Every finding on record at Shady Lane Gloucester Co Home

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive care plan that identified an assistive device to help maintain the resident's highest practical and physical well-being for a resident who required bilateral foot braces. This deficient practice was identified for 1 of 2 residents reviewed for positioning and mobility (Resident #29), and was evidenced by the following:On 9/2/2025 at 8:04 PM, during the initial tour of the facility, the surveyor observed Resident #29 with their eyes closed. The resident's foot braces were observed on the floor near the window.On 9/3/2025 at 10:16 AM, during a follow-up visit with the resident, they stated that they did not like to wear the braces, but would wear them occasionally. On 9/3/2025 at 10:02 AM, the surveyor reviewed the medical record for Resident # 29. A review of the admission Record, an admission summary, reflected that the resident was admitted to the facility with diagnoses that included but was not limited to; spondylosis with radiculopathy (age-related wear and tear in the spine that leads to nerve compression or inflammation), low back pain, pain in the right hip, and muscle wasting and atrophy (a condition that causes a progressive loss of muscle mass, strength and power). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/2/2025, included that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) did not include bilateral foot braces. A review of the Physician Orders (PO) included a PO, dated 6/17/2025 at 6:51 AM, to assist the resident in putting on braces and shoes, and assist with removing braces and shoes, and the resident is not to wear braces for more than three hours daily.On 9/3/2025 at 11:33 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), in the presence of the Director of Nursing (DON), who stated that foot braces should be included in a resident's care plan. At that time, the RN/UM accessed the resident's care plan and stated, I don't see it. She then stated that the Minimum Data Set (MDS) Coordinator (an individual in nursing who helps manage a nursing team in a medical facility, such as a hospital or nursing home), or the occupational therapist would update the care plan for a resident who had foot braces. The RN/UM further stated that it was important for the braces to be on the care plan so the plan of care could be revised if it was not helping the resident. The RN/UM also stated that the care plan should be updated quarterly, annually, and as needed.At that time, the DON also reviewed Resident #29's care plan and confirmed the findings. The DON stated that any Licensed Practical Nurse (LPN) or RN could have updated the resident's care plan to include the foot braces. She further noted that the resident as a whole should be captured in the care plan, as that is how you take care of the resident. On 9/3/2025 at 11:58 AM, the surveyor interviewed the Occupational Therapist (OT), who stated that the resident was admitted with braces, and they should have been included in the resident's care plan. A review of the facility's MDS/Charting Documentation policy, reviewed on 5/25, included, Information from all three shifts will contribute towards a completer [sic.] and more well-rounded IDCP (Interdisciplinary Care Plan). This will give team members a more accurate view of the resident. Interventions and he [sic.] care plan process needed to address the 24 hour needs of the resident.NJAC 8:39-11.1

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) and the State Ombudsman, an unwitnessed fall which resulted in fractures to multiple right foot metatarsal heads (bones located in the mid-foot). This deficient practice was identified for 1 of 3 residents (Resident #22) reviewed for accidents and was evidenced by the following: A review of the facility provided policy and procedure, Incident and Accident Report/Falls reviewed 03/2024, which included but was not limited to; to accurately record any incident or accident when it occurs in accordance with legal liabilities and state and federal regulations. Procedure 1. Incidents or accidents include but are not limited to . any happening or experience which may be traumatic or inflict bodily injury . witnessed or un-witnessed. 4. Incidents and Accidents are . investigated to see if it is a reportable event. 12. Accidents or incidents that endanger the mental or physical health or safety of the resident in cases of abuse must be reported to . the Ombudsman Office and the NJDOH. Points of Emphasis 1. cases of abuse must be reported to the NJ State Ombudsman's Office and NJDOH . On 04/01/24 at 10:14 AM, the surveyor observed Resident #22 in his/her bed and observed there was a protective boot on the right lower extremity. A review of the facility provided, Accident report regarding Resident #22's incident dated 02/13/24, included but was not limited to; Severity: incident resulted in treatment and temporary harm. Type: fall. Injury Foot. Accident Reason: Not following Care Plan. Contributing Factors: resident sat [her/himself] on the side of the bed when CNA (Certified Nursing Assistant) went to get [name redacted] mechanical lift. When CNA returned, resident was on the floor landing on [his/her] right leg and foot under [his/her] body. Resident stated [he/she] heard their leg snap twice. On 04/02/24 at 11:42 AM, in the presence of two surveyors, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were interviewed. The DON was asked what would a reportable event be considered. The DON gave an example that if staff used a [name redacted] mechanical lift without two staff members, and there was a fall with major injury like a fracture, it would be a reportable because the staff failed to follow the policy. The LNHA stated that the facility would do an investigation and if we determine what happened, that would not be reported. The DON further stated that if staff left a resident room and returned to find the resident on the floor, that would be considered an unwitnessed fall. The LNHA and DON both confirmed that the unwitnessed fall which resulted in multiple fractures of the right foot for Resident #22, was not reported to the NJDOH or Ombudsman. When asked if the facility had a policy specific for the staff to follow regarding reportable events, the LNHA stated no and that the only area regarding reporting an event was in the policy and procedure for Incident and Accident Report/Falls that had been provided. NJAC 8:39-9.4(e), 27.1(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure medications were dated upon opening and all medications were secured inside the medication cart. This deficient practice was identified in 1 of 2 medication carts observed and was evidenced by the following: 1. On [DATE] at 7:35 am, the surveyor observed the Licensed Practical Nurse (LPN) in an adjacent hallway. The surveyor approached the LPN and informed her that she would be observed for medication administration. The LPN had a Bingo card of medication in their hands. The LPN placed the Bingo card on top of the medication cart and wheeled the medication cart to the next hallway. On [DATE] at 7:57 AM, the LPN entered Resident #29's room and left the Bingo card on top of the medication cart. The LPN informed the resident that she would be coming with their medications. The LPN went to the bathroom and washed their hands. The Bingo card was left unattended on top of the medication cart. The LPN did not have a line of sight to visualize the medication cart while inside the bathroom. The surveyor remained at the door and observed ancillary staff in the hallway while the Bingo card was on top of the medication cart. The LPN returned to the medication cart, prepared medications for Resident #29, went back to the room and administered the medications. On [DATE] at 08:11 AM, the LPN returned to the medication cart to sign for the medications administered and proceeded with the narcotic count at the surveyor's request. The nurse opened the narcotic book and the first page indicated Tramadol 50 milligrams tablet (medication used to alleviate pain) a specific type of narcotic medicine for Resident #26. The Bingo card was not in the narcotic drawer. The LPN then attempted to pull the Bingo card from underneath the narcotic book on top of the medication cart. The surveyor asked to see the label on the Bingo card. The Bingo card was the missing the Tramadol that was not locked with the other narcotic and had belonged to Resident #26. On [DATE] at 8:25 AM, during an interview with the LPN, she stated that the Tramadol was discontinued and she wanted to remove the medication from the narcotic drawer. The surveyor then inquired regarding the process for the storage of controlled substances. The LPN indicated that all controlled substances should be double locked. A review of the Physician Order Sheet (POS) for Resident #26, revealed that the Tramadol was reordered on [DATE] at 06:15 AM. The order was still active. 