environment, revealed that Facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a.) a clean, sanitary, and orderly environment. A review of the facility's Food Brought in by Visitors revised policy dated February 2026, revealed that Refrigerated foods must be labeled with the resident's name and date the food was brought in and will be discarded by staff no more than three (3) days after being brought in. N.J.A.C. 8:39-31.4(a)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to a.) maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, and b.) post notice of the availability of the inspection results in prominent areas. This deficient practice was identified on 2 of 2 units ([NAME] 5 and [NAME] 6) and was evidenced by the following: On 3/12/26 at 10:15 AM, the surveyor conducted a resident council meeting with five alert and oriented residents. All five residents stated they were not aware of the location of the State Survey results. On 3/13/26 at 11:50 AM, the surveyor toured the [NAME] 5 unit but was unable to locate the most recent State Survey results. There was no signage on the unit to indicate where to find the State Survey results. At that time, the surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM) #1 where the State Survey results were, but he was unable to answer and stated he would get the Licensed Nursing Home Administrator (LNHA). The LNHA approached the surveyor and stated the State Survey results were located in the lobby. On 3/13/26 at 11:55 AM, the surveyor toured the [NAME] 6 unit but was unable to locate the most recent State Survey results. There was no signage on the unit to indicate where to find the State Survey results. At that time, the surveyor asked Licensed Practical Nurse (LPN) #1 where the State Survey results were and the LPN grabbed a binder from behind the nurses' station which was not accessible to residents. The binder contained the most recent recertification survey results. On 3/13/26 at 12:00 PM, the surveyor attempted to enter the facility's lobby from the [NAME] 6 unit, but the doors to the lobby were locked. There was a sign on the lobby doors that indicated to knock on the door to enter. There was also a number keypad next to the lobby doors. After entering the lobby, the surveyor observed a binder on a table which contained the most recent State Survey results with a sign next to it indicating that the State Survey results were located in the lobby. At that time, the surveyor interviewed the receptionist who stated that the lobby doors were locked and that residents had to knock on the door and the receptionist would have to get permission to let the residents into the lobby as elopement risk residents were not allowed in the lobby. On 3/16/26 at 10:22 AM, during a follow-up interview, LPN/UM #1 stated the State Survey results were kept in the lobby and that there were no State Survey results available on the unit. When asked how residents were made aware of the location of the State Survey results, the LPN/UM stated that residents had to ask staff were the results were. The LPN/UM further stated that the doors to the lobby were locked and that residents could not access it without asking staff for assistance. The LPN/UM explained that it was important for the State Survey results to be readily accessible to residents because residents should have knowledge of what's going on in their home. On 3/16/26 at 1:17 PM, the surveyor interviewed the Director of Nursing (DON) and the LNHA in the presence of the survey team. The DON stated the State Survey results were located in the lobby and verified that the State Survey results were not accessible to residents without having to ask for staff to open the lobby doors. The DON and LNHA also verified that the State Survey results located behind the [NAME] 6 nurses' station was not readily accessible to residents and that there should be signage posted on the units to inform residents where to find the State Survey results. A review of the facility's Examination of Survey Results policy, revised April 2017, included the following:Survey reports and plans of correction are readily accessible to the resident, family members, resident representatives, and to the public. A copy of the most recent survey report and any plans of correction are kept in a binder in the residents' day room.Information concerning the rights to examine, the location of and how to request preceding years' survey reports and plans of correction. are posted on the resident bulletin board and at each nurses' station. NJAC 8:39-9.4(b)

Based on interview and review of facility documents, it was determined that the facility failed to consistently provide residents with mail delivery between December 2025 and late February 2026. This deficient practice was identified for 1 of 5 residents (Resident #49) during a resident council group meeting and was evidenced by the following: On 3/12/26 at 10:15 AM, the surveyor conducted a resident council group meeting with five alert and oriented residents (Resident #11, # 22, #49, #65, and #95). The surveyor interviewed the residents regarding mail delivery. All residents stated that the Activities Director (ACD) coordinated mail delivery, but that the facility had no ACD between December 2025 and late February 2026. Resident #49 further stated that he/she did not receive mail between December 2025 and late February 2026 and that an activities aide at that time found a box of undelivered mail. On 3/16/26 at 10:22 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the ACD coordinated mail delivery at the facility and that the previous ACD had left in December 2025. On 3/16/2026 at 10:37 AM, the surveyor interviewed the ACD regarding mail delivery who stated that mail arrived at the facility and was supposed to be distributed to the residents daily. The ACD then confirmed that he began employment with the facility in February 2026, and that there was only one activities aide working in the activities department between December 2025 and February 2026 whose part time schedule covered Mondays, Wednesdays, and Fridays. The ACD stated that it was important for residents to receive their mail upon delivery because mail may contain time sensitive communication. The ACD stated that he did not know what department at the facility would assume responsibility of mail delivery if there was no activities staff available. The ACD explained that a resident council group meeting was held on 2/27/26 after he began employment to discuss resident concerns. The AD stated that he could provide minutes from that resident council group meeting. On 3/16/26 at 11:00 AM, the ACD provided the resident council meeting minutes from 2/27/26 which included interdepartmental concerns. Section five of the meeting minutes indicated a concern for the ACD which revealed, residents would like their mail. On 3/16/26 at 1:17 PM, the surveyor interviewed the Director of Nursing (DON) who stated the activities staff were responsible for delivering the residents' mail but was unable to say how often the mail should be delivered. The DON explained it was important for the residents to receive their mail timely because they might have important mail coming in. On 3/17/26 at 09:50 AM, the Licensed Nursing Home Administrator (LNHA) provided an Ad Hoc QAPI Performance Improvement Plan (PIP) initiated on 3/16/26 by the ACD and LNHA. This PIP document identified the following problem statement: Residents reported not receiving mail over an extended period (December through March). Upon investigation, a box of undelivered mail was identified and subsequently distributed. The lapse was associated with a period in which there was no assigned Activities Aide for mail distribution.This PIP document identified the following items in root cause analysis: Lack of assigned responsibility for mail distribution; Breakdown in oversight during staffing gap; Absence of monitoring processes to ensure daily mail delivery; Failure to identify backlog of undelivered mail in a timely manner. The LNHA also provided timecards for the activities aides employed between 11/30/25 and 3/16/26. These timecards verified that there was only one activities aide working at the facility between 12/27/25 and February of 2026 when the ACD began employment. A review of the facility's mail and electronic communication policy, last revised May 2017, included under Policy Interpretation and Implementation: Mail and packages will be delivered to the resident within 24 hours of delivery on premises or to the facility's post office box (including Saturday deliveries). NJAC 8:39-4.1 (a)(19)

Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to a.) notify the representative of the Office of the State of Long-Term Care Ombudsman about a resident's emergency discharge to the hospital and b.) provide the bed hold policy for 1 of 1 resident (Resident #99) reviewed for hospitalization. This deficient practice was evidenced by:On 3/12/26 at 12:16 PM, the surveyor reviewed the hybrid medical records (combination of electronic and paper medical records) for Resident #99. The resident had a facility-initiated discharge (d/c) and was no longer in the facility. A review of the admission Record (an admission summary) reflected that the resident had diagnoses that included influenza, dysphagia (difficulty swallowing), seizures, heart disease, and dementia. A review of the Progress Notes (PN) revealed the resident was transferred to the hospital on 1/5/26 and admitted with a diagnosis of respiratory distress. A review of the New Jersey Universal Transfer Form (NJUTF) indicated the resident was transferred on 1/5/26 at 11:45 AM. It further indicated that the reason for transfer was increased lethargy (an unusual lack of energy and decreased mental alertness) and low oxygen levels. A further review of the hybrid medical records revealed there was no evidence that the facility notified the representative of the Office of the State of Long-Term Care Ombudsman about a resident's emergency discharge to the hospital or provide the bed hold policy to the resident or the resident's representative. On 3/12/26 at 11:47 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated he could only find the November and December 2025 notifications to the Ombudsman's Office and that he could not find the month of January 2026. He further stated the previous LNHA left the same day he started which was February 16, 2026. He then stated that he could tell the previous LNHA was sending the notification but could not find January. On 3/12/26 at 1:21 PM, during a follow up interview the LNHA stated he still could not find the January 2026 emergency transfer notification to the Ombudsman's Office and was not aware if he was responsible to submit them. He then stated moving forward to ensure it was being submitted monthly he would be sending out the notification. On 3/13/26 at 8:55 AM, the LNHA provided an email that he sent the notification of the emergency transfers. The LNHA confirmed it was not done and acknowledged January 2026 should have been sent prior to surveyor inquiry. On 3/13/26 at 9:54 AM, the surveyor interviewed the LNHA regarding the bed hold notification. The LNHA stated that the previous LNHA sent the bed hold notification and prior to that was the Admissions Director (AD). On 3/13/26 at 10:47 AM, the surveyor interviewed the AD who stated for the emergency transfers she recently started sending out the bed hold notifications by certified mail. The AD explained that the previous LNHA was sending out the bed hold notifications and prior to that was the previous Social Worker. The AD stated she was not sure if the bed hold notification was sent to Resident #99 but would follow up. On 3/13/26 at 12:01 PM, the AD confirmed the bed hold notification was not sent for Resident #99. On 3/17/26 at 9:43 AM, the LNHA stated in the presence of the Director of Nursing (DON), and the survey team that the bed hold would now be done by the AD, and the LNHA would be responsible for notifying the Ombudsman Office. The LNHA confirmed both the bed hold and emergency transfer notifications were not sent until after surveyor inquiry. A review of the facility's Bed-Holds and Returns policy dated revised March 2022, included, 1. All residents/representatives are provided written information regarding the facility bed-hold policies.Residents are provided written information about these policies at least twice: b. at the time of transfer (or, if the transfer was an emergency, within 24 hours). A review of the facility's Transfer or Discharge Emergency policy dated revised August 2018, included, 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: e. Notify the representative (sponsor) or other family member; g. Others as appropriate or as necessary. A review of the facility's Ombudsman Notification of Transfer/discharged policy dated March 2026, included, 2. The Administrator or designee is responsible for ensuring that Ombudsman notification is completed, coordinated, and documented. 3. Copies of the transfer notice will be sent to the Ombudsman. Notification may be completed individually or through a monthly listing of emergency transfers. 5. The facility may submit a monthly list of emergency transfers to the Ombudsman. The list must include all required elements and copies of resident notices. NJAC 8:39-4.1(a)(32); 27.1(a)

Based on observation, interviews, review of medical records, and other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 3 of 20 residents reviewed (Residents #1, #5, and #61).1.) On 3/11/26 at 9:54 AM, the surveyor observed Resident #1 awake and alert sitting in a wheelchair in his/her room. The resident stated that he/she did not speak English. The surveyor reviewed the medical record for Resident #1. A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: osteomyelitis (an infection in the bone). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/19/26, revealed that in section C for cognitive patterns, the Brief Interview for Mental Status (BIMS) assessment was not assessed. The omission did not reflect the residents' true physical, mental, and psychosocial status. 2.) On 3/12/26 at 12:16 PM, the surveyor observed Resident #5 awake and alert sitting in a wheelchair by the nurse's station. A staff member stated that the resident did not speak English. The surveyor reviewed the medical record for Resident #5. A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: nontraumatic subarachnoid hemorrhage from the left middle cerebral artery (a spontaneous bleed not caused by trauma that occurs when an aneurysm on the left middle cerebral artery ruptures), dysphagia (difficulty swallowing), and aphasia (a disorder that affects how you communicate). A review of the resident's comprehensive MDS, dated [DATE], revealed that in section C for cognitive patterns, the Brief Interview for Mental Status (BIMS) assessment was not assessed. The omission did not reflect the residents' true physical, mental, and psychosocial status. 3.) On 3/12/26 at 12:59 PM, the surveyor observed Resident #61 in his/her room. Resident #61 was alert and oriented and conversed with the surveyor regarding his/her care. On the same day, the surveyor reviewed the electronic medical record (EMR). A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to, acute pulmonary edema, anxiety and depression. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/2/26, revealed that in section C for cognitive patterns, the Brief Interview for Mental Status (BIMS) assessment was not assessed. The omission did not reflect the residents' true physical, mental, and psychosocial status. On 3/13/26 at 12:30 PM, the surveyor conducted a telephone interview with the MDS consulting company. The MDS Consultant (MDSC) stated this was a consulting company that conducted the MDS assessments for the facility. She stated that the company had one (1) nurse at the facility and had two (2) remote nurses who completed the assessments for the MDS. The MDSC further stated that MDS assessment was completed based on the Resident Assessment Instrument (RAI) manual and every resident should have a completed BIMS assessment. On 3/16/26 at10:51 AM, the surveyor conducted a follow-up telephone interview with the MDSC who stated that the nurse who had completed the MDS assessments should have communicated to the facility that the BIMS assessments were not completed. The MDSC confirmed that all residents should have a BIMS assessment completed on the MDS, and if non-interviewable, then a staff interview should have been completed. If the residents did not speak English, then a translator would be used to complete the BIMS assessment. During an interview with the survey team, the Licensed Nursing Home Administrator (LNHA), and the Director of Nursing (DON) on 3/16/26 at 1:28 PM, it was determined that the three residents should have been assessed for mental status as required by RAI guidelines. A review of the facility's Resident Assessments policy, revised March 2022, included that residents' assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the OBRA required assessments and the PPS required assessment. A comprehensive assessment included: a), completion of the Minimum Data Set, b), completion of the care area assessments and c), development of the comprehensive care plan. N.J.A.C 8:39-11.1

