Every finding on record at United Methodist Communities at Bristol Glen

Complaint # NJ 2565649Based on observation, interview, review of medical records, and other pertinent facility documents, it was determined that the facility failed to provide a safe environment and follow fall prevention interventions as written on the individual comprehensive care plan (ICCP) for 2 of 2 residents, (Resident #2 and Resident #5). Resident #2 was transferred with the use of a mechanical lift by one staff member, fell, sustained a head injury that required an emergency transfer to a hospital, and was admitted for 8 days with a laceration of the head that required 3 staples. This deficient practice was evidenced by the following: 1. Resident #2 was not in the facility during the survey. The surveyor reviewed the closed medical record for Resident #2. A review of Resident #2’s admission Record reflected the resident was admitted to the facility on [DATE] with diagnoses which included but were not limited to; a displaced fracture of the second cervical vertebra (break in the bone with fractured pieces moved out of their normal alignment), traumatic brain injury (damage to the brain) and hemiplegia (paralysis of one side of the body). A review of the most recent Minimum Data Set (MDS), an assessment tool dated 7/31/25, reflected that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated that the resident had severe cognitive impairment. A review of Section GG assessed that the resident required the assistance of two staff members for transfers. A review of Resident #2’s Care Plan Report reflected a care plan dated 6/20/25, with a focus area that indicated that the resident required assistance with bathing, hygiene, dressing, and grooming related to cognitive impairment, impaired mobility, and incontinence, with interventions that included but were not limited to; mechanical lift (a lift that uses a sling to safely transfer individuals with limited mobility from one location to another) for transfers with 2 persons; apply a neck collar for neck fracture that should be worn whenever out of bed or when transferring. A review of a nurses’ note dated 7/16/25 at 7:02 PM, reflected that a Certified Nursing Assistant (CNA #1) called out from the resident’s room, “I need help”. The nurse went to the room and observed the resident on the floor, next to the bed, with their head resting on the leg of the mechanical lift. CNA #1 stated that the resident “just slid out”. The back of the resident’s head was bleeding and direct pressure, and an ice pack was applied. Additional staff arrived to assist the resident back to bed and the Director of Nursing (DON) was notified. The nurses' note did not indicate that the resident had their neck brace in place. Further review revealed that an ambulance service was called and arrived at 7:25 PM and a neck collar was placed on the resident by EMS and the resident was transferred to the hospital at 7:40 PM. A review of the New Jersey Universal Transfer Form dated 7/16/25, with no documented time of transfer, revealed the reason for the transfer to the hospital, was the resident sustained an occipital (back of the head) wound with bleeding from the head post fall. A review of the Registered Nurse (RN) assessment nurses note dated 7/16/25 at 10:07 PM (late entry), revealed that CNA #1 attempted to transfer the resident with a mechanical lift alone without assistance. A review of the Facility Incident/Accident Report dated 7/16/25, indicated a Certified Nursing Assistant (CNA #1) transferred Resident #2 with a mechanical lift alone without assistance. The resident sustained a laceration to their head, and CNA #1 had been terminated. A review of CNA #1's Total Mechanical Lift Competency dated 3/20/25, reflected that CNA #1 received training and performed the Mechanical Lift Operation appropriately, which included: Ensuring two caregivers are present during the transfer . A review of the nurse's note dated 7/24/25 at 10:48 PM, reflected that Resident #2 was readmitted to the facility at 5:15 PM post fall, with 3 staples to the left occipital area of the head with a neck collar in place. On 8/25/25 at 11:58 AM, during an interview with the surveyor, the DON stated that the nurse called her on 7/16/25, at approximately 8:00 PM, and informed her of the incident. The DON suspended CNA #1 while an investigation was completed. On 8/25/25 at 12:30 PM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA), the Administrator in Training, and the DON. The LNHA confirmed that all mechanical lift transfers require two staff members to be present. A review of the facility policy, “Safe Handling” with a revised date of 8/8/25, reflected…The facility is committed to a culture of safety. All residents will be handled safely using zero manual lifts for mechanical lifting, transferring, and repositioning…The purpose is to ensure residents receive assistance appropriate for their functional level, physical characteristics, level of cooperation, medical condition, and cognitive status while promoting safety and comfort…to increase the quality of care for the resident…examples include but are not limited to bed to chair transfers…A direct care teammate shall consider their own ability, the environment and the resident status prior to any lift/transfer…Follow care plan lift/transfer recommendation. 