2. On [DATE] at 7:40 AM, in the presence of the Licensed Practical Nurse (LPN) the surveyor inspected the low hall medication cart on the Long Term Care unit. The surveyor observed an open Flexpen of Humalog insulin (a medication used to treat high blood sugar) which was delivered from the pharmacy on [DATE]. The Humalog Flexpen was opened and not dated. Also noted was a Lantus Flexpen Insulin which was open and not dated, three other insulin Flexpens were noted with a date on the bag only not the Flexpen. On [DATE] at 7:50 AM, the surveyor interviewed the LPN responsible for the medication cart and asked about the facility's process for dating multidose vial medication. The LPN stated that the Humalog Flexpen and the Lantus Flexpen Insulin should have been dated when opening. According to the manufacturer's recommendations, Humalog and Lantus Insulin should be discarded 28 days after first use. On [DATE] at 12:30 PM, the surveyor reviewed the facility's Administering Oral/ IV Medications/ Insulin's/ Storage of Medications and Treatment Carts with a revision date of ,d+[DATE], revealed that all stock medications are to be dated upon opening. A review of the facility's Medication Management: Skills Evaluation revealed under Medication Administration Technique Medication should be locked when staff are not on the cart. Medications are not left on top of medication cart or residents bedside. Maintains security of scheduled medication under double lock system. On [DATE] at 9:00 AM, the Director of Nursing (DON) provided a revised policy which included that insulin's should be dated with an open and expired date. The DON added that staff were in-serviced. On [DATE] at 09:39 AM, during an interview with the Nurse Educator regarding the insulin, she stated that the staff were to place the date directly on the Insulin Pen not on the bag that contained the insulin. NJAC 8:,d+[DATE].4

Based on observation, interview, record review and review of pertinent documents, it was determined that the facility failed to ensure that all staff used appropriate hand hygiene and proper disinfection while providing wound care to a resident, and were adhered to infection control practices in accordance with facility policy regarding medication administration. This deficient practice was observed for 1 of 1 resident (Resident #15) investigated for Pressure Ulcers/Injury and during the medication administration observation as evidenced by the following: On 04/01/2024 at 9:38 AM, the surveyor observed Resident #15 lying in bed awake and alert. Resident #15 is noted to be on enhanced barrier precautions (EBP). Resident #15 stated that he/she had a bone infection in the left heel that resulted in a left heel wound. Resident #15 also stated that he/she gets dressing changes done daily and goes to the wound doctor every other week. Resident #15 was observed wearing bilateral heel protectors. A review of Resident #15's Electronic Medical Record (EMR) revealed that Resident #15 was admitted to the facility with the following diagnoses including but not limited to: acute osteomyelitis of left ankle and foot (infection in the bone), pressure ulcer of left heel (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and diabetes mellitus type 2 (a disease of inadequate control of blood levels of glucose). A review of Resident #15's Minimum Data Set (MDS), an assessment tool, dated 02/16/2024, revealed that Resident #15 had a Brief Interview for Mental Status score of 9/15, indicating moderately impaired cognition. Section M of the MDS was reviewed and revealed that Resident #15 has a pressure ulcer and was at risk for pressure ulcers. A review of Resident #15's EMR revealed that he/she had the following physician's order Wound cleansing and dressing. Wash your hands with soap and water. Remove old dressing, discard into practice bag and place into trash. Cleanse the wound with normal saline prior to applying a clean dressing using gauze sponges, not tissues or cotton balls. Do not scrub or use excessive force. Pat dry using gauze sponges, not tissue or cotton balls (or vashe wound solution, if available). Protect peri wound skin with 3M no sting barrier wipes. Apply a nickel thick layer of Santyl to wound bed only, then cover with clean dressing. Santyl ointment - apply to wound bed, followed by calcium alginate (cut to size), and lay over opened area after Santyl ointment application. 4 x 4 gauze, abdominal pads times two (well padded), and yard gauze wrap secured using tape. Change dressing every day or as needed for excessive drainage. A review of Resident #15's care plan revealed that he/she had a comprehensive care plan initiated on 01/29/2024 for: Wound Care: L heel wound. Interventions included: Wound treatment as ordered. Weekly wound measurement with documentation. Assess for pain and medicate before wound treatment. Weekly comprehensive skin assessment and documentation. Pressure relieving device in chair and mattress on bed. PT/OT consult as needed. Protect and off load heels. Prevent skin to skin friction by using pillows and padding. Monitor for symptoms of infection such as redness, warmth, drainage, odor at each dressing change. Use positioning devices e.g., pillow or wedges to maintain proper body alignment. Enhanced Barrier Precaution as ordered. On 04/03/2024 at 9:44 AM the surveyor obtained verbal permission from Resident #15 to observe his/her wound care. On the same date at 10:12 AM, the surveyor observed the Licensed Practical Nurse (LPN) begin to perform wound care to the left heel. The LPN performed hand hygiene prior to donning (putting on) gloves at the start of the wound care. The surveyor then observed the LPN doffing (removing) gloves from both hands after removing the old wound dressing and placing it in the trash. At that time, the LPN did not perform hand hygiene. The LPN then donned (applied) a new pair of gloves, cleansed the wound with wound wash, removed both gloves without performing hand hygiene. The LPN then donned a new pair of gloves and applied skin prep to the wound edges. The surveyor then observed the LPN remove the gloves, then donned a new pair of gloves to perform the rest of the wound care treatment without performing hand hygiene. The LPN removed both gloves once the wound care treatment was completed and performed hand hygiene. During the wound care treatment this surveyor observed the LPN cut the prescribed wound dressing with scissors located directly on top of the treatment cart. Prior to the use of the scissors, the LPN did not disinfect the scissors. On the same date at 10:25 AM during an interview with the LPN, the surveyor asked when should you perform hand hygiene during wound care, the LPN said, I would perform hand hygiene before starting the treatment and once I am done with the treatment. The surveyor asked the LPN if hand hygiene should be performed between glove changes. The LPN stated, yes, it should be done but I didn't do it every time. The surveyor asked when providing wound care should the scissors be cleaned prior to using them, the LPN stated, yes, but I did not wipe them before cutting the [name redacted], but I should have. On 04/04/2024 at 9:55 AM, the surveyor asked the Director of Nursing (DON) what were the expectations for staff regarding hand hygiene while performing wound care. The DON said, They should wash their hands before and after the procedure, if they are visibly soiled and in between glove changes. If they remove their gloves, they need to also do hand hygiene with either hand sanitizer or by washing