Based on interview, record review, and review of facility documents, it was determined that the facility failed to notify the physician of the resident's change in condition for 1 of 23 sampled residents (Resident #99). This deficient practice was evidenced by the following:On 3/12/26 at 12:16 PM, the surveyor reviewed the hybrid medical records (combination of electronic and paper medical records) for Resident #99. The resident had a facility-initiated discharge (d/c) and was no longer in the facility. A review of the admission Record (an admission summary) reflected that the resident had diagnoses that included, influenza, dysphagia (difficulty swallowing), seizures, heart disease, and dementia. A review of the individual comprehensive care plan (ICCP) included a focus, dated 1/2/26, that the resident had influenza. Interventions included: Monitor vital signs as ordered and notify the physician of significant abnormalities. A review of the Progress Notes (PN) dated 1/4/26 at 2:41 PM, revealed the resident refused their medications, refused to eat their breakfast and lunch, and their vital signs included the blood pressure (BP) was 85/55 and the temperature was 94.2 degrees. The PN also indicated the nurse informed the supervisor about the resident, the supervisor monitored the resident, scheduled a speech therapy evaluation and would continue to monitor. There was no evidence that the physician was notified of the resident's low BP and the low temperature. A further review of the PN dated 1/5/26, revealed at approximately 10:30 AM, the resident was noted with increased lethargy, requiring a sternal rub for arousal. Vital signs SpO2 (Peripheral Oxygen Saturation - measures the percentage of oxygen-saturated hemoglobin in the blood) was 67 % and the BP was 64/50. The resident was transferred to the hospital and admitted with a diagnosis of respiratory distress. A review of the New Jersey Universal Transfer Form (NJUTF) indicated the resident was transferred on 1/5/26 at 11:45 AM. It further indicated that the reason for transfer was increased lethargy (an unusual lack of energy and decreased mental alertness) and low oxygen levels. On 3/12/26 at 12:52 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated she would notify the physician for any change in condition. On 3/12/26 at 1:13 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Clinical Consultant and the Licensed Nursing Home Administrator (LNHA). The DON stated that she would expect the nurse to notify the MD of the low BP. On 3/13/26 at 8:59 AM, the surveyor and the Medical Director (MD) reviewed the 1/4/26 and 1/5/26 PN together. In the presence of the survey team, the MD stated that on 1/4/26, when the resident's vital signs were abnormal with a BP of 85/55 and temperature of 94.2, the nurse should have notified the physician. On 3/13/26 at 10:59 AM, during a follow up interview, the DON stated her expectation would be for the nurses to notify the physician of the low BP. She stated it was important to see if the physician wanted any new orders and new interventions for the resident. The DON acknowledged the physician should have been notified on 1/4/26. On 3/17/26 at 9:32 AM, both the DON and the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team acknowledged, the nurse should notify the physician for any change in conditions. A review of the facility's Change in a Resident's Condition or Status policy, dated revised February 2021, included, 1. The Nurse will notify the resident's attending physician or physician on call when there has been: d. significant change in the resident's physical/emotional/mental condition; f. refusal of treatment or medication two (2) or more consecutive times; i. specific instructions to notify the physician of changes in the resident's condition. A review of the facility's Resident Examination and Assessment policy dated revised February 2014, included, Reporting: 2. Notify the physician of any abnormalities such as, but not limited to: a. abnormal vital signs. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that therapy services and treatment for range of motion limitations were provided for 1 of 2 residents (Resident #9) reviewed for range of motion concerns. This deficient practice was evidenced by the following: On 3/11/26 at 9:45 AM, the surveyor observed Resident #9 in his/her bedroom, seated in a wheelchair next to the bed. The resident stated that he/she had difficulty using the right side of his/her body. The resident's right hand was contracted, and no orthosis or hand splint was in place. On 3/12/26 at 9:14 AM, the surveyor observed Resident #9 in the hallway on the [NAME] 6 Unit, self-propelling in his/her wheelchair. He/she stated to the surveyor that he/she was going outside to smoke. His/her right hand was contracted, and he/she was not wearing an orthosis or hand splint. The surveyor reviewed the electronic medical record for Resident #9. A review of the admission Record, an admission summary, revealed the resident had diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (brain damage resulting in the inability to fully use the right side of the body). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/28/26, included a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. A review of the Individual Comprehensive Care Plan (ICCP) dated 10/21/26 included a focus area indicating that Resident #9 presents with right hemiplegia, increased difficulty with transfers, and deficits in postural control. Interventions included, but were not limited to, wearing a right-hand (carrot) (a device placed on the hand to prevent contractures and maintain proper hand positioning) at all times, except during care, with pre- and post-skin checks to maintain skin and joint integrity. A review of the Order Summary Report (OSR), dated 12/15/26, included the following physician order (PO): the resident is to wear a right-hand (carrot) at all times, except during care, for comfort and proper positioning, with skin checks performed before and after each shift. On 3/13/26 at 9:45 AM, the surveyor reviewed Resident #9's Treatment Administration Record (TAR). The TAR revealed that the assigned Licensed Practical Nurse (LPN #3) documented on 3/11/26 and 3/12/26 that the resident was wearing the right-hand roll (carrot); however, the resident was not wearing the device at the time of observation. Additionally, no progress note was documented to explain why the device was not in place. During an interview with the surveyor on 3/13/26 at 10:49 AM, Licensed Practical Nurse / Interim Unit Manager (LPN/IUM #1) on the [NAME] 6 Unit stated she was unsure why LPN #3 documented that Resident #9 was wearing the right-hand roll (carrot) if he/she was not. She explained that documentation indicating the device was in place means the resident was wearing it. She further stated she would follow up with the nurse. During an interview with the surveyor on 3/13/26 at 11:20 AM, the Director of Nursing (DON) stated that nursing staff should not document that the resident was wearing the right-hand (carrot) if it was not in place. She further explained that if the resident was not wearing the device, it should be documented and reported to therapy. During an interview with the surveyor on 3/16/26 at 11:00 AM, LPN #3 stated she was unsure why she documented that the resident was wearing the right-hand (carrot) when she was not. She acknowledged that she should not have documented that the device was in use if it was not in place. During an interview with the surveyor on 3/16/26 at 11:21 AM, the Director of Physical Therapy (DPT) stated that nursing staff should not document that the resident was wearing the right-hand (carrot) if it was not in place. He further stated that staff should document the reason why the resident was not wearing the device and notify Physical Therapy. A review of the facility's undated policy titled Resident Mobility and Range of Motion revealed that Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in range of motion, and residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. NJAC 8:39 - 27.1 (a)

Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to provide a nutritional supplement as prescribed by the physician for 1 of 5 residents (Resident #5) reviewed for nutrition. This deficient practice was evidenced by the following: On 3/12/26 at 12:30 PM, the surveyor observed Resident #5 sitting in bed with the lunch tray on the overbed table. The surveyor observed the lunch meal ticket included a [name redacted] nutritional supplement (a fortified protein and calorie dense nutritional frozen dessert designed to fight malnutrition supplement) with the meal. The surveyor observed that the nutritional supplement was not on the lunch tray. At that time, the surveyor interviewed Licensed Practical Nurse (LPN # 1) who confirmed the nutritional supplement was not on the lunch tray. On 3/13/26 at 9:00 am, the surveyor observed Resident #5 sitting in bed with the breakfast meal tray on the overbed table. The surveyor observed the breakfast meal ticket included a [name redacted] nutritional supplement with the meal. The surveyor observed that the nutritional supplement was not on the breakfast tray. At that time the Registered Nurse/Unit Manager (RN/UM#1) confirmed the nutritional supplement was not on the breakfast tray.The surveyor reviewed the medical record for Resident #5.A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: nontraumatic subarachnoid hemorrhage from the left middle cerebral artery (a spontaneous bleed not caused by trauma that occurs when an aneurysm on the left middle cerebral artery ruptures, dysphagia (difficulty swallowing), and aphasia (a disorder that affects how you communicate).A review of the comprehensive Minimum Data Set (MDS), dated [DATE], revealed that in section C for cognitive patterns, the Brief Interview for Mental Status (BIMS) assessment was not assessed. Further review of the MDS revealed the resident needed supervision for eating, had a weight loss of 5% or more in the last month, was not on a prescribed weight loss program, and had a diagnosis of dysphagia. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 2/16/26, that the resident was at risk for nutrition alteration. Interventions included: Supplements as ordered.A review of the Order Summary report (OSR), dated as of 3/13/26, included the following physicians' orders (PO):A PO, dated 2/12/26, for [name redacted] supplement with meals record % consumed. DO NOT SUBSTITUTE due to thickened liquids.A PO, dated 2/10/26, for Regular diet, mechanical soft/ground texture, Nectar/level 2 consistency.A review of the Nutrition/Dietary progress note, dated 2/11/26 at 10:47 AM, revealed that the resident had significant weight fluctuations over the past one month, had good intake of 50-75% of meals and received [name redacted] supplement three times a day.On 3/13/16 at 10:10 AM, the surveyor interviewed the Registered Dietician (RD) who stated that she is an agency dietician filling in for the regular RD. The RD stated that supplements such as [name redacted] nutritional supplement and health shakes come from the kitchen and are not stocked on the nursing units. The RD stated that the nutritional supplement should have been on the meal trays as ordered. The RD further stated that the resident's weights were up and down, and the four weeks of weekly weights were not completed yet to determine if a significant weight loss had occurred.On 3/13/26 at 11:17 AM, the surveyor interviewed the Food Service Director (FSD) who stated that the [name redacted] nutritional supplement should have been on each meal tray. The FSD confirmed that the nutritional supplement was on the resident's meal tickets and must have been missed. The surveyor observed that [name redacted] supplements were available in the kitchen.On 3/16/26 at 1l:18 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, who stated that the [name redacted] supplement should have been on the meal trays as ordered. The DON further stated that it is important that supplements were given as ordered for nutritional purposes.A review of the facility's Weight Assessment and Intervention policy, revised March 2022, included interventions for undesirable weight loss are based on careful considerations of the following: a. Resident choice and preferences; b. nutrition and hydration needs of the resident; .g. the use of supplements and or/feeding tubes. NJAC 8:39-17.4(a)1

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) administer oxygen at the prescribed flow rate, and b.) provide the resident with an appropriate oxygen delivery system while ensuring oxygen was handled and dispensed safely for 1 of 1 resident (Resident #14) reviewed for respiratory care.This deficient practice was evidenced by the following: On 3/11/26 at 10:03 AM, the surveyor observed Resident #14 in his/her bedroom lying in a lateral position with the head of the bed flat. The resident was receiving oxygen via a nasal cannula (NC) (a device used to deliver oxygen), connected to a portable oxygen cylinder in a cart. The regulator (a device attached to an oxygen tank or cylinder that controls and monitors the flow of oxygen) was set at 3 liters per minute (LPM), and the pressure gauge was in the red, indicating the tank required refilling. On 3/11/26 at 10:12 AM, the surveyor observed Resident #14 in his/her bedroom sitting in a wheelchair adjacent to the bed. The resident was receiving oxygen via a nasal cannula (NC) connected to a portable oxygen cylinder in a cart. The regulator was set at 3 LPM. The surveyor reviewed the electronic medical record for Resident #14. A review of the admission Record, an admission summary, revealed the resident had diagnoses including, but not limited to, metabolic acidosis (a medical condition in which the body produces too much acid, affecting the function of organs such as the heart, lungs, and kidneys). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/20/26, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. A review of the Individual Comprehensive Care Plan (ICCP), dated 10/30/25, included a focus area indicating that Resident #14 received oxygen therapy. Interventions included oxygen at 2 LPM via NC. A review of the Order Summary Report (OSR), dated 3/11/26, included the following physician orders (PO):A PO dated 3/11/26: Change oxygen tubing and humidifier bottle weekly, and every night shift on Wednesday for oxygen.A PO dated 3/09/26: Oxygen at 2 LPM via NC as needed (PRN) for shortness of breath or hypoxia. During an interview with the surveyor on 3/13/26 at 10:49 AM, the Licensed Practical Nurse/Interim Unit Manager (LPN/IUM #1) on the [NAME] 6 Unit explained that the resident should have an oxygen concentrator (a medical device located at the bedside that delivers oxygen) in his bedroom if oxygen is prescribed by a physician. She stated that the portable oxygen cylinder was intended for emergencies, for transport outside the facility, or when oxygen was required outside the bedroom, including in hallways or during showering. She further indicated that the regulator on the portable oxygen cylinder should be set at 2 LPM as prescribed by the physician, not 3 LPM. She added that if the resident was receiving oxygen for shortness of breath or hypoxia, the portable oxygen cylinder pressure gauge should not be empty.During an interview with the surveyor on 3/13/26 at 11:20 AM, the Director of Nursing (DON) stated that if Resident #14 was prescribed oxygen, an oxygen concentrator should be present in the room at all times. A review of the facility's undated policy titled Oxygen Administration, revealed that Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess any special needs of the resident. Assemble the equipment and supplies as needed. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate medication dispensing and administration for 1 of 6 residents (Resident #52) observed during the medication pass. This deficient practice was evidenced by the following: On 3/12/26 at 8:10 AM, the surveyor observed License Practical Nurse (LPN) #2 dispense six medications for Resident #52. As the LPN pulled medications from the medication cart, she handed them to the surveyor. The LPN handed the surveyor an over-the-counter (OTC) pill bottle of calcium carbonate 600 milligrams (mg) - vitamin D 10 micrograms (mcg) and then the LPN dispensed one pill from the bottle into the medicine cup. When the LPN finished dispensing the medications, she locked her medication cart and turned on the privacy screen on the electronic medical record. Before the LPN entered Resident #52's room, the surveyor asked the LPN to review the resident's medications with the surveyor. The LPN verified that the resident had the following physician's order (PO): calcium carbonate 600 mg give one tablet by mouth in the morning for supplement. At that time, the LPN acknowledged she dispensed the incorrect calcium carbonate medication and used a drug buster to destroy the medication. The LPN further stated that she would either have to call the physician to have the calcium carbonate order changed to the OTC medication the facility had in stock, or she would have to see if the correct calcium carbonate OTC medication could be ordered. On 3/12/26 at 8:52 AM, the LPN stated she should have checked the PO multiple times against medication bottle because that is what the doctor ordered and to prevent a reaction. On 3/16/26 at 10:22 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that to ensure the correct medication is administered, the nurses should compare the medication dispensed against the PO in the Medication Administration Record (MAR). The LPN/UM further stated that if the nurse did not have the correct medication, she should call the physician to see if an alternative could be given. On 3/16/26 at 1:17 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team. The DON stated the nurses should check the medication against the PO in the MAR to ensure the correct medication is administered. The DON explained that if the nurse did not have the correct medication, she should call the physician for instructions. At that time, the surveyor informed the DON of the above medication error and the DON stated the nurse should have checked the medication bottle against the MAR. A review of the facility's Administering Medications policy, revised 4/2019, included the following: Medications are administered in accordance with prescriber orders.The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. NJAC 8:39-27.1(a)NJAC 8:39 - 29.2(d)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to ensure recommendations made by the pharmacy consultant were acted upon in a timely manner for 2 of 5 residents (Resident #3 and #61) reviewed for unnecessary medications. This deficient practice was evidenced by: 1.) On 3/12/26 at 12:59 PM, the surveyor interviewed Resident #61 in their room. Resident #61 was alert and oriented and conversed with the surveyor regarding his/her care. The surveyor reviewed the electronic medical record (EMR) for Resident #61. A review of the admission Record, an admission summary, reflected that the resident had diagnoses which included, but were not limited to, acute pulmonary edema, anxiety, and depression. A review of the pharmacy consultant's recommendations for February 2026 revealed the following recommendations: Please clarify the incomplete order for Dulcolax suppository, Fleet enema, Milk of Magnesia. The order lacks FREQUENCY. The manufacturer recommends a maximum dosage of 5 mg (milligrams) of Cetirizine per day in those older than [AGE] years of age. Please review the need for the present dosage. A review of the physician's orders and Medication Administration Record (MAR) included the following: Milk of Magnesia Suspension 7.75 (Magnesium Hydroxide) Give 30 ml (millimeters) by mouth as needed for Constipation Give 30 ml by mouth if no bowel movement in 48 hours, order date 2/2/26. Dulcolax Suppository 10 MG (Bisacodyl) insert 1 suppository rectally as needed for constipation if Milk of Magnesia is ineffective give Dulcolax 10 mg suppository via rectum, order date 2/2/26. Fleet Enema 7-19 GM/1118 ML (sodium Phosphates) insert 1 applicatorful rectally as needed for constipation if no bowel movement after Dulcolax suppository give Fleet Enema via rectum. Cetirizine HCI Oral Tablet 10 MG (cetirizine HCI) Give 1 tablet by mouth one time a day for allergies, order date 2/2/26. During an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #1 on 3/13/26 at 11:20 AM, he was unable to immediately respond to the process for following up with the pharmacy consultant's recommendations and stated that he would consult with the Director of Nursing (DON) and report back to the surveyor. On 3/13/26 at 12:46 PM, the surveyor located LPN/UM #1 and at that time LPN/UM #1 stated that a call was just made to the physician for a response to the pharmacy consultant recommendations. LPN/UM #1 was unable to provide an explanation as to why the physician was not notified prior to surveyor inquiry, or as to the process and procedure for the Medication Regimen Review (MRR) or regarding the follow-up to pharmacy consultant's recommendations. On 3/16/26 at 1:55 PM, in the presence of the survey team, the surveyor reviewed the pharmacy consultant's recommendations and corresponding physician's orders with the DON and the Licensed Nursing Home Administrator (LNHA). When the DON was questioned regarding the process, timing, and steps in the MRR, she was unable to provide a response and stated that she would check because she was not sure. A review of the facility's, Pharmacy Services-Role of the Consultant policy, with a revision date of April 2019, did include the timing of responses. 2.) The surveyor reviewed the medical record for Resident #3. According to the admission Record, an admission summary, Resident #3 had diagnoses which included, but were not limited to, hypothyroidism. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 2/3/26, included the resident had a Brief Interview for Mental Status score of 13 out of 15, which indicated the resident's cognition was intact. A review of the individualized comprehensive care plan included a focus area, dated 7/29/25, that the resident had hypothyroidism. Interventions included: Give thyroid replacement therapy as ordered. A review of the Order Summary Report, as of 3/16/26, included the following physician's order (PO): A PO, dated 11/11/25, for levothyroxine sodium oral tablet 75 micrograms (mcg), give one tablet by mouth in the evening for hypothyroidism. A review of the pharmacy consultant's recommendations, dated 11/12/25, included the following recommendation: Levothyroxine is ideally administered on an empty stomach, preferably before breakfast. A review of the March 2026 Medication Administration Record (MAR) revealed the above levothyroxine order was started on 11/11/25 and was scheduled for 4:30 PM daily through 3/11/26. On 3/12/26, the administration time was changed to 6:00 AM, however the PO still instructed to give the medication in the evening. A review of the progress notes included a nurse's note, dated 3/11/26 and written by the Director of Nursing (DON), which revealed a new PO was obtained from the physician to change the levothyroxine administration time. On 3/16/26 at 10:22 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated after the facility received the pharmacy consultant's recommendations, they would immediately notify the physician to approve the recommendation to prevent a delay in care. On 3/16/26 at 1:17 PM, the surveyor interviewed the DON, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team. The DON stated it was the responsibility of the UM to address the pharmacy consultant's recommendations and follow-up with the physician. When asked what the facility's required timeframe to address the pharmacy consultant's recommendations was, the DON stated she would have to check the facility's policy. At that time, the surveyor notified the DON of the delay in addressing Resident #3's pharmacy consultant recommendations and the DON stated the 11/12/25 recommendation should have been addressed sooner than 3/11/26. A review of the facility's Medication Regimen Reviews policy, revised May 2019, included the following: The goal of the MRR [Medication Regimen Review] is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. If the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or the administrator. The policy did not include a timeframe in which the facility should address the pharmacy consultant's recommendations. NJAC 8:39-29.3