2. On 8/20/25 at 12:06 PM, the surveyor observed Resident #5 who was dressed and groomed and was seated in a wheelchair in the dining room, waiting for lunch to be served. The resident was seated in the dining room with other residents and was seated next to a table. A review of Resident #5’s admission Record reflected the resident was admitted to the facility on [DATE], with diagnoses which included but were not limited to; spinal stenosis (the spaces inside the bones of the spine get too small), cervicalgia (pain in the neck and shoulder that varies in intensity), and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). A review of the most recent Minimum Data Set (MDS), an assessment tool dated 7/02/25, reflected that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. A review of Section GG assessed that the resident required maximum assistance for transfers. A review of Resident #5’s Care Plan Report reflected a care plan with a focus area that indicated that the resident required assistance with bathing, hygiene, dressing, and grooming related to impaired mobility, which was initiated on 6/24/25. Interventions included “transfer with moderate assist of 2 and use of a rolling walker and/or grab bar. Gait belt should be used for safety.” A review of the nurse’s note dated 8/25/25 at 4:29 AM, titled as “Incident Note, reflected… a Certified Nursing Assistant (CNA #2) reported that while attempting to transfer a resident out of bed that the resident sat/fell on their buttocks. The nurse wrote that when she saw the resident, they were sitting on the floor with legs out in front. The note continued that the resident denied injury and was successfully lifted by three staff members including a CNA #3 from another unit. Interventions were put in place to assure that the resident had the proper shoes and socks, and that the CNA #2 was in-serviced that the resident required two staff members for transfers, and that the CNA #2 needed to ask for assistance before transferring resident out of bed. A review of the “Daily Assignment Sheet” dated 08/26/25, revealed that Resident #5 was a transfer x 2 with Roller walker and gait belt. On 08/26/25 at 10:00 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who was aware of the incident and stated that the resident was a 2 person assist for transfers from bed or chair and that CNA #2 should have asked for help before trying to transferring the resident by herself. The LNHA acknowledged that CNA #2 was previously educated on transferring residents and that she was re-educated after the incident. On 8/26/25 at 12:40 PM, the surveyor interviewed CNA #2 who stated that she was aware that the resident was a 2-person transfer and that she should have requested help from another staff member. CNA #2 further stated that she was previously in-serviced on properly transferring residents and that she was re-educated after the incident. On 8/26/25 at 12:55 PM, the surveyor discussed the above concern with the LNHA and the Director of Nursing. No further information was provided. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to maintain the resident's room in a homelike manner.This deficient practice was identified on 1 of 3 Nursing Units (Sawmill) and was evidenced by the following: On 08/22/2025 at 11:10 AM, the surveyor entered Resident #25's room (room [ROOM NUMBER]B) and observed that the wall behind the headboard had large cracks and chipped paint across its entire surface. On 8/22/25 at 11:15 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) on the Sawmill unit stated that she had been aware that the wall needed to be repaired, but had not informed the maintenance department, which she should have done. The LPN stated that she would now fill out a work order. On 8/22/25 at 11:30 AM, during an interview with the surveyor, the maintenance staff member stated that he made rounds on the units daily but did not make rounds in the resident rooms. He further stated that it was the staff's responsibility to submit work orders to notify him of repairs that needed to be made. The surveyor showed the maintenance staff member the wall behind the headboard, which was damaged with large cracks across its entire surface. The maintenance staff confirmed that he had not been made aware of the damaged wall but would address it. On 8/22/25 at 12:30 PM, during an interview with the surveyor, the Director of Maintenance stated that he was not aware of the damaged wall in 34-B. He further confirmed that it was the staff who should alert maintenance by putting a request for repairs in the computer. On 8/25/25 at 1:00 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator. A review of the Environmental Rounds Worksheet reflected that no worksheet addressed the cracked wall in room [ROOM NUMBER]B. On 8/26/25 at 10:30 AM, no further information was provided by the facility. NJAC 8:39-31.4 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 1 of 1 Resident (Resident #1), reviewed for Respiratory therapy.