them. The surveyor asked the DON should hand hygiene be done in between glove changes. The DON stated, Yes, they should be cleaned with either hand sanitizer or hand washing. This surveyor then asked the DON, when providing wound care should instruments such as scissors be cleaned prior to use. The DON said, Yes, they must wipe the instruments prior to using them with wipes. On 04/04/2024 at 12:40 PM, a review of the facility policy and procedure for Dressing Change, reviewed on 03/2024, revealed the following under the Policy section: To ensure proper application of treatments. To prevent cross contamination and infection. Under the Procedure section it included the steps of the procedure as follows, 1) Wash hands prior to patient contact or use of ABHS (alcohol-based hand sanitizer) 3) Apply gloves 4) Remove soiled dressing and dispose of it in a plastic bag on treatment cart. 5) Either: a) wash hands, or b) use ABHS 6) Don new gloves after hand washing or use of ABHS 7) Assess wounds for exudates (drainage) before applying treatment. If necessary, clean wound with 4 x 4 dressing and normal saline solution or wound solution. Dispose of dressings in plastic bag. 8) Remove gloves, wash hands or use of ABHS, and apply new gloves. 9) Apply ordered medication 13) All tools ie: bandage scissors that are reusable must be cleaned with antimicrobial wipes prior to placing back in treatment cart and moving to next resident. b. On 4/3/24 at 7:57 AM, the surveyor observed the Licensed Practical Nurse (LPN) administered Fluticasone Propionate nasal spray suspension (a medication used to relieve seasonal and year- round allergies) which was delivered from the pharmacy on 03/24/24. The nasal suspension was observed in a bag and not protected with a cap. The LPN did not wipe the nasal applicator prior to administering the nasal spray. After use, the LPN returned the nasal spray in the bag without cleansing the nasal applicator, and then stored the nasal spray in the medication cart along with other medications. On 04/03/24 at 8:05 AM, the surveyor inquired regarding the missing cap that was not observed when the LPN removed the bottle from the the bag. The LPN stated that the cap had been missing and would not elaborate further. The surveyor asked the LPN if she had received in-service on how to administer nasal spray. The LPN stated that she had not received any in-service regarding how to administer nasal spray but she would read the recommendations on the product box. The surveyor then inquired regarding infection control protocol. The nurse then stated that she should have used a tissue to wipe the nasal applicator before and after administration to prevent the spread of germs. The manufacturer recommendations revealed the nasal applicator should be wiped with a clean tissue after being used and the nasal applicator should be protected with a translucent cap. On 04/08/24 at 9:39 AM, the surveyor interviewed the Registered Nurse Educator regarding the infection control concerns observed during the medication administration. The RN stated that if the cap from the nasal spray had been missing, the LPN should have called the pharmacy and requested another nasal spray to prevent the spread of infection. The RN confirmed that she had not provided in-service to the staff on how to administer nasal spray. A review of the facility's policy titled, Infection Control-Standards Precautions provided by the DON on 04/04/24, indicated that employees will be in-serviced annually on infection control issues, including hand washing and gloves use, standards precautions and epidemiological significant pathogens. N.J.A.C 8:39-19.4(a) 49094

Based on interview and review of other pertinent facility documentation, it was determined that the facility failed to 1.) include a standardized infection assessment tool or management algorithm when prescribing antibiotics, 2.) provide evidence of staff education about antibiotic stewardship and 3.) provide evidence of antibiotic monitoring during quarterly reviews. These deficient practices were identified during investigation of the Infection Control Task. The deficient practice was evidenced by the following: 1.) On 4/6/22 at 1:17 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that the facility does not use any standardized criteria for determining infections. The DON further revealed they use their own clinical experience and microbial cultures (method of multiplying microbial organisms in a culture medium under laboratory conditions) to determine true infections. 2.) On 4/6/22 during the same interview with the surveyor, the DON revealed that a lot of time is spent on educating staff on the facility's antibiotic stewardship procedure. During an interview with the surveyor on 4/12/22 at 9:51 AM, the DON said that there was no documented staff education about antibiotic stewardship during the year of 2021. 3.) A review of a document titled, Pharmacy and Therapeutics Meeting (P&T), QAA (Quality Assurance Assessment) and QAPI (Quality Assurance Performance Improvement)-COVID 19, Outbreak Response Plan, Antibiotic Stewardship Quarterly Review dated 7/21/21 did not include any minutes or documentation of discussions about an antibiotic stewardship quarterly review. A review of a document titled, P&T, QAPI and QAA, Satisfaction Surveys, Policy and Procedure for Visitation, Antibiotic Stewardship Quarterly Review dated 1/19/22, did not include any minutes or documentation of discussion about an antibiotic stewardship quarterly review. During a review of the facility policy titled, Antibiotic Stewardship Program with revised date of 4/5/22, revealed under Standard section that the facility will Communicate with nursing staff and prescribing clinicians the facility's expectations about use of antibiotics and the monitoring and enforcement of stewardship policies. The policy further revealed under Policy section that the facility will Track the amount of antibiotic used in the home to review patterns of use and determine the impact of the new stewardship interventions during quarterly review. N.J.A.C. 8:39-19.4(a)

Based on interview, and review of other facility documentation, it was determined that the facility failed to develop and implement a policy to include contingency plans that address staff who are not fully vaccinated due to an exemption or temporary delay in vaccination, to include implementing additional precautions. This deficient practice was evidenced by the following: During Entrance Conference with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing on 4/1/22, the surveyor requested a copy of the facility policy and procedures regarding staff vaccination for Covid-19. On 4/6/22 at 9:44 AM, the LNHA provided the Surveyor a document titled Infection Control Employee Mantoux Testing, COVID 19 Vaccinations, that included the following vaccination related policies and procedures: COVID 19 Vaccinations are offered through CVS Clinic and Mega Center all staff must be vaccinated and must be able to show proof of CDC Vaccination card. Added booster 2/2022, all staff must be boostered by April 11, 2022, and must show proof of booster on their CDC Vaccination cards prior to April 11, 2022. [NAME] Lane Home will continue to offer booster clinics for all staff. There was no documentation to indicate the facility's contingency plan for staff who were unvaccinated, on temporary delay or who would qualify for an exemption. When the surveyor reiterated the request for a policy that included a vaccination contingency plan as required, the LNHA stated it was in their Outbreak Response Plan. On review of the Outbreak Response Plan, it was found that it did not include a contingency plan for staff that declined the vaccination. On 4/7/22 at 10:35AM, the surveyor met with the LNHA and the Director of Nursing, and they both stated that they are not familiar with the CMS New Staff Vaccination Rule other than Covid-19 administration deadlines. They further stated that they get their information and guidance from the County Department of Health; if an employee asks about exemptions, they refer them to Human Resources. N.J.A.C. 8:39-5.1(a);19.4(a)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to document bimonthly weights per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. During the initial tour of Spruce hallway on 4/1/2022 at 10:53 AM, Resident #29 was observed sitting in his/her wheelchair with bilateral ace wraps on his/her legs. Resident #29 said he/she retains water in their legs. A review of the Resident Face Sheet revealed Resident #29 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set, an assessment tool dated 2/17/2022 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating Resident #29 was cognitively intact. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If weight is above baseline weight of 215.3 by 5 pounds, then call office for additional [MEDICATION(S)] (a diuretic medication given to help remove excess fluids from the body) orders. A review of the Resident Medication Administration Record (RMAR) from December 2021 up to and including April 2022 revealed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the documented weights for Resident #29 under the Monitoring section of the Electronic Medical Record (EMR), revealed weight results for 12/14/21, 1/12/22, 2/3/22 and 3/19/22. There were no negative outcomes to Resident #29. During an interview with the surveyor on 4/6/2022 at 9:42 AM, the assigned Certified Nursing Assistant (CNA) revealed that weights are done monthly at the beginning of the month, according to facility policy. We then give the weights to the nurse. She went on to say, The nurse notifies us if we need weekly or daily weights. During an interview with the surveyor on 4/6/2022 at 9:44 AM, the assigned Licensed Practical Nurse (LPN #1) said, The CNA gives the nurse the weight and I record the weight on the monthly weight monitoring sheets for the hall/unit. I give the sheet to the Director of Nursing (DON) after all the weights and reweights are completed. If a resident is on weekly weights, that will come up on the RMAR and we document the weight on the RMAR, and then the weight goes directly into the monitoring section of the EMR. During an interview with the surveyor on 4/6/2022 at 9:55 AM, the DON said This resident (Resident #29) is on weights every 2 weeks per the physician order. The weights need to be documented in the RMAR and will carry into the monitoring section. The DON then pulled up the documentation of the weights on Resident #29's RMARS and confirmed the weights were not documented. The DON then said she will be calling the involved nurse. The DON said she will check the nurses report sheets for January thru March to see if they are documented. At 10:04 AM, the DON confirmed that the only weights under the monitoring section are the monthly weights and could not find the weights for every 2 weeks as ordered for this resident. During a follow up interview on 4/7/2022 at 10:18 AM, with the DON stated, Absolutely, they (nurses) should have made sure the weight went into the medical record. She went on to say, The Bottom line is they (nurses) took a weight and did not put it in the computer. She went on to say, Whether prompted by the EMR or not, the order is on the RMAR. The surveyor reviewed the facility policy titled Weighing Residents with a reviewed date of 10/21. The policy did not include where specific physician ordered weights were to be documented. NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to follow their own policy for storage of respiratory equipment. This deficient practice was identified for 1 of 3 (Resident #33) residents reviewed for respiratory concerns and was evidenced by the following: During a tour of the facility on 4/1/2022 at 10:40 AM, Resident #33 was observed lying in bed. The surveyor observed the nebulizer machine (a nebulizer machine delivers aerosol medication to the person via a mouthpiece and chamber/cup that holds the medication, via tubing that is attached to the machine. It is used to treat respiratory conditions such as [CONDITION(S)], [CONDITION(S)], and asthma.) on a cabinet next to the resident's bed. The surveyor observed the tubing and mouthpiece of the nebulizer machine exposed to air and uncovered. At that time the surveyor observed moisture in the chamber of the mouthpiece that was attached to the tubing. On 4/4/2022 at 9:21 AM, the surveyor observed the tubing and mouthpiece of the nebulizer machine exposed to air and uncovered . The surveyor observed moisture in the chamber of the mouthpiece that was attached to the tubing. Resident #33 stated that he/she received their last nebulizer treatment at 8:00 AM. On 04/05/22 at 12:09 PM, the surveyor observed the tubing and mouthpiece of the nebulizer machine exposed to air and uncovered. The surveyor observed moisture in the chamber of the mouthpiece that was attached to the tubing. On 04/06/22 at 10:50 AM, the surveyor observed the tubing and mouthpiece of the nebulizer machine exposed to air and uncovered. The surveyor observed moisture in the chamber of the mouthpiece that was attached to the tubing. When interviewed at that time, Licensed Practical Nurse #2 stated that if a nebulizer machine mouthpiece and chamber is not in use, it should be in a bag and not open to air. A review of the medical record revealed Resident # 33 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS also included an order dated 3/20/22 to change then label and date neb (nebulizer) tubing every Friday on 11-7 shift and place in plastic bag when not in use. During an interview with the surveyor on 04/06/22 at 01:43 PM, the Unit Manager in the presence of the Director of Nursing (DON) stated the nebulizer mouthpiece should be in a bag. The Unit Manager went on to say that when not in use the nebulizer mouthpiece and chamber should not be stored with moisture in it. During an interview with the surveyor on 04/07/22 at 10:20 AM, the DON stated the nebulizer mouthpiece and chamber should be dry and, in a bag, when not in use. A review of a facility policy titled Oxygen-Changing of Tubing and Filters with a reviewed date of 10/21, reflected that nebulizer tubing is to be placed into plastic bag when not in use. The policy does not include that the chamber should be kept dry. NJAC 8:39-15.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to provide adequate supervision to a resident who had a history of [REDACTED].#25) and was evidenced by the following. During the initial tour of the facility on 12/1/19 at 10:50 AM, the surveyor observed Resident #25 sitting in the dayroom with a fall deterrent alarm (a pad alarm the resident was sitting on) that was attached to the resident's wheelchair. The resident's head was down, and he/she did not engage in a conversation when attempted by the surveyor. On 12/2/19 at 8:36 AM, the surveyor observed Resident #25 sitting at a table near the nursing station eating breakfast. The surveyor observed the pad alarm in place. The surveyor reviewed the resident's medical record, which reflected that the resident had [DIAGNOSES REDACTED]. The 9/17/19 Minimum Data Set, an assessment tool used to facilitate the management of care, identified the resident as extremely cognitively impaired and requiring extensive assistance of one person for toilet use. The surveyor reviewed the nursing care plan and observed a Focus area of at risk for fall and actual fall dated 8/7/19. Interventions included resident to be in staff supervised areas. During a further review of the resident's medical record, the surveyor observed that Resident #25 sustained falls at the facility on 6/3/19, 6/24/19, and 8/7/19. The resident was not injured in any of those falls. The surveyor observed that on 10/12/19, the resident again sustained a fall while in the bathroom. The surveyor reviewed the 10/12/19 Accident investigative report, which was provided to the surveyor by the facility. According to the Accident report, Resident #25 ambulated out of bathroom on own and fell . The Accident report noted under Contributing Factors that Resident was left on toilet unattended and noted under Accident Reason that Not following care plan. The Accident report included Noted hematoma (bruise) to the right forehead. Also noted red area to the right shoulder and small bruise to top of right hand. When interviewed on 12/2/19 at 11:35 AM, the Certified Nursing Assistant (CNA #1), who cared for Resident #25, stated that Resident #25 was confused and dependent on staff