Based on observation, interview, and review of facility documentation it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of debris and failed to cover 1 of 1 dumpsters. This was evidenced by the following: On 3/11/26 during the initial tour of the kitchen with the Food Service Director (FSD), the surveyor observed the dumpster area. The large green dumpster did not have a lid. The FSD told the surveyor it was delivered with no lid. Just past the dumpster in the same enclosed area the surveyor observed two mattresses, four wood pallets, and a reclining chair on the ground. The surveyor asked the FSD who was responsible for the maintenance of the trash surrounding the dumpster and he stated it was the responsibility of the housekeeping department. On 3/17/26 the surveyor, during an interview with the Licensed Nursing Home Administrator (LNHA), asked why it was important for dumpsters to be closed and why there shouldn't be trash on the ground in the area. The LNHA said it was important for dumpsters to be closed so there were no pest and rodent issues, and the same for the dumpster area, To avoid having rodents. A review of the policy titled, Disposal of Garbage and Refusal, dated 12/2025 indicated that refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers and garbage should not accumulate or be left outside of the dumpster. NJAC 8:39-19.7 (b), 31.5 (a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain medical records that were accurately documented by not signing off medications immediately after administration for 3 of 6 residents (Resident #24, #52, and #77) observed during the medication pass. This deficient practice was evidenced by the following: On 3/12/26 at 8:13 AM, the surveyor observed Licensed Practical Nurse (LPN) #2 dispense and administer six medications to Resident #52. The nurse did not sign off the medications as administered when she returned to the medication cart, and instead moved on to the next resident. At 8:22 AM, the surveyor observed LPN #2 dispense and administer five medications to Resident #77. The nurse did not sign off the medications as administered when she returned to the medication cart, and instead moved on to the next resident. At 8:48 AM, the surveyor observed LPN #2 dispense and administer two medications to Resident #24. The nurse did not sign off the medications as administered when she returned to the medication cart, and instead moved on to the next resident. At 8:52 AM, the LPN stated she was going to prepare the next resident's medications, but the surveyor stopped the medication pass. When asked what should be done immediately after administering medications, the LPN stated nurses should sign off the medications as administered because if it's not documented, it's not done. The LPN acknowledged that she did not sign off the three residents' medications after administration and stated that nurses should sign off the medications as soon as they were administered to maintain an accurate record for administration. A review of the Medication Admin Audit Reports for the three residents, dated 3/12/26, revealed the following:Resident #24's medications were signed off as administered at 9:02 AM and 9:03 AM.Resident #77's medications were signed off as administered at 9:03 AM and 9:04 AM.Resident #52's medications were signed off as administered at 9:04 AM. On 3/16/26 at 10:22 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the nurses should sign the medications off as administered immediately after the resident takes the medication so that the facility knows the time the medications was taken. On 3/16/26 at 1:17 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team. The DON stated that nurses should sign off the medications as administered immediately after the medication was given because it documented that the resident took their medications. The DON further stated that the nurse should not delay signing off the medications because the facility needed to ensure the resident got their medication at the correct time. At that time, the surveyor informed the DON and LNHA that LPN #2 did not sign off medications after administration and the DON stated that the nurse should have signed off the medications as they were given. A review of the facility's Administering Medications policy, revised 4/2019, included the following:As required or indicated for a medication, the individual administering the medication records in the resident's medical record:a. the date and time the medication was administered. A review of the facility's Charting and Documentation policy, revised 7/2017, included the following:The following information is to be documented in the resident medical record: b. Medications administered. NJAC 8:39-35.2 (d)

Based on observation and interview, it was determined that the facility failed to provide a safe environment for facility staff. This deficient practice was identified throughout the kitchen and was evidenced by the following:On 3/11/26 at 09:20 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD). During the tour of the kitchen the surveyor observed that the floor was made up of four inch by four inch tiles throughout the kitchen. Tile size was confirmed with the FSD. During the observation of the three basin sink the surveyor noticed that 18 of the ceramic tiles were missing from the floor creating an uneven floor surface. The FSD acknowledged the missing tiles and told the surveyor, Sometimes they place mats over the area to make it safer. The surveyor then observed the steam table area. In front of the steam table the surveyor observed 14 broken tiles. Some had loose pieces, and some had missing pieces, creating an uneven floor surface. The FSD acknowledged the uneven floor surface. On 3/17/26 at 9:25 AM, during an interview with the Licensed Nursing Home Administrator (LNHA), he stated that the facility was going to initiate repair of the floor tiles. This occurred following surveyor inquiry. No additional information was provided to the surveyor. A review of the policy titled Maintenance Service, dated 12/2009 revealed that maintenance service shall be provided to all areas of the building, grounds, and equipment in a safe and operable manner at all times. NJAC 8:39-31.2

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility did not ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to properly store the oxygen nasal cannula (NC) (a device used to deliver oxygen tubing) for 1 of 1 resident (Resident #14) reviewed for respiratory care, leaving the device exposed on a bare mattress. This deficient practice was evidenced by the following: On 3/12/26 at 9:20 AM, the surveyor observed that Resident #14's oxygen NC tubing was exposed to air, lying directly on the resident's bare mattress. The surveyor reviewed the electronic medical record for Resident #14. A review of the admission Record, an admission summary, revealed the resident had diagnoses including, but not limited to, metabolic acidosis (a medical condition in which the body produces too much acid, affecting the function of organs such as the heart, lungs, and kidneys). A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/20/26, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. A review of the Individual Comprehensive Care Plan (ICCP), dated 10/30/25, included a focus area indicating that Resident #14 receives oxygen therapy. Interventions included oxygen at 2 liters per minute (LPM) via NC. A review of the Order Summary Report (OSR), dated 3/11/26, included the following physician orders (PO):A PO dated 3/11/26: Change oxygen tubing and humidifier bottle weekly, and every night shift on Wednesday for oxygen.A PO dated 3/09/26: Oxygen at 2 LPM via NC as needed (PRN) for shortness of breath or hypoxia. During an interview with the surveyor on 3/13/26 at 11:15 AM, the Infection Preventionist (IP) stated that the oxygen tubing is changed weekly on Wednesdays and should be kept in a plastic bag when not in use. During an interview with the surveyor on 3/16/26 at 11:20 AM, the Director of Nursing (DON) stated that Resident #14's oxygen tubing should have been stored in a bag and not placed on a bare mattress to maintain infection control. A review of the facility's revised policy, dated 2/26, titled Infection Clinical Protocol, revealed that The physician or provider and staff will identify infection transmission risks and, in conjunction with the infection preventionist, will implement relevant precautions. N.J.A.C. S 8:39-19.4(a)

Based on interviews, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to activate their emergency response system including calling emergency services/911 for a resident (Resident #103) who was found unresponsive and was a full-code status (all resuscitation procedures will be provided when a person stops breathing or their heart stops beating) in accordance with the Basic Life Support (BLS) for Healthcare Providers. This deficient practice was identified for 1 of 4 residents (Resident #103) reviewed for a death in the facility. A review of the Progress Notes (PN) and interviews with the licensed nursing staff revealed that on [DATE] at 4:30 AM, the Certified Nursing Assistant (CNA #1) found Resident #103 unresponsive and reported it to the Licensed Practical Nurse (LPN #1) who began performing cardiopulmonary resuscitation (CPR). LPN #1 stopped CPR, did not call 911 and did not notify the Registered Nurse (RN #1) until 5:50 AM (one hour and ten minutes after Resident #103 was found unresponsive). RN #1 did not perform CPR or call 911, and pronounced Resident #103 deceased at 5:55 AM The facility's failure to ensure their emergency response system was activated including calling 911 posed a likelihood that serious injury, harm, impairment, or death could occur to all residents who were a full code. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on [DATE] at 4:30 AM, when Resident #103 was found unresponsive, and the facility failed to call 911. The facility Administration was notified of the IJ on [DATE] at 4:17 PM. The facility submitted an acceptable Removal Plan (RP) on [DATE] at 10:34 AM. The survey team verified the implementation of the RP during the continuation of the on-site survey on [DATE]. The evidence was as follows: A review of the facility provided Code/Blue/CPR policy dated revised February 2022, included it is the policy to activate a Code Blue in response to a cardiac or respiratory arrest. Basic Life Support in this setting will include: 1. initiating CPR, oxygen, and defibrillation (if necessary); 2. Activating the Emergency Response System. In the event of a cardiac and/or respiratory arrest, a Code Blue will be announced on the unit. Providers from each unit will respond to the Code Blue. The resident's assigned nurse will be the designated team leader. The procedure is as follows: first person confirms cardiac or respiratory arrest, checks code status; calls for help and begins CPR; second person assigns someone to activate Code Blue and applies [automated external defibrillator] AED (a device used to deliver an electronic shock to restart heart rhythm) pads and sets up suction machine .third person activates a Code Blue and Emergency Response System; completes transfer form and assigns a staff member to wait for paramedics at front door. On [DATE] at 11:25 AM, the surveyor reviewed the closed medical record of Resident #103. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; essential hypertension (high blood pressure), hemiplegia (one sided weakness) and hemiparesis (one sided paralysis) following unspecified cerebrovascular disease (affects blood flow and the blood vessels in the brain) affecting left non-dominant side, dysphagia (difficulty swallowing) following unspecified cerebrovascular disease, cognitive communication deficit, and a personal history of nicotine dependence. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated [DATE], included the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated a fully intact cognition. A review of Resident #103's Order Summary Report (OSR) revealed a physician's order dated [DATE], which indicated that the resident was a full-code. A review of the New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) dated [DATE], revealed that the resident wanted full treatment which included but was not limited to; a defined trial period of artificial nutrition (a form of nutrition that is given through a tube inserted into a vein, under the skin, or into the stomach or small intestine), attempt resuscitation/CPR, and intubate (insert a tube into the trachea (wind pipe)/use artificial ventilation as needed for ventilation. A review of the individual comprehensive care plan (ICCP) included a focus area dated [DATE], that the resident had an Advance Directive in place related to the completed POLST form on the chart, Power of Attorney, and a living will. Interventions included that the resident requested to be a full-code and that health care wishes were discussed with resident and/or health care representative to assure the resident's wishes were being met. A review of the PN dated [DATE] at 6:57 AM by LPN #1, revealed that upon receiving the resident at the beginning of the 11:00 PM to 7:00 AM (,d+[DATE]) shift, Resident #103 was found sleeping with slight movement. CNA #1 completed rounds at 2:00 AM and turned and repositioned the resident. At that time, the resident was still breathing, and the resident reported no pain or discomfort. Around 4:30 AM, CNA #1 reported something was wrong with the resident, and upon LPN #1 assessing the resident, the resident had no pulse and CPR was initiated until RN #1 was called to assess (the resident). RN #1 pronounced the resident deceased , and the family and doctor were immediately notified. During an interview with the surveyor on [DATE] at 10:34 AM, CNA #3 stated that she was not familiar with Resident #103. When asked what a CNA's role was in a code blue (a medical emergency, usually cardiac or respiratory arrest), she stated the aide got the nurse and emergency equipment, and the Unit Manager (UM) called 911. CNA #3 further stated that an announcement was made for 911 for the specified room number, a code was called, and all staff reported. During an interview with the surveyor on [DATE] at 10:39 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM #1) stated that during a code blue, the nurse obtained vital signs (blood pressure, pulse, respirations, and pulse oximetry (oxygen level in the blood detected by placing a probe on the person's finger)), performed an assessment, got the code cart, called 911, and performed CPR until 911 services took over. LPN/UM #1 stated that it should be documented that 911 was dispatched in the PN. LPN/UM #1 stated that Resident #103 was administered CPR and RN #1 should have been assisting LPN #1 with CPR. LPN/UM #1 stated that LPN #1 was out on medical leave and was not able to be interviewed. LPN/UM #1 read the PN aloud that was written by LPN #1 and confirmed it was not documented that LPN #1 called 911. LPN/UM #1 stated that staff were told that they had to document everything. During an interview with the surveyor on [DATE] at 11:32 AM, the Director of Nursing (DON) stated that during a code blue, the aide would notify the nurse and the nurse would complete a full assessment. The DON stated the nurse checked the resident's code status, and they went straight to work and added that the nurse called an alert, assessed the resident, and if there was no pulse, 911 was called and CPR was performed until emergency medical services (EMS) came to the facility and took over. The DON reviewed Resident #103's PN with the surveyor and confirmed that there was no documentation that was 911 called and 911 should have been called. The DON stated that RN #1 was ultimately responsible for ensuring 911 was called and was disciplined and received education for that on [DATE]. The DON confirmed RN #1 was certified in CPR. On [DATE] at 12:35 PM, the surveyor reviewed an Employee Counseling Record dated [DATE], in RN #1's employee file which revealed that RN #1 failed to follow procedure for the incident on [DATE] at 5:50 AM. The document was signed by RN #1, the DON, and the Licensed Nursing Home Administrator (LNHA). On [DATE] at 8:33 AM, the facility provided the surveyor with copies of Basic Life Support (BLS) Certification (CPR and AED) Program Certificates that were issued to LPN #1 on [DATE], and RN #1 on [DATE]. During a phone interview with the surveyor on [DATE] at 12:41 PM, RN #1 stated that on the morning of [DATE], at around 5:50 AM, he was passing out medications on the 600 Unit, when LPN #1 called him and stated that she needed me urgently and I rushed to her. RN #1 stated that Resident #103 was in bed, and the resident did not respond when he called the resident's name. RN #1 stated, I tried to sit the resident up and there were no heart sounds, and no pulse and the resident was cold. RN #1 stated that the resident was not breathing, and their chest was not rising. RN #1 stated that he tried unsuccessfully to feel a pulse on the resident's neck, and he put the blood pressure cuff on the resident, and it did not register. RN #1 stated that he pronounced the resident dead and notified the physician. RN #1 stated that the BLS protocol was when someone was unresponsive, you had to start CPR and called 911. RN #1 stated that LPN #1 did not call 911, but he acknowledged that he should have. RN #1 stated when he arrived on the unit, LPN #1 was at the nurse's station, and she reported that she performed CPR, and the resident was dead. RN #1 stated, she called me after the fact. RN #1 stated when he went to assess Resident #103, the resident was unresponsive and already dead so I did not call 911. During an interview with the surveyor on [DATE] at 12:54 PM, LPN/UM #1 stated that if the aide informed the nurse that the resident was not breathing, the nurse should have checked the pulse, called a code, called 911, got the crash cart, and AED. When the surveyor asked if an AED was used on Resident #103 during CPR, she stated it was not documented as used. LPN/UM #1 stated, Unfortunately, there was a breakdown in the protocol, and they (911) should have been called. During an interview with the surveyor on [DATE] at 1:58 PM, the surveyor asked the DON if LPN #1 used the AED during CPR for Resident #103, the DON responded it was not documented as used. During an interview with the surveyor on [DATE] at 1:05 PM, the surveyor was unable to reach CNA #1, who was assigned to care for Resident #103 on [DATE], during the ,d+[DATE] shift, by phone and instead interviewed CNA #5 who also worked on the 500 Unit that shift. CNA #5 stated that if something happened that night, she did not notice. CNA #5 stated that if you were aware of a code, you were supposed to help the nurse. CNA #5 stated that she had never been asked to go and get help or to call 911. During an interview with the surveyor on [DATE] at 1:13 PM, in the presence of the survey team, the DON stated that she did not do an investigation and did not question the time lapse from when CNA #1 found the resident unresponsive at 4:30 AM and notified LPN #1, to LPN #1 notifying RN #1 at 5:50 AM. The DON stated that she did not focus on the time and just asked RN #1 about CPR and why 911 was not called. The LNHA who was present stated, RN #1 thought that it was an ethical issue to keep CPR going. During an interview with the surveyor on [DATE] at 2:38 PM, the Medical Director stated that when there was a code blue and someone stopped breathing who was a full-code, he expected whoever was in the building to call the nursing supervisor, perform BLS and call 911. Emergency Medical Services (EMS) would arrive to the facility with Advanced Cardiac Life Support (ACLS- protocols beyond BLS, to treat cardiac emergencies such as cardiac arrest with CPR, airway management, and/or the use of an AED). The Medical Director stated that EMS took over the care of the resident and pronounced them if indicated. The Medical Director stated that he was notified of the scenario and clearly, 911 should have been notified. An acceptable Removal Plan (RP) on [DATE] at 10:34 AM, indicated the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: the facility's Code Blue/CPR policy was updated to reflect staff are to call 911 during emergency response; LPN #1 and RN #1 will be educated by the DON on the facility's Code Blue/CPR policy prior to working next shift; all licensed nurses will be educated on the facility's Code Blue/CPR policy; and the Staffing Coordinator will ensure at least 50% of all licensed nurses in the building at all times are CPR certified. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on [DATE]. NJAC 8:,d+[DATE].1 (3), 9.6 (g),14.2(b)