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.On 08/20/2025 at 11:25 AM, the surveyor observed Resident #1 in bed with Oxygen (O2) delivered via a nasal cannula (NC) tubing, dated 8/19/25, attached to the O2 Concentrator at 3 LPM. On 8/21/25 at 12:00 PM, the surveyor observed Resident #1 seated in a wheelchair. The surveyor observed the Certified Nursing Assistant (CNA) applied the NC tubing to Resident #1's nares and turned on the O2 concentrator. The surveyor observed that the O2 gauge was set and infusing at 3 LPM. A review of Resident #1's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; Hemiplegia (paralysis) and Hemiparesis (partial loss of muscle function) following cerebral infarction (stroke) affecting the left non-dominant side, and Chronic Obstructive Pulmonary Disease ( lung disease that blocks airflow and makes it difficult to breath). A review of the current Order Summary Report revealed an active physician's order for Oxygen at 2 LPM via NC every shift for COPD with a start date 5/20/25. A review of Resident #1's admission Minimum Data Set (MDS), an assessment tool dated 5/27/25, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident had a severe cognitive impairment. A review of Resident #1's Individualized Care Plan (CP) had a focus that indicated the resident had inadequate oxygenation and required the use of oxygen related to Chronic Obstructive Pulmonary Disease (COPD) initiated 6/12/25 with interventions that included but were not limited to; Administer oxygen as ordered and check setting for correct LPM each shift. On 8/21/25 at 12:50 PM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) stated that Resident #1 had a PO for O2 at 2 LPM. The surveyor showed the LPN the concentrator gauge. The LPN confirmed that the O2 was infusing at 3 LPM, but it should have been 2 LPM, as per the PO. On 8/25/25 at 12:30 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Administrator in Training, and Director of Nursing (DON). A review of the facility's policy, Oxygen Management Clinical Practice Guideline revised 8/8/25 reflected .To ensure all residents who require supplementary oxygen receive therapy that is appropriate for their condition safely .Oxygen is a medication that requires a physician's order .NJAC 8:39-27.1 (a)

Based on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regards to: a.) following a physician's order as written for 1 of 15 residents (Resident # 1), and b.) completing neuro checks (an assessment of neurological status that must be done when a resident hits his or her head or if it is unknown if they hit their head) after a resident had a history of fall for 1 of 1 resident (Resident #14) reviewed for falls. The 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 and potential physical and emotional health problems, through such services as casefinding, 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 casefinding; 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. 1. On 5/15/24 at 11:34 AM, the surveyor observed Resident #1 seated in a wheelchair in their room. The resident was alert and oriented. Resident #1 stated they had a wound that was being treated by the nursing staff and verbalized no concerns. The surveyor reviewed the electronic medical records (EMR) of Resident #1 which revealed the following: The Admission Record (a summary of important resident information) documented Resident #1 had diagnoses that included, but were not limited to, osteoarthritis, peripheral vascular disease, hypertension, a pressure ulcer to the left heel, and a pressure ulcer to the right heel. A Quarterly Minimum Data Set (MDS) assessment, dated 4/9/24, indicated the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). Resident #1 scored a 12 out of 15 which indicated that the resident had moderate cognitive impairment. A review of the Order Summary Report documented Resident #1 had a physician order (PO), dated 5/17/24, which read: Dakins (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) Apply to Left heel topically two times a day for wound treatment for 14 days .Cleanse with normal saline, pat dry, apply Dakin's moistened fluffed gauze and crushed Metrodinazole to base of wound the[then] secure with bordered foam. A review of the May 2024 electronic Treatment Administration Record (eTAR) for Resident #1 documented the above PO for the left heel wound treatment and it was signed by the nursing staff as administered twice a day in the morning and evening shifts. A review of the resident's care plans included a care plan with a focus that read I have potential for pressure ulcer development r/t[related to] Immobility and I currently have pressure injury to my left heel (stage 3). An intervention for the care plan dated 11/15/23 read, Administer treatments as ordered and monitor for effectiveness. On 5/21/24 at 9:50 AM, the surveyor observed Registered Nurse #1 (RN #1) perform the left heel wound treatment for Resident #1. RN #1 reviewed the wound treatment PO with the surveyor prior to starting the wound treatment. On 5/21/24 at 10:07 