for care. CNA #1 said Resident #25 was a fall risk and should be supervised at all times. CNA #1 further stated that she did not have Resident #25 on 10/12/19, but she had reported to the agency CNA (CNA #2) who cared for Resident #25 that day. CNA #1 said she had informed CNA #2 that Resident #25 should not be left unattended in the bathroom. When interviewed on 12/2/19 at 11:45 AM, the Director of Nursing (DON) confirmed that the CNA who cared for Resident #25 on 10/12/19 was an agency CNA and that she had been informed that Resident #25 was not to be left unattended in the bathroom. On 12/3/19 at 9:55 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who cared for Resident #25 on 10/12/19. The LPN stated she recalled that Resident #25 was getting restless after lunch. The LPN said CNA #2 took the resident to the bathroom and left the resident in the bathroom. The resident attempted to ambulate and fell . The LPN further stated that CNA #2 was informed during morning report that day that Resident #25 should not be left unattended in the bathroom. The LPN also said that she interviewed CNA #2 after the fall, and CNA #2 told her that she thought she could leave the resident alone on the toilet. The LPN said CNA #2 said that she left the resident in the bathroom to answer a call light. The surveyor reviewed an Employee Statement that had been written by the LPN after interviewing CNA #2. The LPN wrote, CNA stated, 'I took the resident to the bathroom because she was restless in her wheelchair after lunch. I took her into the bathroom and put her on the toilet. I came out of the bathroom, leaving the resident on the toilet. I thought I could leave her on the toilet. When I came back, resident had walked out of the bathroom and fell .' (The surveyor attempted to call the agency CNA for an interview. The phone number provided by the facility was incorrect.) During a follow-up meeting with the survey team on 12/4/19 at 9:35 AM, the DON stated: On 10/12/19, the resident should not have been left alone in the bathroom. When asked how long that intervention had been in place, the DON replied, for a while, (the LPN) would know. When interviewed on 12/4/19 at 10:25 AM, the LPN stated the intervention of not leaving the resident alone in the bathroom had been in place since at least September. The facility was unable to provide a policy that was pertinent to supervising a resident. NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous food and maintain kitchen sanitation in a safe and consistent manner in order to prevent food borne illness. This deficient practice was evidenced by the following: On 3/18/19 from 6:16 PM to 7:10 PM, the surveyor, accompanied by the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), observed the following in the kitchen: 1. The surveyor observed a Food Service Worker (FSW) perform handwashing at 6:40 PM. The FSW turned on the faucets with bare hands. The FSW then proceeded to wet her hands under running water, apply soap and washed her hands vigorously for 14 seconds. The FSW then rinsed her hands under running water and dried her hands with a paper towel. The FSW then proceeded to turn off the faucets with the hand towel and place the dirty hand towel into the waste receptacle. 2. In the Prep Area on an upper shelf, a sealed plastic bin containing individual portion control servings of sugar free syrup and an additional sealed plastic bin of breakfast syrup had no dates. The LNHA instructed a FSW to label the bins with a received and use by date. 3. On 3/19/19 at 11:49 AM, during the lunch meal in the main dining room, the surveyor observed a FSW exit the kitchen with a tray of prepared resident lunch plates. The FSW had a hair net on which only partially covered the FSW 's hair, leaving the front third of the FSW'S hair exposed. The surveyor reviewed the facility policy with the topic Hand Washing, reviewed Oct. (YEAR). Under the Procedure section, the policy specifies under #2: Turn the faucet on with a paper towel. Adjust the water temperature. The policy further states under procedure number 8: Use friction for at least 20 seconds interlacing fingers and rubbing vigorously. In addition, procedure number 13 indicated Then apply [MEDICATION NAME] hand solution or gel. The surveyor reviewed the facility policy titled Hygiene Points of Emphasis, Reviewed Oct. (YEAR). Point of Emphasis #5 stated, Wearing, where appropriate, in an effective manner, hair nets, headbands, caps, beard covers, scarf/head wrap, or other effective hair restraints. NJAC 8:32-17.2 (g)

Based on observation and interview, it was determined that the facility failed to detect and remove expired medication from a stock medication storage cabinet. This was cited at a level E as the deficient practice of expired medications not being removed from supply had occurred at the last standard survey of 1/30/2018. This deficient practice was evidenced by the following: On 3/20/19 at 09:10 AM, the surveyor reviewed the medication storage area in a nursing supervisor's office (back of the nurses station) in the presence of the Director of Nursing (DON). The facility was storing stock medications that included over the counter items such as pain relievers, Vitamins, antacids etc. The surveyor randomly chose bottles from the stock supply in order to check for expiration dates. The surveyor found the following expired medications: [REDACTED] 1. There were two bottles of Folic Acid (a supplement that aids in the treatment of [REDACTED]. Both bottles were labeled with an expiration date of 8/2018. 2. There was a bottle of [MEDICATION NAME] Coated Aspirin 325 mg 100 tablets. The bottle had an expiration date of 9/2018. 3. There was a bottle of Multiple Vitamin with Iron 100 tablets. The bottle had an expiration date of 11/2018. 4. There was a box containing multiple packets for individual use of Uty Max (a supplement that supports urinary tract health). The packets had an expiration date of 8/18/2018. As the expired items were being identified, the surveyor handed them to the DON. When questioned about monitoring of the expiration dates, the DON said a Certified Nursing Assistant (CNA) was responsible and said, she just did it on Friday, she's going to be upset. When interviewed on 03/21/19 at 9:38 AM, the CNA said she had been checking the medications for expiration dates since August. The CNA said her procedure is to make sure there is more than 4 of each item still in stock, that they are in orderly rows and nothing has expired. The CNA said she checks the stock medications a couple of times each week. The CNA stated, I missed them. NJAC 8:39-29.1(e)

Based on observation and record review, it was determined that the facility failed to perform hand hygiene in accordance with the facility's policy. This deficient practice was identified for 1 of 2 nurses during the medication pass observation, and was evidenced by the following: On 03/19/19 at 7:55 AM, the surveyor observed a Licensed Practical Nurse (LPN) administer medications to Resident #39. Following the medication administration, the LPN went into the resident's bathroom and washed her hands. The LPN wet her hands, added soap and rubbed her hands together for 10 seconds (as timed by the surveyor's stopwatch.) The LPN then went on to the next resident and prepared medications for administration to Resident #32. Following the medication administration the LPN went to wash her hands. The LPN wet her hands, applied soap and rubbed her hands for 9 seconds (as timed by the surveyor's stopwatch). The surveyor reviewed the facility's Hand Washing policy which noted to Apply soap, work up lather and Use friction for at least 20 seconds interlacing fingers and rubbing vigorously. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to maintain a clean and sanitary environment for the residents. This deficient practice was identified for 3 of 5 resident room hallways and was evidenced by the following: On 1/26/18 the surveyor observed the following in the Maple hallway: 1. At 9:24 a.m. in Resident room [ROOM NUMBER] there were gray streaks and dark scuff marks on the white walls in the bathroom. There was a build-up of dirt in the corners and at the floor/wall junctures in the room. 2. At 9:27 a.m. in Resident room [ROOM NUMBER] there were scuff marks on the white walls in the room and in the bathroom. The bottom of the shower curtain was dirty in appearance. There was a build-up of dirt in the corners and at the floor/wall junctures in the room. 3. At 9:30 a.m. in Resident room [ROOM NUMBER] there were gray streaks on the white wall around the bathroom sink. There were scuff marks on the white walls in the room. There was a build-up of dirt in the corners and at the floor/wall junctures in the room. 4. At 9:32 a.m. in Resident room [ROOM NUMBER] there were gray marks on the white walls in the bathroom. The bottom of the shower curtain appeared dirty. There was an unknown substance/debris clogging some of the drain holes of the floor shower drain. There was a build-up of dirt in the corners and at the floor/wall junctures in the room. 5. At 9:36 a.m. in Resident room [ROOM NUMBER] there were gray streaks and marks on the white walls in the bathroom. There was a build-up of dirt in the corners and at the floor/wall junctures in the room. 6. At 9:37 a.m. in Resident room [ROOM NUMBER] there was a build-up of dirt in the corners and at the floor/wall junctures in the room. 7. At 9:39 a.m. in Resident room [ROOM NUMBER] there were gray marks on the white walls in the bathroom. The bottom of the shower curtain appeared dirty. There was a build-up of dirt in the corners and at the floor/wall junctures in the room. 8. At 9:41 a.m. in Resident room [ROOM NUMBER] the shower curtain in the bathroom was touching the floor and appeared dirty. There was a build-up of dirt in the corners and at the floor/wall junctures in the room. 9. At 9:42 a.m. in Resident room [ROOM NUMBER] the shower curtain was touching the floor and appeared dirty. There were gray marks on the white bathroom walls. There were gray scuff marks on the walls in the room. There was damage to the covebase molding in the area between the bathroom door and the resident's bed. There was a build-up of dirt in the corners and at the floor/wall junctures in the room. 10. At 9:46 a.m. in Resident room [ROOM NUMBER] there were gray streaks and marks on the walls in the bathroom and the room. The bottom of the shower curtain was touching the floor and appeared dirty. There was a build-up of dirt in the corners and at the floor/wall junctures in the room. 11. At 9:47 a.m. there was a build-up of dirt in the corners and at the floor/wall junctures in the Maple hallway. On 1/26/18 the surveyor observed the following in the Common hallway: 1. At 9:56 a.m. in Resident room [ROOM NUMBER] there were gray streaks and marks on the bathroom walls (white walls) and room. There was a build-up of dirt and dust in the corners and at the floor/wall junctures in the room. 2. At 9:59 a.m. in Resident room [ROOM NUMBER] there were gray streaks and marks on the bathroom walls and room walls. There was a build-up of dirt and dust in the corners and at the floor/wall junctures in the room. 3. At 10:01 a.m. in Resident room [ROOM NUMBER] the shower curtain had stains. There were gray streaks and marks on the bathroom and room walls. 4. At 10:04 a.m. in Resident room [ROOM NUMBER] the shower curtain had stains. There were gray streaks and marks on the bathroom walls and room walls. There was build-up of dirt and dust in the corners and at the floor/wall junctures in the room. In the corner behind the door, there was a spider web with a spider in it. There was debris of unknown origin in the floor drain in the shower. 5. At 10:07 a.m. in Resident room [ROOM NUMBER] there were black streaks along the walls by resident bed W. There were gray streaks and marks on the walls in the bathroom and the shower curtain had dark brown stains on it. There was dirt and debris behind resident bed W. 6. At 10:11 a.m. in Resident room [ROOM NUMBER] there were gray streaks and brown stains on the wall by resident bed W and along the walls of the resident room. There were gray marks on the walls of the bathroom. There was a build-up of dirt and dust in the corners and at the floor/wall junctures in the room. 7. At 10:14 a.m. in the Common hallway there was a build-up of dirt and dust in the corners and at the floor/wall junctures. On 1/26/18 the surveyor observed the following in the Oak hallway: 1. At 10:18 a.m. in Resident room [ROOM NUMBER] there were gray streaks on the walls by both resident beds. There were gray streaks on the walls in the bathroom. The shower curtain and privacy curtain had stains. There were stains on the floor in the bathroom, light brown in color. There was a build-up of dirt and dust in the corners and at the floor/wall junctures in the room. 2. At 10:21 a.m. in Resident room [ROOM NUMBER] an EZ stand resident lift was in the resident's bathroom. There was a heavy accumulation of dirt and a brown substance on and around the inner base. There were gray streaks on the walls in the bathroom. There was a build-up of dirt and dust in the corners and at the floor/wall junctures in the room. 3. At 10:24 a.m. in Resident room [ROOM NUMBER] there were gray streaks and a dark brown substance on the walls in the bathroom. The shower curtain was touching the floor and it was dirty along the base. 4. At 10:26 a.m. there was a build-up of dirt and dust in the corners and at the floor/wall junctures in the Oak hallway. On 1/29/18 at 10:27 a.m. the surveyor reviewed the facility's policy titled Operations Maintenance Engineering (7 Cleaning Steps - Resident Rooms) that was provided by the Administrator at 10:22 a.m. The policy included under #5c (Wet Mop) Use a scraper to get gum, debris and to clean corners and under #5f (Wet Mop) Move furniture to ensure a thorough cleaning. The policy included under discharge checklist ***Ensure there is no buildup around edges of rooms, behind doors/furniture, or in corners of room***. On 1/29/18 at 10:41 a.m. the surveyor reviewed the facility's policy titled Housekeeping Policies (Frequencies) provided by the Administrator at 10:22 a.m. The policy included under Resident Rooms (iv.) Quarterly - Deep clean resident beds; Deep clean furniture and appliances; Window cleaning; Dry-clean draperies and curtains. The policy included under Bathrooms and Lavatories (iv.) Quarterly - Window cleaning; Dry-clean draperies and curtains; Wet-clean shower curtains. NJAC 8:39 - 31.4 (a

Based on interview and medical record review, it was determined that the facility failed to complete a resident assessment that accurately reflected the resident's status/behaviors. This was identified during a review of the Minimum Data Set (MDS), an assessment tool, for 1 of 21 residents reviewed (Resident #33). This deficient practice was evidenced by the following: On 1/26/18 at 8:30 a.m. the surveyor reviewed an Annual MDS Assessment that had a reference date of 6/7/17. According to Section C0500 Resident #33 scored an 8 on a Brief Interview for Mental Status which indicated that the resident was moderately cognitively impaired. Further review of Section E0200 revealed that the resident had not displayed any physical or behavioral symptoms such as hitting, scratching, grabbing or threatening others. The MDS noted that the resident's [DIAGNOSES REDACTED]. On 1/26/18 at 9:33 a.m. the surveyor reviewed a Progress Note (PN) dated 6/6/17 at 5:12 p.m. in which a nurse documented that Resident #33 was agitated and attempted to scratch the Nurse's hand and stab her with a fork from the breakfast tray. The resident then attempted to stab a Certified Nursing Assistant (CNA) with a butter knife when the CNA attempted to assist the resident. Lastly, the resident refused care and tried to hit the CNA. The resident behaviors that were described in the PN were not documented in the Annual MDS Assessment of 6/7/17 as required. On 1/26/18 at 11:51 a.m. the surveyor interviewed the MDS Coordinator who stated that she had not documented any incidence of behaviors on the Annual MDS assessment dated [DATE] as she normally performed a seven day look back of the nurse's notes and had not observed any abnormal behaviors. The surveyor reviewed the details of the PN dated 6/6/17 with the MDS Coordinator and she then stated, Maybe I overlooked that note. The MDS Coordinator agreed that the Annual MDS Assessment should have included the aforementioned resident behaviors.