Complaint # NJ 00173863 Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure a treatment that was ordered for a right shin tear was implemented without a 23-day delay which resulted in the wound worsening with a necrotic (death of cells in your body tissues) wound infection that required a seven-day antibiotic treatment. This deficient practice was identified for 1 of 4 residents (Resident #305) reviewed for pressure ulcer and was evidenced by the following: On 11/6/24 at 12:30 PM, the surveyor reviewed the closed medical record for Resident #305. A review of the Admission Record face sheet (an admission summary) revealed that the resident had diagnoses which included but were not limited to; Alzheimer's disease, dementia, heart failure, diabetes mellitus, and muscle weakness. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/10/24, included the resident's cognition was severely impaired; the resident needed minimal assistance with eating, moderate assistance with mouth care; and dependent in all other activities of daily living and mobility. Further review revealed the resident had two (2) unstageable pressure ulcers (full-thickness tissue loss) with wound treatment and received hospice care. A review of the Progress Notes (PN) included a Nurses Note (NN) dated 4/23/24 at 2:18 PM, which revealed that the nurse was notified by the resident's Hospice Nurse that the resident had a new wound on the right shin. The resident was assessed for a stage 2 wound (an open wound that breaks the skin), the doctor was notified, a new treatment order was put in the electronic medical record (EMR), and all necessary documentation was completed. A review of the Progress Notes included a Physicians Note (PN) dated 5/15/24 at 5:16 PM, which revealed a late entry for worsening wounds. The PN included that the resident developed a right shin wound which was now enlarging with necrotic (dead) tissue and malodorous (foul smelling) drainage with surrounding erythema (reddening of the skin). Assessment and plan included that the right shin wound had necrotic and infected tissue; to cleanse the right shin with 1/4 strength Dakin's, apply Medihoney (honey-based ointment), Flagyl (an antibiotic) powder, Abdominal pad (ABD; wound dressing) pad and [gauze] wrap daily. To start doxycycline (an antibiotic) 100 milligrams (mg) by mouth twice a day for seven days. A review of the Order Summary Report (OSR) dated as of 5/1/24, included the following physician orders (PO): A PO dated 4/23/24, to cleanse sacral wound (lower back) with Normal Saline Solution (NSS); apply Medihoney; cover with ABD and paper tape one time a day for sacral wound. This order did not address the right shin wound which was documented on the 4/23/24 Progress Notes. A review of the April and May 2024 Physician's Order Sheet (POS) and Treatment Administration Record (TAR) did not include any PO for the new right shin skin tear until 5/16/24, which was 23 days after. A review of the OSR dated as of 6/1/24, included the following PO: A PO dated 5/16/24, to clean right shin wound with 1/4 strength Dakin's (a topical antiseptic used to treat and prevent infections in wounds); apply Medihoney, then Flagyl powder; cover with ABD pad and wrap with [gauze] wrap daily one time a day for right shin wound. A PO dated 11/14/23, for weekly skin checks every day shift every Saturday. A review of the resident's individual comprehensive care plan (ICCP) did not include a focus area or interventions for the new right shin skin tear identified on 4/23/24. On 11/8/24 at 12:40 PM, the facility was unable to provide the hospice nursing notes but provided the hospice care plans that included the following: A hospice care plan dated 4/22/24, included a stage 3 (a full-thickness tissue loss that extends through the skin into the fatty tissue below, but does not expose bone, tendon, or muscle) on the middle of the right shin to clean with wound spray; apply Medihoney and apply four-by-four (4 x 4) adhesive pad. Wound care to be provided daily; facility to provide care on non-hospice days. A hospice care plan dated as of 6/1/24, included a right shin (stage 3) wound to cleanse with Dakin's 1/4 strength, pat dry; apply Medihoney to wound bed; cover with ABD pad, [gauze] wrap daily and secure with paper tape by facility nurse daily. A review of the Incident Report (IR) for a skin tear to the right shin dated 4/23/24, included that the treatment order was placed in the EMR for wound care and that the care plan was updated. The IR did not include any measurements or description of the right shin skin tear. The IR included the risk management form dated 4/23/24 at 2:23 PM. The risk management form did not include any wound measurements or description of the right shin skin tear. A review of the weekly skin assessment dated [DATE], included that the resident did not have any open areas or marks on the skin but also identified that the resident's right lower leg had a stage 2 skin tear to the right middle shin. The weekly skin assessment did not include the measurements of the skin tear, the color, the odor, or if the skin tear had any drainage. There was no documented evidence of weekly skin assessments completed after 4/23/24, through 5/25/24. A review of the weekly skin assessment dated [DATE], included that a right shin wound had a treatment currently in place. There was no description or measurement of the right shin wound. On 11/12/24 at 10:08 AM, the surveyor interviewed the Director of Nursing (DON), who confirmed that the Licensed Practical Nurse (LPN) who wrote the Progress Note on 4/23/24, and the Nurse Practitioner (NP) who signed the PO on 4/23/24, for the sacral wound treatment were not employed at the facility anymore. On 11/12/24 at 10:30 AM, the surveyor interviewed the Certified Nursing Assistant (CNA#2), who stated that she remembered Resident #305 and that the resident was on hospice. CNA#2 stated the Hospice Aid came in early to wash, dress and feed the resident, then then she cared for the resident the rest of the shift. CNA#2 could not recall if the resident had any open areas or wounds. On 11/12/24 at 10:37 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM#1), who stated that that if a new skin tear or wound was identified, the nurse completed a risk management form in the EMR; completed an Incident Report; measured the wound; contacted the doctor; and obtained treatment orders. The weekly skin assessments were completed by the medication nurse and included the location, measurements, if there was any drainage or smell, how the skin around the wound appeared and any treatments that were ordered. LPN/UM#1 further stated that when a resident was on hospice, the Hospice Nurse assessed the wounds and gave recommendations for a treatment. The staff nurse obtained a PO for the treatment and completed the wound treatments as ordered. LPN/UM#1 stated that the ICCP should be updated with interventions when a new wound or pressure ulcer was identified. At that time, the surveyor and LPN/UM#1 reviewed the Progress Notes, the PO, the ICCP, and the weekly skin assessments in the EMR. LPN/UM #1 confirmed that she had entered the PO on 4/23/24, in the EMR and it should have been for the right shin skin tear and not the sacral wound. LPN/UM#1 stated that weekly skin assessments should have been completed weekly and should have included location, measurements, and any drainage or foul odor of the wound. LPN/UM#1 confirmed that a treatment order for the right shin skin tear was not on the POS or the TAR until 5/16/24. LPN/UM#1 further stated that on 5/16/24, when the right shin skin tear had worsened, a skin assessment should have been completed. After reviewing the Progress Notes, LPN/UM#1 could not recall if the Hospice Nurse had notified her about the right shin skin tear between April to May 2024. LPN/UM #1 stated that the Hospice Nurse usually visited the resident twice a week. On 11/12/24 at 11:56 PM, the surveyor interviewed Resident #305's Attending Medical Doctor (AMD), who stated that if the nurse identified a new wound or pressure ulcer, they called the AMD, and a wound treatment would be ordered as well as a wound consultation (consult) if needed. The AMD stated that Resident #305 was on hospice so a wound consult would not have been ordered. The surveyor and the AMD reviewed the Progress Notes and POs for Resident #305. The AMD confirmed that the treatment PO on 4/23/24, had been entered wrong and should have been for the right shin skin tear. The AMD reviewed the weekly skin assessments and confirmed that the assessments were not completed weekly and did not include measurements, or identifiable assessments such as drainage or foul order. The AMD stated that it was important to complete wound care as recommended or the wound could get worse or infected. The AMD further stated, I think that when a resident is on hospice, the staff relies too much on the hospice aides and nurses for the resident's care. On 11/12/24 at 1:11 PM, the surveyor interviewed the Director of Nursing (DON), who stated that when a new wound or pressure ulcer was identified, the nurse assessed the wound, completed an Incident Report, called the doctor, obtained new treatment orders, updated the ICCP, and notified the resident's representative. The DON further stated that weekly skin assessments were completed by the medication nurse or unit managers and the weekly skin assessments should include the location, wound measurements, type of wound and details about the wound. The DON stated that it was important to obtain a PO for wound treatment and complete the wound treatment as ordered because it could prevent any deterioration and worsening of the wound. When a resident was on hospice, the Hospice Nurse made wound care recommendations and the staff nurse obtained a PO from the attending physician. On 11/13/24 at 1:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that he was made aware of Resident #305's right shin wound infection by the Hospice Nurse and by the local ombudsman. The LNHA stated he could not remember the exact date, but it was when the resident was still in the facility. A review of the facility's undated Pressure Ulcer- Clinical Protocol policy, included that once a pressure ulcer/open area is identified, nursing will: immediately assess the area, obtain measurements, and identify the possible source and or cause, notify MD/Nurse practitioner (NP) and obtain orders, notify resident primary contact, implement risk management in PCC (EMR), implement skin packet and interventions, administer pain medications as needed, update care plan to reflect new skin issue and interventions and notify wound NP . A review of the facility' Hospice policy, dated revised December 2022, included that generally it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. A review of the facility's Physicians Order policy, dated revised January 2022, included that the purpose of the policy is to ensure all physician orders are complete and accurate. The policy also included that treatment orders will include the following: a description of the treatment, including the treatment site. A review of the facility's Treatment Administration policy, dated revised January 2016, included that the nurse will administer all treatments as ordered and document. NJAC 8:39-27.1(a)