AM, during the wound treatment, the surveyor observed RN #1 wash her hands appropriately for 35 seconds at the bathroom sink and don gloves. RN #1 took gauze moistened with normal saline, cleansed Resident #1's left heel wound, and dispose the used gauze in the garbage bin. RN #1 took a clean, dry gauze, and patted the wound area dry. RN #1 took a gauze moistened with dakin's solution, cleansed the left heel wound bed, and then dispose of the gauze in the garbage bin. RN #1 took a gauze with crushed metronidazole and applied the medication to the wound bed. RN #1 then disposed of the gauze in the garbage and applied a bordered gauze dressing. On 5/21/24 at 10:32 AM, the surveyor observed RN #1 sign for the wound treatment being administered to Resident #1. RN #1 confirmed she had completed the resident's wound treatment. On 5/21/24 at 10:35 AM, the surveyor reviewed with RN #1 the wound treatment order and the application of the Dakin's solution. RN #1 acknowledged she did not perform the wound treatment as written in the physician order and she did not apply the Dakin's moistened gauze to the wound bed with the crushed metronidazole. On 5/21/24 at 12:50 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Executive Director (ED), and the Regional Director of Clinical Services about the concern observed during the wound treatment of the physician's order not being followed as written. There was no additional information provided by the facility. A review of the facility's policy titled, Pressure Injury Prevention & Managing Skin Integrity with a last revised date of 2/14/2024 read under Policy, Any resident with a wound shall receive treatment and services consistent with the resident's goals of treatment. The policy did not further address following written physicians' orders for wound treatments. A review of the facility's provided wound treatment competency titled, UMC-Wound Treatment Observation Utilizing Clean technique read under Quality of Care, .Physician order is checked before starting treatment .Physician Order includes location of wound, frequency of treatment, method for cleaning wound, medication to be applied if any and type of dressing to be utilized . 2. On 5/15/24 at 12:20 PM, the surveyor observed Resident #14 seated in their wheelchair in the dayroom of the unit. Resident #14 was alert and verbally responsive to simple questions. On 5/20/24 at 9:47 AM, the surveyor reviewed a fall investigation report, dated 3/5/24 for Resident #14. The resident had a fall incident at approximately 6:45 pm in which Resident #14 attempted to assist another resident move their wheelchair and fell out of their wheelchair. Resident #14 fell on their right side to the floor and bumped the right side of their head. There were no visible injuries, an ice pack was provided and neuro-checks were initiated. The surveyor reviewed the EMR of Resident #14 which revealed the following: The Admission Record documented Resident #14 had diagnoses that included, but were not limited to, Chronic Kidney Disease, Dementia, and Hypertension. A Quarterly MDS assessment, dated 5/7/24, indicated the facility assessed the resident's cognitive status using a BIMS. Resident #14 scored a 3 out of 15 which indicated that the resident had severe cognitive impairment. A nurse progress note dated 3/5/24 at 20:17 [8:17 pm], documented Resident #14 attempted to move another resident's wheelchair and fell out of their wheelchair onto their right side in the dining room area. The note further detailed the resident had bumped the right side of their head on the floor and neuro-checks for the resident were WNL [within normal limits]. A nurse progress note dated 3/6/24 at 23:05 [11:05 pm], detailed a neuro-check completed for Resident #14 which included, a neurological assessment and vital signs obtained. There were no other progress notes found that documented any additional neuro-checks being completed after the resident's fall. A review of the Order Summary Report for March 2024 revealed, there were no PO to account for neuro-checks being completed after the resident's fall incident. A review of the March 2024 electronic Medication Administration Record (eMAR) and eTAR revealed that there were no entries for the neuro-checks being completed after the resident's fall incident. A review of the March 2024 list of vital signs (VS) revealed that there were no VS documented to account for the neuro-checks being completed after the resident's fall incident. On 5/20/24 at 11:20 AM, the surveyor requested from the DON for further documentation of the neuro-checks related to the fall incident of Resident #14. The DON stated she would review and provide further information. On 5/20/24 at 12:40 PM, the DON provided the surveyor a document titled UMC NEUROLOGICAL CHECK LIST dated 3/5/24 and timed 19:41 [7:41 pm], which was found in the resident's EMR. A review of the document revealed under the section titled, Vital Signs, the VS documented were dated 3/1/24. The other sections of the document which included mental status assessments, pupil assessment, pain assessment, and range of motion of extremities were