Based on observation, interview and record review, it was determined that the facility failed to detect and remove expired medication in 1 of 1 intravenous medication supply kits and in 1 of 1 Omnicell units, a trademarked, automated medication dispensing system. This deficient practice was evidenced by the following: On 1/25/18 at 9:20 a.m. the surveyor observed, in the presence of the Director of Nursing (DON), an intravenous medication supply kit with an expiration date of 11/17. The surveyor examined the contents of the kit because of the referenced expiration date and found 1 box of [MEDICATION NAME] 50% (0.5g/mL) that expired on 1/1/18. The surveyor then inspected the Omnicell and found the following expired medications: [REDACTED]. When interviewed on 1/25/18 at 9:45 a.m., the DON stated that the provider pharmacy was responsible for ensuring that expired medications were detected, removed, and replaced on a routine basis. The DON contacted the provider pharmacy and advised them to check the Omnicell unit immediately. The DON also stated that the facility nursing staff provided assistance in checking pending expiration dates of medications in the Omnicell. When interviewed on 1/26/18 at 8:38 a.m., the DON advised the surveyor that the provider pharmacy staff representative checked all medication in the automated dispensing medication system. Furthermore, the DON stated that all medication would be removed 90 days in advance of the expiration date in the future, as per the provider pharmacy ' s representative. The DON supplied the surveyor with a memorandum titled, RE: Omnicell stock expiration check to this effect and advised that the following medications were also found to be expired by the provider pharmacy ' s staff: 6 tablets of irbesartan (a blood pressure medication) 150 mg, which expired on 1/12/18; 5 tablets of [MEDICATION NAME] (a muscle relaxant medication) 10 mg, which expired on 1/17/18; 4 tablets of [MEDICATION NAME] (an [MEDICATION NAME] medication)12.5 mg, which expired on 1/6/18; 6 tablets of [MEDICATION NAME]/[MEDICATION NAME] (an [MEDICAL CONDITION] medication) 25/100 mg, which expired on 1/4/18; and 3 tablets of [MEDICATION NAME] (an antibiotic medication) 100 mg, which expired on 1/3/18. NJAC 8:39 - 29.1(e)

Based on observation, interview and record review, it was determined that the facility failed to maintain a clean and homelike environment in all residents' bathrooms. This deficient practice occurred on 1 of 3 nursing units, the Maple Unit, and was evidenced by the following: 1) On 1/3/17 at 1:55 p.m., the surveyor observed a small pile of soiled wash clothes in the corner of the shower floor in resident room 210. 2) On 1/3/17 at 2:00 p.m., 1/4/17 at 9:05 a.m. and on 1/5/17 at 8:36 a.m., the surveyor observed that the wall under the soap dispenser in the bathroom of resident room 210 was heavily soiled with drippage. 3) On 01/03/17 at 1:50 p.m., the surveyor observed streaks of discoloration on the wall of the bathroom, below the soap dispenser, located in resident room 206. 4) On 01/05/17 at 8:50 a.m., the surveyor observed the bathroom of resident room 207. There was a dark brown streak coming down, along the wall, to the right side of the soap dispenser. In addition, the resident's toothbrush was placed on the sink basin, near the faucet and the toilet seat was noted to have dark gray residue/soiling on it. According to documentation provided by the Housekeeping Supervisor, the housekeepers were to clean the bathrooms of all resident rooms daily. NJAC 8:39-31.4(f)

Based on observation, it was determined that the facility failed to provide a safe environment for all residents. This deficient practice occurred in 2 of 13 bathrooms of residents who were reviewed and was evidenced by the following: 1) On 1/3/17 at 1:55 p.m., on 1/4/17 at 8:59 a.m. and on 1/5/17 at 8:34 a.m., the surveyor observed that the emergency call light in in the bathroom of resident room 210 on the Maple Unit was wrapped around the grab bar next to the toilet. 2) On 1/3/17 at 1:55 p.m., on 1/4/17 at 8:59 a.m. and on 1/5/17 at 8:34 a.m., the surveyor observed that the emergency call light in in the bathroom of resident room 213 on the Spruce Unit was wrapped around the grab bar next to the toilet. NJAC 8:39-27.1(a)

Based on observation and record review, it was determined that the facility did not perform adequate hand hygiene during the medication pass conducted on 1/4/17. This deficient practice occurred with 2 of 2 nurses observed and was evidenced by the following: 1) During the medication pass on 1/4/17 at 8:19 a.m., the surveyor observed that Licensed Practical Nurse (LPN #1) washed her hands for only 10 seconds after administering medications to a resident. At 8:25 a.m. on the same day, LPN #1 washed her hands for only 13 seconds after administering medications to a resident. 2) During the medication pass on 1/4/17 at 8:47 a.m., the surveyor observed that LPN #2 washed her hands for only 15 seconds. At 8:56 a.m., LPN #2 did not wash her hands at all after administering medications to a resident. LPN #2 then poured and administered to another resident. 3) During the medication pass on 1/4/17 at 9:02 a.m., the surveyor observed LPN #2 put on gloves then administer eye drops to a resident. Once the administration was completed, LPN #2 removed the gloves, touched the medication cart to put the eye drops away then touched the Electronic Medication Administration Record (EMAR), without any hand hygiene. According to documentation provided by the Director of Nurses (DON), hand washing should occur with at least 20 seconds of friction. This documentation also indicated that when wearing gloves during the medication pass, hands should be washed before moving on to the next task. The DON also provided information indicating that both LPN #1 and LPN #2 received inservicing on the appropriate hand washing technique on 11/29/16. NJAC 8:39-19.4(a)

Based on observation and record review, it was determined that the facility failed to enhance the self worth and self esteem of all residents. This deficient practice occurred to 2 of 5 residents (Residents #8 and #9) reviewed for dignity and was evidenced by the following: 1) On 11/5/15 at 9:53 a.m., the surveyor observed Resident #8 seated in a merriwalker, being wheeled into the activity area by a facility Licensed Practical Nurse (LPN). Coffee and snacks were being served by the activity staff to some of the residents that were seated in this area. The surveyor observed Resident #8 seated in his/her wheelchair from 9:53 a.m. through 10:07 a.m. At 10:07 a.m., Resident #8 was wheeled out of the activity area by a staff member without the resident being served a snack like other residents in this area. 2) On 11/5/15 at 10:38 a.m., the surveyor observed Resident #8 seated in a werriwalker in the hallway, outside of his/her room. During this observation, the agency Certified Nursing Assistant (CNA) that was assigned to provide care to Resident #8, pulled the resident backwards into his/her room then pushed the resident into the bathroom. Once in the bathroom, the agency CNA pulled the resident's pants down without closing the bathroom door. As the agency CNA was pulling his/her pants (resident's) down, the resident was saying, Stop it. Stop it. The surveyor also observed that Resident #8's room mate was in the room while the resident was receiving care with the bathroom door open. 3) On 11/6/15 at 9:05 a.m., the surveyor observed that the agency CNA was pulling Resident #8 in a merriwalker down the hallway towards the resident's room. While pulling the resident down the hallway, the surveyor observed the agency CNA say You want to go on the toilet, don't you?' to the resident. 4) On 11/5/15 at 10:45 a.m., the surveyor observed the agency CNA wheel Resident #9 into the bathroom, stand the resident up, pull down the resident's pants then transfer the resident onto the toilet while the bathroom door was open. NJAC 8:39-4.1(a)(15)