COMPLAINT #: 9 Based on interviews, Medical Record (MR) review, and review of other pertinent facility documents on 3/9/2021 and 3/12/2021, it was determined that the facility staff failed to provide a safe environment to ensure residents were protected from actual physical/sexual abuse by failing to adequately monitor and supervise a known sexual seeking resident (Resident #1) with a known history of sexual encounters with residents. On 2/20/2021, Resident #1 was observed by the staff in bed with Resident #2, a cognitively impaired resident, partially unclothed from the waist down. The facility also failed to follow their policy titled Abuse Policy and notify the police for 2 of 3 residents (Resident #1, and Resident #2) sampled for abuse. This placed all residents with cognitive impairment who were living in the facility in an immediate jeopardy situation. The IJ was identified on 3/12/2021 at 2:27 p.m., when the Administrator (Admin) and the Director of Nursing (DON) were notified of the IJ situation and were provided with the IJ template. The IJ ran from 2/20/2021 to 3/5/2021, until Resident #1 was discharged from the facility and the staff were in-serviced on Abuse. The facility provided an acceptable Removal Plan which included in-servicing of the staff on Abuse, and Reporting of Abuse which removed the Immediacy. The IJ was Past Non-Compliance. 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), an assessment tool dated 12/15/2020, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12/15, which indicated the resident had moderate cognitive impairment. The MDS also revealed that Resident #1 required extensive assistance for Activities of Daily Living (ADLs). Review of the Care Plan (CP), revealed a Focus of: Resident found in bed with female resident, dated 12/22/2020. Interventions included: Resident agreeable to be separated, Social Worker spoke with resident in regard to the incident. Psychiatrist (Psych) consult placed. Resident sent to Crisis for evaluation and will be place on 1:1 upon return. The CP for Resident #1 also showed a Focus of: Potential risk for Abuse, Resident noted with peer in his/her bed in resident's room sleeping, dated 2/20/2021. Interventions included: every 15-minute monitoring until seen by Psychiatrist and Psychology. The CP for Resident #1 also showed a Focus of: Psychosocial well-being problem related to sexual behavior with a female resident, dated 2/26/2021. Interventions included: Monitor behavior closely for signs and symptoms of engaging in inappropriate relations. Ensure resident and other female resident are not in close proximity. Review of the Progress Notes for Resident #1 dated 1/20/2021 at 8:07 a.m., documented by the Advanced Registered Nurse Practitioner (ARNP), revealed the following: Under Mood Disorder, Assessment and Plan: Patient with sexual behaviors, also issues with outbursts and aggression. Patient now back on 1:1. Under Alzheimer's Disease with behavioral disturbances, Assessment and Plan: Patient is now here for Long-term Care. Resident has adjusted well, still with behavior issues at times. Resident can be very sexual to staff and other residents. Now on 1:1 to redirect from these episodes. Review of a progress note for Resident #1 dated 2/12/2021 at 10:16 a.m., documented by the ARNP, revealed the following: Under Mental Status: He/she is alert. Mental status is at baseline. He/she is disoriented. Patient with sexual behaviors, also issues with outbursts and aggression. He/she had 1:1 for several weeks but it appears to have ended at this time. 2. According to the AR, Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS, an assessment tool dated 1/16/2021, Resident #2 had a BIMS score of 2/15, which indicated the resident had severe cognitive impairment. The MDS also revealed that Resident #2 required extensive assistance for ADLs. According to the CP, Resident #2 had Impaired cognitive function/dementia or impaired thought processes related to moderately impaired: BIMS 8/15 with short-term memory loss dated 10/23/2020. Interventions included but were not limited to: Use task segmentation to support short-term memory deficits. Cue, reorient and supervise as needed. The CP also showed a Focus of: Potential for Abuse dated 2/20/2021, and Resident noted lying in male peer's bed. Psych (Psychiatric) and Psychology prn (as needed), every 15-minutes monitoring until seen by Psych, to monitor resident for any s/s (signs or symptoms) of distress and overall mood and behavior. Review of the progress notes for Resident #2 dated 1/31/2021, revealed the following documentation by the Psychiatric Nurse Practitioner/Advanced Registered Nurse Practitioner (ARNP): Patient had a recent incident, was found in a male resident's room partially clothed. Resident was confused, had poor judgment and insight, attention and concentration were poor, and was easily distracted. Currently on antibiotics for a Urinary Tract Infection (UTI). According to the documentation on the Facility's Reportable Event Record/Report (FRE), reported to the New Jersey Department of Health (NJDOH) by the Administrator on 2/25/2021, with an event date and time of 2/20/2021 at 11:30 p.m., the Type of Incident, as Other: two residents found in bed together. The Narrative included: On 2/20/2021, at approximately 11:30 p.m., Resident #2 was found in Resident #1's bed. Both have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the witness statements with the FRE with an event date and time of 2/20/2021 at 11:30 p.m., the nurse documented that on 2/20/2021 at 11:30 p.m., she was alerted that Resident #2 was not in bed, the staff proceeded to look for the resident, Resident #2 was found in Resident #1's room in the bed. Both residents were partially clothed, naked from the waist down, and were asleep. The residents were separated, and Resident #2 was taken to his/her room, evaluated and placed in bed. Resident #2 was placed on every 15-minute safety checks. The Supervisor was notified and also witnessed the incident. According to the FRE the following interventions were put in place: Resident #2 was taken back to his/her room. A body check was completed on both residents, no apparent injuries were noted. Both residents were able to express themselves separately, verbally, and nonverbally and neither showed any expressions or signs of pain, discomfort or fear. Both residents were placed on every 15-minute checks until evaluated by Psychology and Psychiatry. The FRE also indicated that the Medical Doctor and the Ombudsman were notified of the event, however, there was no documentation that the Local Law Enforcement was notified of the alleged abuse. Review of the Investigation Summary dated 2/20/2021, revealed Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Investigation Summary dated 2/20/2021, revealed Resident #2 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Investigation Summary dated 2/20/2021, under Incident, revealed the following: Resident #2 was observed on 2/20/2021, in Resident #1's room in bed together. They were observed lying next to each other partially unclothed from the waist down. Room light was not on. Both residents appeared to be sleeping when the staff entered the room. Resident #1 was observed with a shirt on but no pants. Resident #2 was observed with a shirt on but with pants down above the knees. Both residents stated, they were cuddling and lying down. Resident #2 reported that he/she propelled the wheelchair to Resident #1's room and Resident #1 assisted him/her into the bed. According to the FRE Conclusion dated 2/20/2021, documented by the Regional Director of Nursing (RDON) who had been covering for the DON, revealed the following: It is my professional opinion that no neglect, abuse or mistreatment has occurred. Both residents remain safe. Nursing will continue to monitor resident for safety. Review of the Safety Check Logs for Resident #2 verified that the every 15-minute safety checks were in place from 2/20/2021 until 3/5/2021, then discontinued. Review of the progress notes for Resident #2 dated 2/21/2021 at 12:07 a.m., revealed the following documentation by the Licensed Practical Nurse (LPN#1). On 2/20/2021 at 11:30 p.m., Resident #2 was found in Resident #1's room, both residents clothes were partially removed from the waist down. Residents were asleep. No signs of sexual activity observed. Resident #2 was removed from Resident #1's bed, evaluated and taken back to his/her room and placed in bed. Both residents placed on every 15-minute checks until further notice. Review of the Safety Check Logs for Resident #1 verified that the every 15-minute safety checks were in place from 2/20/2021 until 3/4/2021 at 11:00 p.m., then discontinued. Review of the progress noted for Resident #1 revealed documentation by Psychiatry/ARNP dated 2/21/2021 at 2:51 p.m., as follows: Staff reported resident exhibits inappropriate sexual behavior and can be verbally/physically aggressive towards staff and peers. Easily annoyed and angered. Can be difficult to redirect. Reduction of [CONDITION(S)] mediation is clinically contraindicated at this time and would likely result in decompensation, impairment of the patients functions and an increase in emotional distress and behaviors. According to the progress notes dated 2/21/2021 at 5:34 p.m., documented by the RDON, Resident #2 was observed by the staff during rounds in bed with a male resident in his/her room. Staff observed both residents partially unclothed from the waist down. Both residents appeared to be sleeping when the staff entered the room. Resident #1 was observed with a shirt on but no pants. Resident #2 was observed with a shirt on but with pants down above the knees. Both residents reported they were cuddling and lying down. Both residents stated no interaction was made they just cuddled and slept. Resident #2 reported feeling safe in the facility. The residents were separated, Resident #2's room was changed to another unit, and both residents were placed on every 15-minute monitoring until seen by Psychiatrist and the Psychologist. Review of the medical doctor's progress note for Resident #2 dated 2/25/2021 at 7:48 a.m., revealed the following documentation by the physician: On 2/20/2021, Patient was found in bed with a male resident and the resident reported wheeling down to Resident #1's room and was helped into the males bed. Patient denied any distress and appeared to have liked cuddling. No physical discomfort observed after the incident. Patient is a poor historian due to memory loss, however, with poor judgement due to dementia. Review of the progress notes for Resident #2 dated 2/28/2021 at 6:18 p.m., revealed the following documentation by the Psychiatric Nurse Practitioner/Advanced Registered Nurse Practitioner (ARNP): Staff reported that the Patient had a recent incident that involved wheeling self into a male resident's room. Staff found both residents in bed, partially clothed and cuddling. Patient denied any distress and no physical discomfort was observed after the incident. Poor safety awareness . Attention/Concentration: Poor, easily distracted .Thought Rate/Content: Confused . Judgement/Insight Poor. During an interview on 3/9/2021 at 11:36 a.m., the Licensed Practical Nurse (LPN #2) reported that she did not feel that Resident #1 or Resident #2 were able to consent to sex due to their impaired cognitive status. I don't believe (Resident #2's name) or (Resident #1's name) were able to consent. They are not alert enough to consent. LPN #2 also stated that Resident #2 is confused and only alert to self. Resident #1 is not there all the time. Resident #1 is confused. During an interview on 3/9/2021 at 12:07 p.m., the DON reported that there was a previous incident between Resident #1 and Resident #2 back in December of 2020. The evening nurse had observed Resident #1 and Resident #2 in Resident #1's room in bed together on 12/22/2020 at 3:10 p.m., with their pants down and only a brief in place from the waist down. The nurse separated the 2 residents. Resident #1 was placed on 1:1 observation and a Psychiatric consultation was ordered. Resident #1 was already being followed by the Psychiatrist for dementia with aggressive behaviors. The DON also stated that she believed Resident #2 went willingly, however, the DON stated I'm not sure he/she (Resident #2) knew who he/she (Resident #1) was. I feel like he/she (Resident #2) was not alert enough to know what he/she (Resident #2) was doing. Review of the staff assignments revealed 1:1 monitoring was in place from 12/22/2020 to 2/4/2021. During an interview on 3/9/2021 at 2:23 p.m., the Director of Social Services (DSS) reported that she was aware that Resident #1 had 3 episodes of sexual contact with residents in the Facility. The DSS reported she felt Resident #1 was alert and oriented. During an interview on 3/12/2021 at 9:44 a.m., the Certified Nursing Assistant (CNA#1), reported that the nurse informed her after the December incident that Resident #2 needed to be watched for safety reasons. Resident #1 would often try to get Resident #2 to go to his/her room by giving him/her the eye and telling Resident #2 Let's go. Resident #1 would say I can get anybody, when the staff would stop Resident #2 from going to Resident #1's room. We always watched him/her (Resident #2) to make sure he/she would not go down to his/her (Resident #1's) room. After the December incident we (CNAs) were told by the nurse to keep them apart. The CNA further stated that she did not feel that Resident #2 was cognitively with it to have consensual sex with Resident #1. During an interview on 3/12/2021 at 9:56 a.m., the DON reported that Resident #1 was discharged to another Facility on 3/5/2021, secondary to his/her behaviors. During an interview on 3/12/2021 at 10:10 a.m., CNA#2 reported that she was the regular CNA for Resident #2 and the resident was alert and oriented on some days and other days the resident was confused. The CNA reported that she had often witnessed Resident #1 trying to get Resident #2 to his/her room by shaking his/her head then wheeling down towards the room, trying to get Resident #2 to follow. Resident #2 would try to follow Resident #1, however, the staff would stop them. The nurse had informed the CNA's to keep them apart for safety. CNA #2 also reported that at times Resident #1 would brag and stated, That was old stuff (referring to Resident #2). I can get anybody else. Resident #1 had stated this after the CNA had stopped Resident #2 from going to Resident #1's room. During an interview on 3/12/2021 at 11:30 p.m., the DON reported that when the Social Worker (SW) interviewed both residents. Resident #2 stated the following, I have wifely duties. However, the DON was not sure if Resident #2 thought Resident #1 was his/her husband due to his/her dementia. The DON also stated that she felt Resident #2 was cognitively intact enough to decide to have intimate relations with Resident #1. The DON further verified that she was aware that Resident #2 had a BIMS score of 2/15 on 1/16/2021, which indicated severe cognitive impairment. During an interview on 3/12/2021 at 12:09 p.m., the RDON reported that she was notified the next day by the Supervisor on 2/21/2021, of the incident between Resident #1 and Resident #2 on 2/20/2021, and she did not report it to the Police since interviews had to be completed first. The RDON stated, that she was able to look up both resident's BIMS at home and Resident #1's BIMS was 12/15, and Resident #2's BIMS was 2/15 which indicated moderate cognitive impairment for Resident #1 and severe cognitive impairment for Resident #2. The RDON was asked if she felt a resident with severe cognitive impairment could consent to have sex with other residents, she responded, well no intercourse occurred. When asked if intercourse had to occur for sexual abuse, the RDON responded, No. The RDON also stated that she was not aware that Resident #1 had prior sexual incidents in the facility. During an interview on 3/12/2021 at 2:22 p.m., the Administrator reported that what we did was because we felt both residents were able to make their own decisions. We did not feel it was abuse so the police were not called. We just now called the Police to see if they will investigate for abuse. They (Resident #1 and Resident #2) developed a friendship with each other. They needed human touch. Everyone is missing their families at this time. According to the facility policy titled Abuse Policy, dated 3/2016, revised date of 10/2017, under Policy; the Facility prohibits the mistreatment, neglect, and abuse of residents/patient and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility has designed and implemented processes which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Under Reporting, Notify the local law enforcement and appropriate State agency(s) immediately by fax or telephone after identification of alleged/suspected incident. Initiate process according to the Elder Justice Act and State specific regulations. The IJ was identified on 3/12/2021 at 2:27 p.m., when the Administrator and the Director of Nursing were notified of the IJ situation and were provided with the IJ template. The IJ ran from 2/20/2021 to 3/5/2021 when Resident #1 was discharged from the facility and the staff were in-serviced. The facility provided an acceptable Removal Plan which included in-servicing of the staff on Abuse, and Reporting of Abuse which removed the Immediacy. The IJ was Past Non-Compliance on 3/12/2021. N.J.A.C. 8:39-4.1(a)5