completed. There was no additional documentation to indicate additional neuro checks being performed after the resident's fall. On 5/21/24 at 12:40 PM, the surveyor informed the LNHA, DON, ED and Regional Director of Clinical Services about the concern that there was no documentation to indicate neuro-checks for the resident were completed after their fall on 3/5/24. The DON and the LNHA acknowledged it would be expected for neuro-checks to be completed and documented for an unwitnessed fall or a bump to the head. On 5/22/24 at 9:58 AM, the surveyor interviewed the DON who stated there was no additional information found for completion of the neuro-checks. The DON stated the facility protocol for neuro checks once initiated was that it would be done every 2 hours for 12 hours, then every 3 hours for 24 hours, and every 4 hours for another 24 hours. The DON further stated a physician order should have been written and the facility's policy was for neuro checks to be initiated when a resident had an unwitnessed fall, a head injury or if a head injury could not be ruled out. On 5/22/24 at 10:13 AM, the surveyor interviewed over the phone Registered Nurse #2 (RN #2) who was the assigned nurse for Resident #14 at the time of the fall incident. RN #2 stated for unwitnessed falls or falls with possible head injury, neuro checks were to be initiated. RN#2 could not explain the facility's protocol on how often neuro checks were to be performed and stated the facility policy was different from what she was used to. RN #2 further stated neuro checks were entered as physician's orders and would be triggered for nurses to assess the resident's vital signs at a certain frequency. RN #2 was not sure where the triggered neuro check documentation would be found in the EMR and stated she would write her neuro-check assessments in her progress notes instead. RN #2 could not recall the details of the 3/5/24 fall incident for the resident. The surveyor discussed with RN #2 the concern that there were no neuro checks found for the resident other than the two progress notes and the neuro checklist documentation provided by the DON. RN #2 could not speak to why there was not further documentation of the neuro checks and no physician order found. A review of the facility's policy titled, Fall Prevention and Management with a last reviewed date of 7/6/2023 read under Post Fall Management, B. Minor Head Trauma or Impact, it read: .performs neuro-checks every two hours for the first 12 hours, every three hours for the next 24 hours, every four hours for the following 24 hours .2. Neuro-checks shall be implemented if a resident cannot communicate that they may have hit their head due to cognitive impairment . NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to clarify a Physician's Order (PO) in accordance with professional standards of practice for 1 of 16 residents (Resident #16) reviewed. The deficient practice was evidenced by the following: 1. On 5/15/24 at 11:15 AM, the surveyor observed Resident #16 in a Geri-chair (a specialized chair designed specifically for seniors and individuals with limited mobility), receiving oxygen (O2) via nasal cannula (medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) at 3 Liters Per Minute (LPM.) The surveyor reviewed the medical records of Resident #16, who was admitted to the facility with diagnoses that included but not limited to Human Metapneumovirus Pneumonia, Chronic Respiratory Failure, and Chronic Obstructive Pulmonary Disease. A review of the Minimum Data Set Assessment (MDS), an assessment tool, used to facilitate the management of care, dated 4/21/24, revealed that the resident had a score of 13 out of 15 on the Brief Interview for Mental Status, which indicated that the resident was cognitively intact. Further review of the MDS under Section O also revealed that the resident received continuous oxygen therapy. A review of the PO for Resident #16 revealed a PO, dated 4/17/24, for 2-4 LPM Oxygen via nasal cannula, keep oxygen saturation (SpO2) above 90% every shift for Shortness of Breath (SOB). On 5/17/24 at 9:18 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1), who was assigned to Resident #16, and stated that Resident #16's O2 rate was set at 2 LPM but would increase the rate if their SpO2 (the amount of oxygen in your blood that can be measured by a device called a pulse oximeter) would decrease below 90%. LPN#1 further stated that the PO for O2 rate must be at a specific rate and not in a range. On 5/17/24 at 10:05 AM, the surveyor interviewed the Registered Nurse/Nurse Mentor (RN/NM #1), who stated oxygen orders should not be written with a range but a specific number setting, like 3 LPM. On 5/17/24 at 12:35 PM, the surveyor interviewed the Respiratory Therapist, who acknowledged that the PO for the O2 rate should have been at a specific rate and not in a range. On 5/17/24 at 1:00 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Oxygen Management Clinical Practice Guideline, with a revised date of 4/22/22. The facility policy does not specifically address the O2 rate order administration. On 5/20/24 at 01:18 PM, they survey team met LNHA, Director of Nursing (DON), Regional Director of Clinical Service (RDCS) and Executive Director (ED) to review concerns. The DON stated the O2 orders should be clearer and not have a range. The facility did not provide any further information. NJAC 8:39- 27.1 (a)