Based on observation, interview and record review, it was determined that the facility failed to provide assistance with eating and ambulation to residents who required the assistance of staff to perform their Activities of Daily Living (ADL). This deficient practice occurred to 3 of 4 residents (Residents #7, #8 and #12) reviewed for ADL assistance and was evidenced by the following: 1) According to the medical record, Resident #7 had a physician's orders [REDACTED]. The nursing staff were to document in the resident's Medication Administration Record [REDACTED]. On 11/4/15 at 11:10 a.m., the surveyor observed Resident #7 being pushed into the main dining room while seated in a merriwalker. Once in the dining room, the staff member assisted Resident #7 into a regular chair at the dining table. On 11/5/15 at 11:16 a.m., the surveyor observed Resident #7 being wheeled into the dining room for the lunch meal by the agency CNA. As this CNA was wheeling the resident in the merriwalker, Resident #7's feet were moving in an attempt to keep up with the speed of the merriwalker. Once near the table, the agency CNA pushed the merriwalker so that it was moving freely across the floor towards the dining table with the resident seated in it. Once the merriwalker arrived at the table's edge, the agency CNA told Resident #7 to stand up from the merriwalker and sit in a dining chair. The resident eventually stood up and without any assistance from the agency CNA, ambulated about 3 steps to sit in the dining chair. After eating lunch at 12:10 p.m., the surveyor observed the agency CNA assist Resident #7 in transferring into the merriwalker then told the resident to ambulate out of the dining room. Although the staff did not follow the physician's orders [REDACTED]. 2) According to the annual Resident Assessment Instrument (RAI) dated 6/17/15 and the quarterly RAI dated 9/14/15, Resident #7 was cognitively impaired and had a history of [REDACTED]. Resident #7 had a plan of care indicating that the resident should be encouraged to attend food related activities. This plan of care also indicated that the resident should be cued and redirected to finish his/her meals. On 11/6/15 at 8:23 a.m., the surveyor observed Resident #7 seated in a merriwalker in the activity area of the nursing unit. A facility staff member retrieved a regular chair from another resident's room and transferred Resident #7 from the merriwalker into this chair. While seated in the regular chair, the resident was pushed up to a table. The staff member brought the resident's breakfast meal of pancakes and bacon to the table. The staff member cut the pancakes and opened the packets of sugar and poured them into the coffee that was served with the meal. The empty sugar packets were left on the resident's tray. The staff member left the resident at the table. Once this staff member left the area, there were no staff supervising this resident. At 8:25 a.m., the surveyor observed Resident #7 use a spoon to scoop up an empty sugar packet and was bringing the spoon with the empty sugar packet to his/her mouth. Just as the resident was putting the empty sugar packet into his/her mouth, the surveyor observed a Licensed Practical Nurse (LPN) walking down the hallway towards this activity area. The surveyor told the LPN that there was paper on the resident's spoon. The LPN immediately went to the resident and removed the paper, which was partly in the resident's mouth. This LPN also removed all of the other trash from the resident's tray. It was not until this incident that a facility CNA came into this area and stayed with Resident #7. This CNA cued and supervised the resident while he/she finished his/her breakfast meal. On 11/6/15 at 11:34 a.m., the surveyor oobserved Resident #7 seated at the dining table for the lunch meal. The resident received barbeque chicken, tater tots and broccoli. Once the food was cut, the CNA left the resident to eat the meal. The resident used the fork to take a bite of the chicken. The resident put the fork down as he/she chewed the food but could not locate the fork when he/she was preparing to eat more of the lunch meal. Resident #7 put his/her fingers into the pile of chicken on the plate and ate it with his/her fingers. There was a rehab staff member seated at the table assisting another resident with their meal. This staff member had been looking at Resident #7 when he/she ate with fingers but did not redirect or assist the resident. 3) According to the initial RAI dated 3/25/15 and the quarterly RAI dated 9/18/15, Resident #8, who was cognitively impaired, required setup only with eating. The plan of care for this resident indicated that this resident had fluctuating weights and that his/her food consumption be monitored. On 11/5/15 at 11:50 a.m., the surveyor observed Resident #8 being fed his/her lunch meal by a CNA, in the main dining room of the facility. On 11/6/15 at 8:20 a.m., the surveyor observed that Resident #8 was in bed, alone in his/her room. The resident's breakfast meal was on the table on the overbed table in front of the resident. The pancakes were cut but the pieces were large. During this observation, Resident #8 stated that she was all balled up with this as he/she pointed to the breakfast meal. On 11/6/15 at 11:35 a.m., the surveyor observed Resident #8 being fed his/her lunch meal by a CNA. When interviewed at this time, the CNA stated that this resident must be fed. 4) On 11/4/15 during the lunch meal, the surveyor observed Resident #10 being fed his/her lunch meal by a CNA. The CNA was feeding the resident with adaptive equipment that was molded specifically for Resident #10. When interviewed at this time, the CNA stated that Resident #10 must be fed. On 11/5/15 at 8:15 a.m., the surveyor observed the resident in bed with the breakfast meal on an overbed table if front of the resident. There were no staff in the room at the time of this observation. The resident was holding a cup of juice in one hand and a specialized fork in the other. The fork had no food on it. On 11/6/15 at 8:21 a.m., the surveyor observed that Resident #10 was being assisted with eating breakfast by a CNA. When interviewed by the surveyor at 8:40 a.m., the CNA stated that the resident was able to feed him/herself with encouragement. This CNA stated that she would let the resident feed herself and then the CNA would feed the resident the rest of the meal. According to the most recent RAI dated 10/27/15, Resident #10, who was cognitively impaired, Resident #10 required the extensive assistance of one for eating. NJAC 8:39-27.1