Based on observation, interview, medical record review, and review of other facility documentation, it was determined that the facility failed to implement mitigation strategies to prevent the transmission of COVID-19 by not appropriately identifying residents exposed to COVID-19 as persons under investigation (PUI) for [MEDICAL CONDITION]. This deficient practice was identified for 7 of 89 residents (Resident #2, #6, #7, #8, #9, #10, and #11) on 2 of 2 nursing units (Nelson 5 and Nelson 6) reviewed for a known exposure to COVID-19 during a Focus Infection Control Survey on 1/20/21. On 1/13/21 and 1/19/21, the facility became aware that two staff members, Physical Therapist Assistant (PTA) #1 and a Certified Nursing Assistant (CNA), were confirmed positive for COVID-19 in the facility. PTA #1 tested positive for COVID-19 on 1/13/21 and had direct contact on 1/11/21 and 1/12/21 with six residents who were not previously infected with COVID-19 within the last three months. The CNA tested positive for COVID-19 on 1/19/21 and had direct contact on 1/18/21 with one resident on the Nelson 5 unit who was never infected with COVID-19. The seven exposed residents resided in the green (well, non-COVID) zones of the two units. The facility failed to identify the residents residing on both green zones exposed to COVID-19 as persons under investigation (PUI) in an effort to mitigate the spread of [MEDICAL CONDITION]. The facility's failure to identify residents on the Nelson 5 and Nelson 6 units as exposed to COVID-19 and implement strategies to prevent the spread of COVID-19 posed a serious and immediate threat to the safety and well-being of all non-ill residents. This resulted in an Immediate Jeopardy (IJ) situation that began on 1/13/21 when the facility was notified of the confirmed positive staff member. The facility administration was notified of the IJ on 1/20/21 at 2:40 PM. On 1/22/2021 during an Onsite Removal Plan Verification survey, the facility was found to be out of compliance. The surveyor observed three rehab staff enter a PUI room without donning (putting on) an isolation gown which was required to be worn. The immediacy was removed on 01/22/21 at 3:21 PM, based on an acceptable revised Removal Plan that was implemented by the facility after the surveyors identified the continued deficient practice and verified by the surveyors during the Onsite Removal Plan Verification survey conducted on 1/22/21. The evidence is as follows: On 1/20/21 at 9:30 AM, the surveyors met with the Administrator, Director of Nursing (DON), the Infection Preventionist (IP), and the Executive Director (ED) in the conference room. The IP stated the Nelson 5 unit consisted of a green zone and a red (COVID-19 positive) zone, and the Nelson 6 unit consisted of a green zone and a yellow (PUI) zone. The IP further stated that staff wear N95 masks and eye protection in the green zones and full personal protective equipment (PPE), which included N95 masks, eye protection, gown, and gloves when staff entered resident rooms on the yellow and red zones. The Administrator stated that the facility had 12 COVID-19 positive residents who resided in the red zone on Nelson 5 and eight new admission residents who resided in the yellow zone on Nelson 6. The Administrator also stated there were no exposed residents but that exposed residents are placed in the yellow zone. The Administrator further noted that seven staff members who tested positive for COVID-19 had not yet recovered. On 1/20/21 at 9:50 AM, Surveyor #2 toured the facility and observed all the resident rooms in the green zones did not have signage for transmission-based precautions (TBP) or PPE supply bins outside of resident rooms. On 1/20/21 at 10:35 AM, the DON emailed Surveyor #1 a copy of the facility's line list (a spreadsheet containing information related to the facility's COVID-19 positive staff and residents and used as a tool for infection control tracking). A review of the line list included two direct care staff members, PTA #1, who tested positive for COVID-19 on 1/13/21, and a CNA who tested positive for COVID-19 on 1/19/21. During an interview with the surveyors on 1/20/21 at 11:45 AM, the IP stated the CNA tested positive for COVID-19 on 1/19/21 and was sent home to quarantine for ten days. The IP further said she did not know if the CNA worked 48 hours prior to her positive test result or which residents the CNA had direct contact with. At 12:05 PM, the IP stated the CNA worked on 1/18/21 and was assigned to Resident #6, who resided in the green zone of Nelson 5 and had never been infected with COVID-19. The IP further stated Resident #6 was not moved to the yellow zone or placed on TBP. During an interview with the surveyors on 1/20/21 at 12:30 PM, the IP stated PTA #1 tested positive for COVID-19 on 1/13/21 and was sent home to quarantine for ten days. The PTA worked on 1/11/21 and 1/12/21 and had direct contact with residents in the green zones of Nelson 5 and Nelson 6. Review of the PTA's schedule for the two days included Resident #2, #7, #8, #9, #10, and #11, who were not infected with COVID-19 within the last three months. The IP further stated that none of the residents on the PTA's schedule that resided in the green zone were moved into the yellow zone or placed on TBP, but that all residents in the facility were monitored for signs and symptoms of COVID-19 three times per day and were tested for COVID-19 two times per week. The IP further stated that the purpose of staff wearing full PPE in the yellow and red zones is to prevent the spread of infectious droplets from room to room. A review of the facility's Nelson 5 and Nelson 6 roster, updated 1/20/21, and the facility's floor plan verified the seven residents exposed to the COVID-19 positive staff remained in the green zones. On 1/20/21 at 2:40 PM, the surveyors met with the Administrator, DON, IP, ED, and Regional Nurse in the conference room. The ED stated that the facility utilized three zones. The green zones were for healthy and recovered residents, the yellow zone was for PUI residents such as new admissions, symptomatic, or exposed, and the red zone was for COVID-19 positive residents. The Regional Nurse stated that residents exposed to COVID-19 would be placed in the yellow zone where staff wear full PPE when entering resident rooms. The IP noted that the seven residents exposed to the COVID-19 positive staff should have been moved to the yellow zone upon receiving the positive test results. This resulted in an Immediate Jeopardy (IJ) situation that began on 1/13/2021 when the facility was notified of a confirmed positive staff member. The facility's Administrator, DON, IP, ED and Regional Nurse were notified of the IJ on 1/20/21 at 2:40 PM. On 1/20/2021 the facility submitted a Removal Plan by e-mail to The New Jersey Department of Health (NJ DOH) which identified the seven residents that had been affected would be moved to the PUI zone where each resident room included signage for TBP and three-compartment storage bins that contained the appropriate PPE for each room. Additionally, the Removal Plan included that the facility would educate all staff on contact tracing, TBP, and PPE. On 1/22/2021 during an Onsite Removal Plan Verification survey, the facility was found to be out of compliance. The surveyor observed three rehab staff enter a PUI room without donning (putting on) an isolation gown which was required to be worn. Review of the facility's COVID-19 Infection Control policy, revised 1/20/21, included, The facility will do contact tracing per CDC/regulatory guidelines for residents and employees who are positive and Residents who are exposed to employees or other residents who are positive will then be placed on observation/quarantine x14 days with the appropriate PPE based on Transmission Based Precaution (gown, gloves, mask/eye protection, N95). Review of the facility's Outbreak Plan, revised 1/20/21, included, Staff members who are tested positive who have worked in the facility, contact tracing be done indicating residents/employees and/or units/floors/areas in the facility that need to be quarantine/under observation. Review of the NJ DOH guidelines, Testing in Response to a Newly Identified COVID-19 Case in Long-Term Care Facilities, updated 10/29/20, included, Identify close contacts including 48 hours prior to symptom onset/date of specimen collection of associated case, if applicable and Quarantine close contacts for 14 days from last exposure and provide care using all COVID-19 recommended personal protective equipment (PPE). Review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, COVID-19 Personal Protective Equipment (PPE) for Healthcare Personnel, dated 3/23/20, included Preferred PPE - Use N95 or higher respirator, face shield or goggles, one pair of clean, non-sterile gloves, isolation gown. Review of the U.S. CDC guidelines, Clinical Questions about COVID-19: Questions and Answers, updated 1/7/21, included, Place exposed patients who are currently admitted to the healthcare facility in appropriate Transmission Based Precautions and monitor them for the onset of COVID-19 until 14 days after their last exposure and If a person has clinically recovered from [DIAGNOSES REDACTED]-CoV-2 infection and is then identified as a contact of a new case 3 months or more after the date of symptom onset of their previous illness episode, then they should follow general quarantine recommendations for contacts. PART B Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to wear the required PPE in resident rooms on TBP. This deficient practice was identified for 2 of 19 residents (Resident #2 and #6) in the Nelson 6 unit's yellow zone reviewed for TBP. This deficient practice was evidenced by the following: On 1/22/21 at 9:56 AM, Surveyor #2 entered the Nelson 6 yellow zone and observed signage, which revealed that rooms #620 to #632 were Covid-19 Under Investigation. Each resident door had signage that it was an observation room, to follow all isolation protocols, to follow required PPE (with written instructions and pictures), sequence for donning (putting on) and doffing (removing) PPE, and instructions for Nurses/Aides and Housekeeping/Therapy about gown usage. On 1/22/21 at 10:33 AM, Surveyor #2 observed PTA #2, an Occupational Therapist (OT), and an Occupational Therapist Assistant (OTA) enter the room [ROOM NUMBER], where Resident #2 and #6 resided. The three rehab staff members did not don an isolation gown and wore N95 masks, eye protection, and gloves when entering the resident room. On 1/22/21 at 10:34 AM, Surveyor #2 observed PTA #2 exit the resident's room and walk to the utility room where the surveyor heard the water running for 23 seconds, exit utility room, and return down the hallway near room [ROOM NUMBER]. When interviewed at that time, PTA #2 stated that N95 masks, goggles, gowns, and gloves were to be worn in the PUI resident rooms. The PTA noted the importance of wearing the correct PPE was so [MEDICAL CONDITION] was not taken out of the room. PTA #2 acknowledged the posted PPE signage on the resident's doorway and that she did not don a gown while in room [ROOM NUMBER]. On 1/22/21 at 10:37 AM, Surveyor #2 observed the OT and OTA in room [ROOM NUMBER] wearing gloves, N95 masks, and face shields. The OT removed his gloves and used hand sanitizer before exiting the room. When interviewed at that time, the OT stated goggles, N95 mask, gown, and gloves were to be worn in the PUI resident rooms. The OT acknowledged the posted PPE signage on the resident's doorway and that he did not don a gown while in room [ROOM NUMBER]. The OT stated the importance of wearing proper PPE was for infection control. During the OT's interview, the surveyor observed the OTA exit room [ROOM NUMBER] and don a gown in the hallway outside of the next resident room. During an interview with Surveyor #2 on 1/22/21 at 10:58 AM, the OTA acknowledged he did not don a gown before entering room [ROOM NUMBER]. He further stated that an N95, face shield, gown, and gloves were to be worn in PUI resident rooms. The OTA also acknowledged the posted PPE signage on the resident's doorway and stated the importance of proper PPE is to not spread [MEDICAL CONDITION]. During an interview with Surveyor #2 on 1/22/21 at 11:03 AM, the Unit Manager (UM) stated an N95 mask, goggles or face shield, gown, and gloves were required in PUI resident rooms. The UM further noted the importance of wearing PPE was to protect residents and self, prevent spreading [MEDICAL CONDITION], and if not wearing the correct PPE while caring for a positive resident, you are exposed. During an interview with Surveyor #2 on 1/22/21 at 11:16 AM, the Director of Rehab (DOR) stated the required PPE in a PUI room was N95 masks, face shield or goggles, gowns, and gloves. The DOR noted the importance of wearing proper PPE was to decrease cross-contamination. The DOR further stated that rehab staff were in-serviced by the DOR or IP on donning/doffing PPE, cross-contamination with COVID-19, handwashing, proper techniques, and TBP signage. A review of in-services held on 1/21/21, validated signatures identifying that the above rehab staff attended the in-service conducted that day. During an interview with the surveyors on 1/22/21 at 12:15 PM, the DON acknowledged the seven exposed residents were moved to the yellow zone on 1/20/21, where required PPE in resident rooms included N95 masks, eye protection, gowns, and gloves. The DON stated the importance of wearing the correct PPE in the yellow zone was to prevent the spread of COVID-19. The DON further stated that PTA #2, the OT, and the OTA should have donned a gown before entering room [ROOM NUMBER]. The immediacy was removed on 01/22/21 at 3:21 PM, based on an acceptable revised Removal Plan that was implemented by the facility after the surveyors identified the continued deficient practice and verified by the surveyors during the Onsite Removal Plan Verification survey conducted on 1/22/21. The revised Removal Plan included that the three rehab staff who did not follow TBP were re-educated and disciplined. The revised Removal Plan also addressed any future non-compliance of staff not following TBP and an audit schedule to ensure staff are following TBP. A review of the facility's COVID-19 Infection Control policy revised 1/20/21, revealed, Healthcare personnel (HCP) can minimize their risk of exposure when caring for confirmed or possible COVID-19 patients by following CDC infection prevention and control guidelines, including use of recommended personal protective equipment (PPE) and, When COVID-19 is identified in the facility, staff wear all recommended PPE (gloves, gown, eye protection, and respirator or face mask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (refer to CDC guidelines for conservation and use of PPE). A review of the facility's Infection Control-Transmission Based Precautions policy, revised 1/20/21, revealed, Droplet Precautions: Obtain equipment from Central Supply. Assure that all necessary materials are present, i.e., gowns, masks, goggles, face shields, B/P cuff, stethoscope, and thermometer. Review of the U.S. CDC's guidelines, Responding to Coronavirus (COVID-19) in Nursing Homes, updated 4/30/20, included, All recommended COVID-19 PPE should be worn during care of residents under observation, which includes the use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. NJAC 8:39-19.4 (a)(b)(c)(d); 27.1(a)

Census: 89 Based on observation, interviews, and other pertinent facility documentation on 4/30/2020, it was determined that the facility staff failed to ensure that the appropriate transmission based precautions were practiced by healthcare staff while caring for both Covid-19 positive and PUIs (Persons Under Investigation), and non-ill residents by permitting health care staff to wear the same long sleeve paper isolation gowns from a Covid-19 positive resident room into a non-PUI, non-ill resident room. Health care staff were placing a short sleeve resident cloth gown over the long sleeve paper isolation gown, leaving the long sleeves exposed and providing care for a Covid-19 positive resident, removing the short sleeve resident cloth gown in the resident room, exiting the Covid-19 positive room, and caring for the non- PUI, non-ill residents leaving the contaminated long sleeves on the paper isolation gown exposed risking the likelihood of cross contamination. This deficient practice placed all residents at risk for contracting the Covid-19 virus in an immediate Jeopardy (IJ) situation. After office Supervisor review on May 5th, 2020, it was determined that due to the usage of short sleeve resident cloth gowns over the long sleeve paper isolation gowns in Covid-19 positive and non PUI, non-ill rooms, and the likelihood of cross contamination placed 46 Covid-19 negative residents out of an 89 census, at risk for contracting the Covid-19 virus in an Immediate Jeopardy (IJ) situation. The IJ was identified and reported to the Director of Nursing (DON) on 5/5/2020 at 2:24 p.m., when the IJ template was provided to the DON. The IJ ran from 4/30/2020, until the facility provided an acceptable Removal Plan on 5/6/2020 at 3:40 p.m. This deficient practice was further evidenced by the following: During a tour on 4/30/2020, of the Nelson 5 unit at 09:30 a.m., with the DON, the staff were observed wearing long sleeve paper isolation gowns on the unit. Also observed on tour was a stack of short sleeve resident cloth gowns folded at the nurses station. The Director of Nursing (DON) stated that the facility does not have enough gowns (Long sleeve paper isolation ) and that the Administrator and the Central Supply manager have been in contact with the Local Department of Health. The DON further stated that the unit is mixed with Covid-19 positive residents, and residents not showing any signs of [MEDICAL CONDITION], and all staff were caring for all the residents on the unit. During an interview on 4/30/2020 at 10:23 a.m., a facility staff nurse stated that the Certified Nursing Assistants (CNA's) on the unit are wearing long sleeve paper isolation gowns and putting a short sleeve resident cloth gown over them when going into Covid-19 positive rooms, removing the short sleeve resident cloth gown upon exiting the rooms, then caring for non-PUI, non-ill residents still wearing the same long sleeve paper isolation gown with the contaminated sleeves exposed. During an interview on 4/30/2020 at 11:30 a.m., the Central Supply manager stated that the facility uses 50 to 60 long sleeve paper isolation gowns per day, and today the facility started directing the staff to save their gowns by putting them in a plastic bag when done with them. If the gowns were visibly soiled or ripped throw them out, go to the front desk and get another one from the Receptionist. The Central Supply manager further stated that they have been in contact with the Local Health Department (4/28/2020), and were told they are waiting for a gown shipment and when they arrive the facility will be contacted. During a tour of the Central Supply Department it was noted that there were approximately 300 long sleeve paper isolation gowns. During an interview on 4/30/2020 at 11:43 a.m., a CNA stated when entering a Covid-19 positive resident room compared to resident's that are asymptomatic is that they put on a short sleeve resident cloth gown over the long sleeve paper isolation gown, when they have completed the resident care, they put the short sleeve resident cloth gown in a red linen bag, and leave the room in the long sleeve paper isolation gown. During an interview with the DON on 4/30/2020, at 12:52: p.m., the DON stated that there is a gown shortage and care givers are putting short sleeve resident cloth gowns over long sleeve paper isolation gowns and her only concern at this time is gown supply. During an interview with the DON on 4/30/2020, at 1:35 p.m., the DON was asked what the facility was going to do about staff wearing long sleeve isolation gowns under a short sleeve resident cloth gown, since the sleeves of the isolation gown would be exposed as the CNA's are only changing the short sleeve resident cloth gown therefore it would lead to cross contamination when caring for Covid-19 positive resident, and residents that are non-PUI, non-ill. The DON responded by saying I don't know , I'll call corporate. At 2:30 p.m., the DON handed this Surveyor a written document titled Plan related to Covid-19 Positive Residents. The written plan included on April 30, 2020: All positive Covid residents on N (Nelson) 6 hall will be moved to N (Nelson) 5 hall 1. All asymptomatic or negative Covid on N5 hall 1 will be moved to N6. This action was not directed by the Surveyor. The written plan also included: May 1, 2020: All positive Covid residents on N6 hall 2 will be moved to N5 hall 2 and all negative/asymptomatic from N5 hall 2 will be moved to hall 2. May 4, 2020: All remaining Covid positive residents on N6 will be moved to N5 and all remaining N5 negative or asymptomatic residents will be moved to N6. Until this is accomplished all staff will be given an extra disposable gown to wear over their existing gown and will remove this gown in between rooms. Going forward all new admissions/readmissions or converted status residents will be placed on N5. After office Supervisor review on May 5th, 2020, it was determined that due to the usage of short sleeve resident cloth gowns over the long sleeve paper isolation gowns in Covid-19 positive and non- PUI, non-ill rooms, and the likelihood of cross contamination an Immediate Jeopardy (IJ) was cited at 2:27 p.m. The IJ ran from 4/30/2020, until the facility provided an acceptable removal plan on 5/6/2020 at 3:40 p.m. All residents were put at risk for contracting the Covid-19 virus by the staff placing a short sleeve resident cloth gown over a long sleeve paper isolation gown upon entering rooms to care for Covid-19 positive residents, and exiting the rooms after removing the short sleeve resident cloth gown while continuing to wear the long sleeve paper isolation gown with the sleeves expose while caring for PUI, and non-ill residents risking the likelihood of cross contamination. The IJ was identified and reported to the DON on 5/5/2020, at 2:24 p.m., and was lifted on 5/6/2020 when the facility provided an acceptable Removal Plan at 3:40 p.m. The removal plan was verified on the revisit of 5/11/2020. NJAC 19.4 (a)