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 3/13/22 at 10:06 AM, in the presence of the Chef Manager and Operations Manager (OM), the surveyor observed the following: 1 The surveyor observed two of five red sprinkler caps and fire suppression poles above the cook top area, which were soiled with a black grease-like substance and white colored particles. 2. In the standing refrigerator number 5, the surveyor observed two wrapped and undated 1/2 sheet sized steam table pans which contained a corn and lima bean salad and a wrapped and undated full sized sheet pan containing a green colored gelatin. 3. In walk in refrigerator, the surveyor observed a 1/2 of a slab of provolone cheese wrapped and with a use by date of 2/27/22 still on shelf. The surveyor also observed a container of rice pudding wrapped with a use by of 3/12/22. 4. At 11:44 AM, in the presence of the OM, on the 2nd floor the surveyor inspected three standing refrigerators. In the first standing refrigerator, the surveyor observed 21 separately wrapped slices of pumpkin pie which were undated. In the second refrigerator on the floor, the surveyor also observed three wrapped and undated containers of bean salad, and 6 separately wrapped slices of pumpkin pie which were undated. On 3/13/22 at 11:37 AM, the surveyor discussed the above concerns with the Administrator and Director of Nursing. The surveyor reviewed the facility's policy with a revised date of 1/12/17 titled, Food Product Shelf Life Guidelines. The policy indicated that the pumpkin pie should only be refrigerated for 2 to 3 days after opening and the pudding should be refrigerated for 2 days after opening. The facility did not provide the surveyor with any additional requested policy and procedure. NJAC 8:39-17.2(g)

Based on interview and record review, it was determined that the facility failed to issue the required Medicare Beneficiary Protection Notification. This deficient practice was identified for 3 out of 3 residents reviewed, Resident #13, Resident #282, and Resident #283. The deficient practice was evidenced by the following: On 3/14/22 at 12:25 PM, the facility presented the surveyor with a list of residents who were discharged from a Medicare covered Part A in the last 6 months. These residents should have received Beneficiary Notices. The surveyor reviewed three residents selected from the list. Resident #283 was discharged from the facility. Resident #282 and Resident #13 remained at the facility. On 3/15/22 at 1:15 PM, the surveyor received the beneficiary notifications for 2 of the 3 residents to review. At that time, the Administrator (LNHA) stated the notification forms for Resident #283 could not be located. The LNHA did not know where the previous social worker placed the forms. According to the SNF Beneficiary Protection Notification Review form, Resident # 282 was admitted to the facility on [DATE] and the last documented covered day for Medicare Part A service was 10/8/21. The facility did not present the resident with the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form. According to the SNF Beneficiary Protection Notification Review form, Resident #13 was admitted to the facility on [DATE] and the last documented covered day for Medicare Part A service was 1/17/22. The facility did not present the resident with the required SNFABN form. On 3/16/22 at 10:55 AM, the surveyor interviewed the Social Worker (SW) about the beneficiary notices for Resident #282 and #13. The SW stated Resident #282, and Resident #13 received the Notification of Medicare Non-Coverage (NOMNC) form. The surveyor asked if the residents should have received the SNFABN form. The SW said she didn't know and would have to follow up with the Administrator. The SW looked up the SNFABN form and confirmed she had not given it to any residents. On 3/16/22 at 11:00 AM, the surveyor asked the SW about the beneficiary notifications for Resident #283. The SW stated she looked in the electronic and paper files of the previous SW and could not find any notification forms for that resident. On 3/16/22 at 1:09 PM, the surveyor informed the LNHA and the Director of Nursing (DON) of the concern with the residents not receiving the proper notification of potential liability for payment. On 3/17/22, 9:10 AM, the surveyor received the Beneficiary Notification for Resident #283 from the LNHA. According to the SNF Beneficiary Protection Notification Review form, Resident #283 was admitted to the facility on [DATE] and the last documented covered day for Medicare Part A service was 11/28/21. The facility provided a copy of the ABN form that had been given to the resident. There was no evidence that the resident received the required NOMNC form. On 3/17/22 at 11:41 AM, the surveyor informed the LNHA and the DON of the above concern. No further information was provided. NJAC 8:39-5.1

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 2 of 16 residents reviewed for resident assessment; Resident #1, and #2. This deficient practice was evidenced by the following: On 12/4/19 at 10:26 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically send the MDS up to 14 days of the assessment being completed. 1.) Resident #1 was observed to have a quarterly MDS with an Assessment Reference Date (ARD) of 10/11/19 and was due to be transmitted no later than 11/7/19. The MDS was not electronically sent when reviewed by the surveyor on 12/5/19. 2.) Resident #2 was observed to have a quarterly MDS with an ARD of 10/17/19 and was due to be transmitted no later than 11/13/19. The MDS was not transmitted when reviewed by the surveyor on 12/5/19. On 12/6/19 at 9:25 AM, the surveyor spoke to the Director of Nursing and the MDS Coordinator regarding the above concern. The MDS Coordinator agreed that the assessments were not submitted timely. NJAC 8:39-11.2

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness; b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness; c.) failed to record refrigerator temperatures and d.) failed to restrain employee hair. This deficient practice was evidenced by the following: The surveyor reviewed the facility's policy titled, Sanitation and Infection Control with a revision date of 08/17/16. The policy indicated that items are to be stored a minimum of six inches from the floor. The surveyor reviewed the facility's policy titled, Receiving/Storage with a revision date of 08/17/16. The policy indicated that the manufacturer's expiration, use by or sell by dates must be adhered to and all foods must be covered and labeled as to contents and date. The surveyor reviewed the facility's policy titled, Personal Hygiene with a revision date of 08/17/16. The policy indicated that employees with facial hair longer than ¼ inch will require beard restraints. On 11/18/18 at 09:15 AM, in the presence of the Chef, the surveyor observed the following: 1. The surveyor observed five of five red sprinkler caps located above the stove cook top area soiled with gray colored particles and a black grease-like substance. 2. On a shelf in the food preparation area the surveyor observed three spices with the lids opened. The Chef stated that the lids should be closed. 3. In the standing ice cream freezer, the surveyor observed two containers of ice cream with no lids on and the ice cream exposed to the air. 4. In the walk-in refrigerator, the surveyor observed the following: - A 1/2 full opened and undated container of apple cider with a stamped manufacturer use by date of 11/12/18. - A cart which contained several steam table pans of prepared foods that had no covering and was open to the air. - A 1/2 full opened, undated and unwrapped bag of diced potatoes. 5. In the walk-in freezer, the surveyor observed the following: - Four boxes stored on the floor and one of the boxes contained an opened and unwrapped bag of breaded chicken cutlets. - A random sampling of dented cans stored on a shelf which were in rotation for use. The surveyor observed a # 10 sized can of tomatoes with a 4-inch dent on the body of the can, a # 10 sized can of pudding with a 1 and a 1/2-inch dent on the upper lip and a # 10 sized can of pudding with a 1-inch dent on the upper lip. - A box which contained an opened and unwrapped bag of raw hamburger patties. - A box which contained an opened and unwrapped bag of breadsticks. The surveyor also observed five breadsticks out of the box, on the shelf in the walk-in freezer. 7. The surveyor observed a food service worker with 1/2-inch-long beard hair with no beard covering. On 11/18/18 at 12:01 PM, in the second-floor activity room, the surveyor observed a Resident Refrigerator log sheet for the month of (MONTH) attached to the right side of the refrigerator. The log sheet had blanks for the dates of (MONTH) 1-5, (MONTH) 8 and (MONTH) 16-18. During an interview on 11/19/18 at 01:30 PM, the surveyor brought the above concerns to the attention of the Administrator and Director of Nursing. NJAC 8:39-17.2(g)

Based on observation, interview, policy review and record review, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan to meet the resident's medical needs. This deficient practice was observed for 1 of 15 residents reviewed, Resident #98, and evidenced by the following: Record review of the facility's policy titled, Infection Prevention and Control Program, updated 11/22/2017, indicated that the facility Infection Prevention and Control Program shall ensure that they would develop, implement and maintain a program for the prevention, control and investigation of infections in order to reduce the risks of infections in residents, visitors and associates. On 11/18/18 at 9:40 AM the surveyor observed a plastic cabinet containing personal protective equipment (PPE) along with a red sign reading See Nurse Before Entering Room, located outside of the room belonging to Resident #98. The surveyor observed the Licensed Practical Nurse (LPN) enter the resident's room, without utilizing any PPE garments. The surveyor interviewed the