Not Corrected Based on observation, interview and record review, it was determined that the facility failed to handle some potentially hazardous food (PHFs)in a manner that would prevent food borne-illness. This deficient practiced was evidenced by the following sequence of events that occurred on 6/30/14. During the tour of the kitchen, interviews with dietary staff and lunch tray line observation from 9:50 a.m., till 12:35 p.m., in the presence of the team leader (TL), Administrator (Adm), Director of Dining Services (DDS), it was determined that the facility failed to monitor and maintain cold food temperatures as evidenced by: At 10:15 a.m. on 6/30/14, it was determined that one sampled egg salad sandwich in the walk-in refrigerator was 47 degrees Fahrenheit. (deg. F.). The egg salad sandwich was above the required temperature, and verified with the facility's thermometer. During an interview with one of the Dietary Managers (DM) at 10:45 a.m., the DM stated that she took the temperature of the egg salad at approximately 9 a.m., when the sandwich prep employee was making sandwiches. The DM indicated that she documented the the temperature of the egg salad on a temperature log sheet for June 30, 2014, but did not indicate the time. She also indicated that she does not usually "open" in the mornings so she would not be there to monitor the temperatures during sandwich preparation on a routine basis. The surveyor asked for temperature logs and was given Food Temperature Serving Logs for the month of June 2014. When the surveyor asked for documentation of the monitoring the temperatures of protein contents of sandwiches prior to/during preparation of the sandwiches, the DDS indicated that DMs do not document temperatures when sandwiches are being made. The Immediate Jeopardy Corrective Action Plan dated 5/4/14 indicated ""Cold food temperatures and special order food items will be taken prior to preparation of the sandwiches and recorded by the dietary managers at each meal." There was no evidence of any implementation of this plan until 6/30/14. There was a second policy and procedure provided on 6/30/14 that addressed "To safely prepare cold salads/sandwiches for meal service following federal, state, and local guidelines. Item 7 states instructions if the product is not below 40 degrees, follow the procedure for cooling potentially hazardous foods. Use an ice bath, freezer or any other approved method until 40 deg. F. or below. This instruction implies taking the temperature, monitoring, and insuring the temperature of the cold PHF foods reaches and maintained at an acceptable level. Also, there was no evidence of any system in place to monitor adequate temperature maintenance of protein salads, and sandwiches during preparation. During the lunch tray line on 6/30/14 from 11:30 a.m., till 12:22 p.m., the surveyor observed an open cart in the kitchen near the tray line area. The cart was used to hold items including protein salads and sandwich platters with egg salad, cream cheese and jelly sandwiches, diced chicken salad, vanilla and chocolate pudding, etc. There was no system in place to keep these potentially hazardous food items (PHF) items cold, i.e., ice, refrigeration, etc. during the preparation of residents' trays During tray line service, employees routinely removed items including sandwiches, salads, puddings, etc. from the cart and placed the items on resident trays. Immediately, at the end of the tray line at 12:22 p.m., the surveyor removed several items from the open cart and checked the temperature of the items in the presence of the DDS with the surveyor's and facility's thermometer. The thermometer readings were in within acceptable range of variation. The puree egg salad platter was 54.7 deg. F., the vanilla and puddings were 52 deg. F. In comparison, other items were maintained in a reach-in refrigerator near the tray line. The chopped egg salad sandwich from the reach in refrigerator was within an acceptable range. During the operation of the tray line, the DDS was asked if there was a policy and procedure for setting up the tray line. The DDS stated that there was none. During the review of the Temperature Serving Logs TSLs) for the month of June 2014, it was determined that there were temperatures missing for several items. Temperature Serving Logs were reviewed for the month of June 2014 from 6/1/14 through 6/27/14. No TSLs were provided for June 26, 28 or 29, 2014. The dates on 2 logs were not legible and and 2 logs were dated 6/7/14. There was lack of documentation on at least 12 of the TSLs dated June 4, 7, 9, 16, 17, 18, 19, 20, 21, 23, 24, and 25. Missing documentation included: ? 6/4/14 Lunch (L) No temperature documented for the sandwich-According to the DDS bologna and cheese was on the sandwich of the day. ? 6/7/14 (L) No temperatures for regular and puree turkey soup ? 6/9/14 (L) No temperatures for regular and puree soup ? 6/16/14 (L) No temperature for lunch sandwich ? 6/17/14 Dinner (D) No temperatures for regular and puree coleslaw and regular and puree sweet potato. ? 6/18/14 Breakfast (B) No DM signature ? 6/19/14 (L) No temperature for regular and puree soup, no salad temperature, no chicken sandwich temperature ? 6/19/14 (D) Dinner No temperature for regular and puree soup, no temperature for regular, ground or puree chicken and no signature by DM ? 6/20/14 (L) No temperature for puree soup, no signature by DM ? 6/21/14(L) No temperature of sandwich for the day ? 6/23/14 (L) No temperature for puree soup, and no temperature for grilled cheese sandwich ? 6/24/14 (L) No temperature for 3 bean salad, and puree vegetables ? 6/25/14 (L) No temperature for turkey club sandwich, alternatives for puree and no temperature for sandwich of the day Dates on TSLs were not legible. The temperatures documented failed to indicate the kind of sandwiches that were served during lunch. The pot washing logs that were found on the reverse side of the TSLs were not revised to show the concentration of the sanitizer in the 3rd compartment of the sanitizing sink after all 3 meals. The 3 compartment sink was monitored only twice daily. There was no documentation on the TSLs or Equipment Temperature Logs that logs were reviewed by the DDS. Also, there was no indication of any system for oversight or follow up based on review of lack of documentation on the TSLs. When the DDS was questioned about the logs on 6/30/14, at 11:05 a.m., the DDS stated that the staple in the groups of TSLs show his oversight review. The following food contact services were not maintained in a sanitary manner and/or food was not maintained in a manner to preserve its integrity. The following items were observed during the tour of the kitchen on 6/30/14: 1. There was heavy soil buildup on the lowerator's used hold clean plates prior to meal service. 2. There was heavy soil buildup on the 2 steam table shelves used to hold the cutting boards in place. 3. There were pieces of waffle fries spread on the steam table prior to lunch meal service. Soup was already in place in the 1st well of the steam table. The last well was uncovered and there was grease visible in the water in this well. 4. There was partially uncovered pieces of meat that were wrapped in plastic wrap. The meat looked dried, gray and freezer burned. There was some pieces of raw fish wrapped up in plastic wrap, and stored between boxes. The fish looked like it was dripping. Surveyor was told raw fish was refrozen. 5. Both doors of of 1 chest ice cream freezer were ajar. There was excessive frost build up in the unit. One door was jammed open by what appeared to be a small piece of crust of bread, and the second door was not closed tight. 6. The liner of 1 can opener cradle was very sticky with residue. NJAC 8:39-17.2(g), 17.4(a)2

Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous foods in a manner that would prevent food borne-illness. This deficient practice could potentially affect all residents who would consume food prepared in the facility's kitchen. The immediate jeopardy for substandard food preparation and storage of such potentially hazardous foods ( PHFs) as cooked roast beef, roasted turkey breasts, cooked shredded pork, sliced ham for sandwiches, protein sandwiches on the tray line, malfunctioning waste water drain line under the three compartment sink and a walk-in refrigerator unable to maintain required cold temperature were identified in the presence of Dining Managers, the kitchen cooks and pantry staff on 5/4/13 from 9:55 a.m. till 12:35 p.m. The Administrator and the Director of Nursing were notified of the immediate jeopardy by the team at 1:00 p.m. The immediacy was corrected on 5/4/14 at 6:35 p.m. On this date and time the facility submitted to the survey team an acceptable plan of correction that included in-service of the kitchen staff the same day, 5/4/14, which covered food preparation and storage. The walk-in refrigerator was repaired and the sewer drain was cleaned. The POC also included in-services of the kitchen staff will be conducted on 5/5/14, 5/6/14, and 5/7/14 and will cover the preparation, cooling and storage of Potentially Hazardous Foods (PHFs.), preventing cross contamination, can opener cleaning and maintenance, steam table cleaning, sanitation audit, taking and recording food temperatures, pot washing, equipment log, dish machine temperature log, labeling, dating, and proper temperatures, preparation of cold foods and salads, and hair restraints. This deficient practice was evidenced by the following sequence of events that occurred on 5/4/14. During the tour of the kitchen on from 9:55 a.m. till 12:35 p.m. in the presence of one of the Dining Managers (DMs) at 9:55 a.m., the surveyor observed a deep square pan of sliced ham on the preparation table. The deep pan was sitting on a layer of ice in a shallow steam table pan. The pantry worker was making ham and cheese sandwiches for the lunch "Sandwich of the Day" for the residents. The deep pan was filled between ? and ? full of ham. A sample of ham was removed from the top of the pan and was checked with the surveyor's thermometer. The sample of ham was 57.2 degrees Fahrenheit (deg.F.). The facility's thermometer was sanitized and used to check the temperature of the ham in the pan. The facility's thermometer registered 57 deg. F. Both temperatures were checked in the presence of one of the facility's DM. At that time the DM confirmed that the temperature of the ham should be 40 deg. F. There was no temperature recorded on the food temperature/temperature serving log for 5/4/14 for the sandwich ham. Staff later explained that when making sandwiches in the kitchen, temperatures should be recorded under the section labeled "deli meats" on the temperature serving log. During an interview with the DM at 11:35 a.m., on 5/4/14, the DM confirmed that the ham for sandwiches had been thrown out. At 10:10 a.m. on 5/4/14, the surveyor observed a clogged drain filled with dirty water under the three compartment sink. The pot washer continued to drain water from the sink. The waste water and food residue resembling scrambled eggs and vegetables spewed 15-20 feet across the kitchen floor to the area of the cook's table which was adjacent to the steam table. At 10:10 a.m. the pot washer told the Life Safety Code surveyor that this was never a problem before. At 10:08 a.m. a second DM said that a work order was put in last week for the floor drain. When the Director of Facilities (DF) was interviewed in the presence of the LSC inspector at 10:12 a.m. on 5/4/14, the DF confirmed that a work order was placed and this drainage issue was a chronic, ongoing problem for a long time with no planned permanent or systemic solution. On this same day, the DF gave the LSC inspector documentation of service that had been provided to the inside and outside grease traps. According to the documentation, the facility's inside and outside grease traps were serviced by a vendor on 2/21/14, with the next scheduled service for 5/16/14. The next scheduled service was 12 weeks after the 2/21/14 service. During an interview by the LSC inspector with the DF on 5/4/14 at 10:15 a.m., the DF stated that the drains were cleaned out every 12 weeks, however this schedule was insufficient and could not keep up with the problem so it was scheduled to be cleaned every 8 weeks. There was no evidence provided to the surveyor of the drains being serviced 8 weeks after 2/21/14. At 11 a.m., the surveyor entered the cook's walk in-refrigerator and observed 4 sheet pans of raw Italian sausage stored in the open baker's rack. The raw sausage was stored directly above the cooked shredded pork. At 11:03 a.m. on 5/4/14 the surveyor interviewed the DM about the cooked shredded pork. He stated that the cooked pork needs to go into the trash. The surveyor observed the pork placed into the trash at 11:05 a.m. on 5/4/14. The shredded pork was scheduled to be Monday's (5/5/14) lunch meal. While the surveyor was in the cook's walk-in refrigerator, another cook removed 4 cooked whole turkey breasts from this refrigerator. The turkey breasts were stored on one sheet pan. The surveyor observed the turkey breasts on the work table at 11:07 a.m. Immediately, the surveyor checked the temperature of each of the 4 cooked turkey breasts in the presence of the DM. The temperature of each of the 4 cooked turkey breasts was 56 degrees F. The DM brought over the cook who roasted the whole turkey breasts the day before. The cook was interviewed by the surveyor at 11:10 a.m. and stated that he put the whole turkey breasts in the oven after 11:30 a.m. on 5/3/14. He also stated that he pulled the turkey breasts out of the oven at 6 p.m., covered the whole turkey breasts and put them in the refrigerator. When this cook was questioned about the whole turkey breasts he prepared and placed in the refrigerator, the cook stated that the turkey "should have quartered and put on ice, my error." At 11:35 a.m. the DM told the surveyor that the roast turkey breast was scheduled to be served for the Sunday (5/4/14) night meal. The surveyor and the DM reviewed the U.S. Food order confirmation sheet dated 5/1/201 at 3:10 p.m. that revealed the whole turkey breasts cooked on 5/3/14 weighed 10 pounds each. During the 5/4/14 tour of the kitchen and cook's walk-in refrigerator, the surveyor observed 2 whole cooked/ roasted top rounds of beef. The two pieces of meat were large and filled a full size sheet pan. At 11:15 a.m. the surveyor checked the temperature of the 2 roasts that were cooked on 5/3/14 in the presence of the DM. The temperature of the 1st roast was 50 degrees F., and the temperature of the 2nd roast was 52 degrees F. using the facility's thermometer. The temperature of the 2 roasts using the surveyor's thermometer was 50.1 degrees F. The DM identified the cook who roasted the meat on 5/3/14. On 5/4/14 at 11:18 a.m., the surveyor interviewed the cook. The cook confirmed that he placed the roasts in the oven on 5/3/14 at 8 a.m. and cooked them till 12 noon, took them out of the oven and placed them in the freezer. This cook stated that it should take "2 hours to get it to 40 deg. F." He also stated that he took the roasts out of the freezer and put them in the refrigerator at 1:30 p.m. because he leaves at 2 p.m. He stated that he did not take temperatures of the roasts when he removed them from the freezer and placed them in the refrigerator. The surveyor and the DM reviewed the U.S. Food order confirmation sheet dated 5/1/201 at 3:10 p.m. that revealed the 2 top round beef roasts weighed 25 pounds each. The surveyor observed the lunch tray line in progress at 12:15 p.m. on 5/4/14. There were 3 protein sandwiches and 1 chef salad with protein on the tray line on an open cart. There was no system in place to keep the PHFs cold, such as ice, cold storage, etc. In the presence of the DM the surveyor checked the temperature of the chicken salad sandwich on wheat bread. The temperature of the sandwich was 69.3 degrees F. as per the surveyor's thermometer. The temperature was verified with the facility's thermometer at 69 degrees F. The other sandwiches and chef's salad were thrown away immediately. During an interview with staff members the surveyor learned there was no system in place to check the temperature of food served to individuals who request sandwiches and salads. The Temperature Serving Log (TSL) forms provided by the DM on 5/4/14 at 2: 50 p.m. was the standard form used to record food temperatures. The TSL form was used by the cooks, then signed and reviewed by the DMs. The Temperature Serving Log forms used from 4/2/14 through 5/4/14 by the DM indicated standard temperatures for compliance for hot and cold foods. According to the TSL form, Standard Food Temperatures for cold food including protein salads, and deli meats is 40 degrees F. During an interview with one of the DMs on 5/4/14 from 2:50 p.m. till 4 p.m., the surveyor reviewed TSLs for April through May 2014. The DM gave the surveyor 20 of 34 Temperature Logs, and 3 additional Temperature Logs that had no date. There were 14 Temperature Logs missing April 1, 5, 6, 11, 14, 17, 18, 19, 20, 25, 26, 29, 30, 2014 and May 2, 2014. Eighteen of 20 Temperature Logs provided were incomplete. The incomplete Temperature Logs were noted to be left blank in the following areas: 1. No cold food temperatures were recorded for lunch, or supper or both meals. An alternate sandwich meal is served at both lunch and supper. There was no system in place to record temperatures on any resident requested sandwiches. No pureed food temperatures were recorded for lunch or supper or both meals. 2. Pureed food temperatures were only recorded for 1 item, not 2 or more. The log sheet dated 4/3/14- revealed Temperatures were recorded for Deli Meats at the lunch meal were 40 degrees F./ "S" (Satisfactory Taste) at the start of tray line and service for Roast Beef, Turkey, Salami, Bologna and Corned Beef, and 56 degrees F./ "U" (Unsatisfactory Taste) at the midpoint of service for all of the cold meats listed. The log sheet dated 5/4/14 revealed no record of cold deli meats i.e., ham, being used to make the "Sandwich of the Day" (see above) Also, only one puree temperature was recorded for the breakfast and lunch meal. The surveyor interviewed the DM and Director of Dining Room Services ( DDS) at 6:20 p.m. on 5/4/14 who stated that the log sheet dated on 4/3/14 was signed off by a DM who had resigned 5/2/14. The Food Service Director (DDS) who was called in by the Administrator stated to the surveyor that the cooks did not do their job. He also agreed there was no oversight for the temperature log on 4/3/14. The DDS indicated that in the past the lead cooks were responsible to take food temperatures, now the DMs had that responsibility. The DDS did not provide any additional information regarding the unacceptable temperatures on the log. It could not be determined whether any interventions were initiated at the time that unacceptable temperature was recorded. During the tour, the surveyor observed that the Cook's walk-in refrigerator was unable to hold cold temperature as required. The temperature was monitored by the surveyor and then by the dietary staff. Temperatures were as follows: 11:20 a.m.- Thermometer in the cook's walk-in refrigerator was 45 degrees F. A second thermometer was placed in the refrigerator at 11:28 a.m. 11:50 a.m.- Thermometer near the door read 48 degrees F., surveyor's thermometer on a shelf 47.3 degrees F., third thermometer under the refrigeration unit read 46 degrees F. 12:13 p.m.- Thermometer near the door read 44 degrees F., surveyor's thermometer on a shelf read 43.4 degrees F. At that time the surveyor asked the DM to monitor the cook's walk-in refrigerator every 15 minutes. The facility started a log. The facility's dietitian provided a copy of the log at 2:35 p.m. on 5/4/14. Documentation on the log indicated that the facility started the log at 12:15 p.m., and the temperature was 43 degrees F. at that time. At 12:45 p.m., the temperature was 44 degrees F., and at 1:30 p.m. the temperature was 46 degrees F. The surveyor confirmed that all foods were removed and placed in another refrigerator. During an interview with the DM on 5/4/14 at 3:25 p.m., the DM indicated that there was no Equipment Temperature log available for review for the cook's walk-in or any other refrigerators, freezers, dish washer, etc. for 5/3/14 and 5/4/14. The surveyor interviewed the DDS, who confirmed that the unit was not working properly due to a build up of ice on the back of the refrigeration unit and that vendor was called in today to fix the problem. The Jeopardy was abated at 6:45 p.m. on 5/4/14. The deficiency continued at an F level as evidenced by the following: The facility failed to maintain sanitation in the kitchen and related storage areas. This deficient practice was evidenced by the following observed during the tour of the kitchen on 5/4/14 from 9:55 a.m. till 12:35 p.m., and again from 4:25 p.m. till 5:15 p.m.: 1. There was spilled ice cream in the ice cream freezer outside the entrance to the kitchen. There was splash on the shelves in the same area. Also, there was ice build up in the ice cream freezer near the dish washer. 2. There was one missing ceiling tile over the steam table in the kitchen, and there was an exposed pipe in the ceiling in the same area. 3. There were 2 heavily worn green cutting boards that had deep scores and stains. 4. There were 4 dirty pots stored on the floor on the grease trap in the pot washing area. 5. During the tour on 5/4/14 at approximately 10:30 a.m., the surveyor saw that 4 of 5 wells of the steam table were filled with dirty water with food residue floating in the water. The 5th well had a full size steam table pan with soup in it for the lunch meal. There was also a round container (also filled with soup for lunch) in the first well of the steam table. The top perimeter of the steam table wells were soiled with residue from the breakfast meal, i.e., dried cereal. There was a soiled pancake turner sitting on top of the full size steam table pan of soup for lunch. When the cook was asked to take a temperature of the soup in the round container, the cook sanitized the thermometer, and then blew on it. During interviews with the cooks on 5/7/14, all cooks confirmed that hot foods should be held in the hot holding box till time shortly before tray line service. The shelf under the cutting board on the steam table and the upper shelf were soiled. 6. There was heavy black residue and metal shavings on the cradle, gear, and blade of the two can openers. The base of one of 2 can openers was peeling. During the tour of the kitchen on 5/4/14, one of the DMs provided a copy of the "Weekly Cleaning Schedule" done by 5/4/14. There was no evidence of any system in place to assign responsibility to insure routine cleaning of the 2 can openers. The DM who provided the cleaning schedule confirmed that the can openers were not included on the cleaning schedule. 7. There were clean cups and plates stored in a bin on a soiled cart. 8. There was heavy grease build up on the liner in the drip tray in the stove. Also, there was excess accumulation of charred residue on the grille. 9. One clean pot dropped to the floor, the pot washer picked up the pot and returned it to the clean pot storage area. 10. There was water accumulating on the floor of the cook's walk-in refrigerator. 11. There were missing floor tiles at the interior entrance to the loading dock. The overhang in the area over the dumpster was damaged, and there was concrete hanging and peeling from the ceiling/overhang. 12. The floors in both walk-in freezers had deep cracks and were not considered cleanable surfaces. One freezer had ice on the floor and on the back wall. The shelves were rusted and there was spillage on the floor. There was damaged metal at the wall to floor junctures and around the door jambs on the interior of the refrigerators. 13. There was water dripping from the drain line in the juice refrigerator. The external refrigerator unit above the refrigerator was soiled. 14. The dome cover truck and clean pot racks were soiled. 15. There was spillage on the floors, walls and under the shelves in the dry goods storage room. There was one damaged ceiling tile and one ceiling tile out of place. 16. There was spilled residue and soil in the walk-in dairy refrigerator at the wall to floor juncture. 17. There was rusted shelving and peeling paint on the floor in the paper goods room. Also, there was one missing ceiling tile. 18. There were soiled ceiling panels in the produce refrigerator. 19. There was red splash on one ceiling light cover near the dish washing area, and there was 1 damaged ceiling light cover near the pot washing/cooking area. Also, there was splash on the exterior wall of the walk-in refrigerators near the hooks used to store utensils. The knife sharpener stored in this area was heavily soiled. 20. The Robot Coupe used in this area had a small amount of water in the bottom of the bowl and orange food residue remaining under the removable gasket. The Robot Coupe was again observed at 4:25 p.m. with water in the bottom of the bowl and orange residue under the gasket. 21. There was ice build up on the door of the walk-in freezer. The door gasket was damaged and falling off the door. There were 5 boxes of ice cream cups stored directly on the floor of one of 2 walk-in freezers. There was soil build-up on the cart used to store potato skins and another cart was rusted. There was a partially uncovered package of Panini bread. 22. There was soil and spillage on the plate lowerator/heater. 23. There was a jar of garlic in oil on the spice rack. The label stated " Keep refrigerated at all times. " The contents of the jar was ? used and the temperature of the remaining garlic was 71 deg. F. This was discarded immediately. Later that afternoon, the surveyor observed another open jar of garlic was in the refrigerator however the jar was not dated when it was opened. 24. There was a damaged handle on the pizza cutter that was located by the dish washer. 25. There were missing floor tiles near the three compartment sink. There was missing and worn grout around the kitchen in several areas. The wall behind the 3 compartment sink was soiled. 26. The green wall board was used to build a support for the cook's sink near the walk-in refrigerator. The green wall board was splashed with soil and water. The green board was unfinished. It was not painted, sealed and the surface was observed to made of material that could not be cleaned when soiled. 27. One employee was observed with hair only partially covered while working in the kitchen. NJAC 8:39-17.2 (g), 17.4 (a) 2

Based on observation, interview and record review it was determined that the facility failed to provide pressure relief to a staff dependent resident's heels who was at risk for pressure ulcer development. The resident developed an unstageable Left heel ulcer and a Stage II Right heel ulcer. This deficient practice was identified for 1 of 3 residents reviewed for pressure ulcers, Resident #7 and was evidenced by the following: During the initial tour of the facility on 5/30/13 at 10:00 a.m. the tour nurse identified Resident #7 to be confused, staff dependent for care and mobility and had facility acquired bilateral heel ulcers. On 5/31/13 at 11:00 a.m. the surveyor reviewed the medical record of Resident #7 which revealed the following: The resident was admitted to the facility on [DATE] from the Assisted Living section due to an overall decline with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED].#7 was at significant risk to develop further pressure ulcers. The 1/29/13 Minimum Data Set (assessment tool) indicated that the resident had functional limited range of motion in both lower extremities and required the extensive assistance of staff for bed mobility and transfers. An Interdisciplinary Progress (IDCP) Note of 2/5/13 documented that the writer had found a Left heel necrotic pressure sore on Resident #7. The physician was contacted that same day and gave a telephone order to off load the left heel while Resident #7 was in bed, clean the wound with saline and apply skin prep to the left heel daily. A review of the 2/7/13 Wound Progress Report Sheet revealed that the Left heel ulcer was discovered on 2/5/13 but was not measured until 2 days later on 2/7/13. At that time the wound measured 5 cm x 4 cm. On 2/15/13 the wound progress report sheet noted that the ulcer formation was "likely from shoes" and recommended that no shoes be worn unless the resident was working with the Physical Therapist. A physician's entry in the IDCP note of 2/20/13 documented that the resident had a "5 centimeter (cm) broken blister with a 1 cm purple area at edge" on the Right heel and a "hardened intact blister 5 cm" on the Left heel. Some of the recommendations at that time were for the staff to keep pressure off heels, no shoes should be worn unless Resident #7 was ambulating with therapy, off load the heels while in bed and have the wound doctor see the resident. The surveyor reviewed the 2/20/13 PT Daily Notes and Weekly Progress Summary which noted that the resident was seen "with some slip on shoes on feet today. Spoke with nrg, no orders to the contrary, switch footwear to diabetic shoes to provide pressure relief to affected areas." The 2/21/13 initial evaluation by the wound care specialist revealed that the resident had a Stage II Right heel pressure ulcer which measured 3 cm x 3.5 cm. x 0.1 cm. The note also documented that "This is a blister that opened, likely from shoe." It further revealed there was also an unstageable Left lateral heel ulcer which measured 3 cm x 4 cm and was further identified as "a dark blister, likely from shoe." The recommendations made at that point were for sponge cradle boots to be worn in bed, to reposition per facility protocol and to offload the wounds. A physician's orders [REDACTED]. This is a device which reduces pressure and minimizes friction to the affected area while elevating the foot and separating the heel from the mattress. A review of the February 2013 "Treatment Administration Record" (TAR) revealed the following: On 2/5/13 "off load 'Left heals' while in bed," was initially identified for the 3 p.m. -11 p.m. and 11 p.m.-7 a.m. shifts. However, the 7 a.m.-3 p.m. shift was not identified as having to off load the heels while in bed. This intervention of off loading the heels was initiated after ulcer development. The Sponge cradle boots, ordered on [DATE], were not identified on the TAR as having been applied to the resident. The May 2013 TAR indicated that the resident received the Prevalon boot on 5/5/13, approximately 3 weeks after ordered by the physician. A review of the 1/18/13 care plan identified the problem of incontinence which placed Resident #7 at increased risk for skin breakdown. Some of the identified interventions for this problem included: "Provide prompt and timely incontinence care; assess skin every shift during incontinence rounds; weekly skin assessment by nursing and daily skin check with a.m. care." The care plan did not identify interventions which would be more specific to the protection of the skin integrity of the resident's heels. On 3/29/13 (7 1/2 weeks after ulcer development) the care plan was revised to identify "pressure ulcers" as a problem for Resident #7. Some of the identified interventions included: "Encourage mobility with assist if needed and frequent position changes; administer wound care as ordered by MD; off loading of affected area; provide optimal nutrition and hydration; consult wound doctor and no shoes." A review of the Certified Nurses' Aide (CNA) care card which directed the care provided to the resident by the CNA did not identify off loading of the resident's feet, no shoes were to be applied or any other pressure reduction measures for the resident's feet. On 5/31/13 at 12:30 p.m. the Unit Manager (UM) told the surveyor that the causal factor of the bilateral heel pressure ulcers was most likely from the resident's shoes. The UM stated that the shoes were of a "clog type with a raised lip in the back that most likely caused pressure on the resident's heels." The UM further stated that the nurse initialed the TAR to ensure off loading of the resident's heels and boot application had been done. The UM was not aware that off loading of the heels in bed had not been identified on the 7 a.m.-3 p.m. shift on the February 2013 TAR or that the Sponge cradle boots had not been identified on the February TAR. The UM stated that the Prevalon boot was not applied in a timely manner since it had to be special ordered. On 5/31/13 at 12:45 p.m. the surveyor observed Resident #7 seated in a wheelchair in the main dining room with a Prevalon boot applied to the Left foot (incorrect foot) and a sock applied over a dressing to the Right foot with the resident's Right foot resting on the floor. On 5/31/13 at 1:30 p.m. the Director of Nursing (DON) stated that pressure ulcers were to be measured when discovered and that care plans were to be updated as issues were identified. The DON was not aware that this had not been done for the resident, or that the Prevalon boot was applied 3 weeks after it had been ordered by the physician. On 6/3/13 at 8:10 a.m. the surveyor along with the UM and DON observed the resident's skin. The resident had a Prevalon boot applied to the Right foot. The resident's Left foot was elevated off the mattress with a pillow. However, the resident's Left inner heel was resting directly on the pillow. An unstageable Left outer heel ulcer was observed which measured 1.8 cm x .6 cm. and the inner heel was reddened. An unstageable Right heel ulcer was observed which measured 3 cm x 1.6 cm x .3 cm. A review of the facility's "Nursing responsibilities in the identification and management of pressure ulcers" policy (revised [DATE]) revealed the following: "The nurse will complete an Occurrence Form for any new pressure ulcers stage 2 or greater. The Nurse will assess the ulcer and complete a Wound Progress Report Sheet for each identified ulcer (unless followed by our wound doctor)." On 6/3/13 at 1:00 p.m. the Assistant Director of Nursing (ADON) provided a "Resident Occurrence Report" for the Left heel pressure ulcer. However, the ADON stated that an occurrence report had not been completed for the Stage II Right heel pressure ulcer. There was no documented evidence that the policy had been consistently followed. NJAC 8:39-27.1(e)

Based on observation, interview and record review it was determined that the facility failed to develop a plan of care based on individual assessment to protect the heels of a staff dependent resident from pressure ulcer development. Following ulcer development the facility failed to identify interventions to promote healing in a timely manner. This deficient practice was identified in 1 of 3 residents reviewed for pressure ulcers, Resident #7. The facility also failed to develop care plan interventions for residents with aggressive and socially inappropriate behaviors. This deficient practice was evidenced in 2 of 9 residents, Resident #1 and #2. These deficient practices were evidenced by the following: 1) On 5/31/13 at 11:00 a.m. the surveyor reviewed the medical record of Resident #7 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/29/13 Minimum Data Set (assessment tool) indicated that Resident #7 had functional limitation in range of motion in both lower extremities. It also revealed that the resident required the extensive assistance of staff for bed mobility and transfers. An "Interdisciplinary Progress (IDCP) Note" of 2/5/13 revealed the following: "This nurse found a left heel necrotic pressure sore on this resident." A physician's telephone order of 2/5/13 indicated to "offload left heel while in bed; clean w/ NSS apply skin prep to L heel daily." A review of the 2/15/13 the Wound Progress Report Sheet indicated that the ulcer formation was "likely from shoes-No shoes unless with PT." A physician's entry in the IDCP note of 2/20/13 initially noted that the resident had a "5 centimeter (cm) broken blister with a 1 cm purple area at edge" on the right heel and a "hardened intact blister 5 cm" on the left heel. Some of the recommendations at that time were to "keep pressure off heels; no shoes except while ambulation with therapy; offload heels in bed and to see wound doctor." A review of the 1/18/13 care plan identified the problem "Incontinence, increased risk for skin breakdown." some of the identified interventions included: "Provide prompt and timely incontinence care; assess skin every shift during incontinence rounds; weekly skin assessment by nursing and daily skin check with am care." The care plan did not identify interventions to protect the skin integrity of the resident's heels. On 3/29/13 ( 7 1/2 weeks after ulcer development) the care plan was revised to identify "pressure ulcers" as a problem. Some of the identified interventions included: "Encourage mobility with assist if needed and frequent position changes; administer wound care as ordered by MD; offloading of affected area; provide optimal nutrition and hydration; consult wound doctor and no shoes." A review of the Certified Nurses' Aide (CNA) care card which directed the care provided to the resident by the CNA did not identify any pressure reduction measures for the resident's feet. On 5/31/13 at 1:30 p.m. the Director of Nursing (DON) stated to the surveyor that care plans were to be updated as issues were identified. The DON was not aware that this had not been done for Resident #7. 2). On 5/30/13 at 11:30 a.m. the surveyor reviewed the medical record of Resident #1 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the "Interdisciplinary Progress Notes" revealed the following: On 4/17/13 at 12:30 p.m. "Resident was in main dining room when he saw another resident (#2) getting cookies out of the cookie jar and (resident's name) started hitting (Resident #2) on the arm and said he has to be killed." On 5/16/13 at 11:00 p.m. "Resident being aggressive with another resident (#2), separated with no further incident." A review of the 3/22/13 care plan identified the problem: "behaviors-sometimes verbally abusive to staff/other staff, refuses care and meds at times" with interventions which included: "keep other residents out of (resident's name) space; encourage (resident's name) to vent about what is bothering him; encourage (resident's name) to participate in activity of his choice and allow (resident's name) time to calm down if he becomes agitated or upset." The care plan was not revised following the altercations with Resident #2. There were no identified interventions to prevent recurrence. 3). During the initial tour of the facility on 5/30/13 at 11:00 a.m. the tour nurse identified Resident #2 with wandering behavior. The tour nurse stated that the resident was able to self propel the wheelchair on the unit. At 11:10 a.m. while the tour was in progress, Resident #2 was found in another resident's room (522) with straw wrappers hanging from his nose. On 5/31/13 at 8:30 a.m. the surveyor reviewed the medical record of Resident #2 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the "Interdisciplinary Progress Notes" revealed the following: On 3/20/13 at 2:00 p.m. "Pt having increased irritability. He is pointing his middle finger to staff and saying inappropriate comments. He also ate another resident's meal (knowingly) and he puts straw wrappers into drinks then sticks them into his nose." On 4/17/13 at 12:30 p.m. "Resident was in the main dining room and was getting cookies out of the cookie jar. Another resident (#1) started hitting him on his arm and tried to keep him from taking cookies." On 5/1/13 at 9:30 a.m. "Continues to rummage in trash, goes to resident's trays while they are eating, taking items from their tray. This morning went in dirty trays while on cart. When CNA tried to redirect (resident's name) started swinging/hitting CNA on left arm/shoulder cursing saying [***] es, f--k you and sticking his middle finger up at CNA's" On 5/7/13 "Pt seen going thru dirty trays, when asked why he was doing it or what he was looking for, Pt reports he was looking for creamers." On 5/29/13 at 2:30 p.m. "Was digging in hallway trash can redirect with difficulty, became agitated. Went down hall to room [ROOM NUMBER] and started going through showers and closet of 518A. CNA tried to redirect, (resident's name) started swinging then cursing and gave the middle finger. Finally able to remove him from 518 with much difficulty." A review of the 3/29/13 care plan identified the following problems for Resident #2 problem "Behaviors-verbal and rejection of care with interventions which included: Approach resident gently with a low, calm voice; Explain tasks to be done shortly and simply prior to care; Breakdown tasks to simple, easy steps and monitor for any sudden change in mentation and refer to MD." The care plan was not revised following the altercations with Resident #1. The care plan did not identify the wandering and socially inappropriate behaviors displayed by the resident. There were no interventions identified to prevent recurrence of these behaviors. Refer to F314 for Resident #7 Refer to F224 for Resident #1 and #2 NJAC 8:39-11.2(e)(2)