LPN when she exited the resident's room and the LPN informed the surveyor that the PPE was placed in front of the resident's room in error, she was not aware as to why the resident had PPE equipment outside of their room. The surveyor along with the LPN reviewed the medical records belonging to Resident #98 and could not find any indication that a care plan was developed for Contact Precaution (infection prevention and control interventions that are used in addition to routine practices intended to prevent transmission of infectious microorganisms which are spread by direct or indirect). Resident #98 was admitted to the facility on [DATE] and was readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. ESBL is a Gram-negative bacteria that produce an enzyme; beta-lactamase that has the ability to break down commonly used antibiotics, such as [MEDICATION NAME] and cephalosporins and render them ineffective for treatment. On 11/20/18 at 11:21 AM, the surveyor met with the Director of Nursing who informed the surveyor that upon admission a contact precaution care plan should have been developed for Resident #98. N.J.A.C. 8:39-11.2 (g)

Based on observation, interview and record review, it was determined that the facility failed to administer [MEDICATION NAME] nutrition consistent with professional standards of practice and in accordance with physician orders. This deficient practice was observed for 1 of 3 residents reviewed receiving [MEDICATION NAME] nutrition, Resident #98, and evidenced by the following: On 11/18/18 at 10:15 AM the surveyor observed Resident #98 lying in bed receiving Intravenous (IV) feeding of [MEDICATION NAME] 1.5 (an IV food supplement). The surveyor along with the Licensed Practical Nurse (LPN) reviewed the IV Pump program which was set to provide 60 milliliters (ml) per hour (hr) for a total volume of 954 ml. The digital pump displayed that 779 ml was already infused. Along with the [MEDICATION NAME] 1.5 there was 800 ml of water which was programmed to infuse 200 ml every 8 hours. The LPN informed and revealed to the surveyor that the pump was set incorrectly: the shift to shift nursing communication sheet documented 50 ml/ hr. The surveyor reviewed the physician's orders [REDACTED]. 30 ml of water before and after medications and 10 ml between medications which was documented on the Electronic Medical Record (EMAR). On 11/18/18 at 10:55 AM, the surveyor met with the Director of Nursing (DON) and the Registered Nurse Manager (RN). The RN explained that the dietician had changed the admission order from 50 ml/hr to start 60 ml/hr on 11/14/18. The RN revealed to the surveyor that she had entered the order incorrectly into the EMAR. The RN informed the surveyor that the total volume infused to Resident #98 was ordered to be infused as 1320 ml over 22 hours and was set incorrectly set on the IV pump as 954 ml. The surveyor reviewed the EMAR from 11/14/18 to 11/17/18. The total volume of [MEDICATION NAME] 1.5 infused on 11/14/18 was 1720 ml. The total volume of [MEDICATION NAME] 1.5 infused on 11/15/18 was 1620 ml. The total volume of [MEDICATION NAME] 1.5 infused on 11/16/18 was 1720 ml and the total volume of [MEDICATION NAME] 1.5 infused on 11/17/18 was 1980 ml. The surveyor reviewed the resident's weight history from 11/13/18 to 11/18/18 and there was no weight loss documented. On 11/19/18 at 2:06 PM, the surveyor met with the DON who could not explain the discrepancy with the total infusion volume of [MEDICATION NAME] 1.5 documented on the EMAR as infused to Resident #98. On 11/20/18 at 12:51 PM, the surveyor interviewed the Dietician. The dietician provided the Dietician Visitation Report dated 11/14/18 to the surveyor which documented Increase by 5 ml every 8 hours to goal note of 60 ml/hr x 22 hours Volume 1320 ml. Provide 200 ml every shift 30 ml before and after medications with 10 ml between medications. Total ml=2013 ml. The dietician explained that she when she wrote the recommendation she reviewed it with the RN. On 11/20/18 at 11:21 AM, the surveyor met with the DON who could not explain why the input of the order for [MEDICATION NAME] 1.5 was incorrect. The DON could not supply any further information as to the discrepancy of the total volume administered of the Feed to Resident #98. NJAC 8:39-27.5 (a)

Based on observation, interview and record review, it was determined that the facility failed to maintain the necessary respiratory care and services ordered by the physician for 1 of 2 residents (Resident #24) reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the admission record for Resident #24, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/18/18 at 11:35 AM, the surveyor entered the room belonging to Resident #24. The surveyor observed the nebulizer mask and tubing dated 11/14/18, stored inside of a plastic bag. The surveyor noted that the bottom of the plastic bag contained a light brown hard substance. On 11/19/18 at 2:00 PM, the surveyor accompanied by the Licensed Practical Nurse in Charge (LPN) entered the resident's room and observed the nebulizer mask and tubing stored inside the soiled plastic bag. The surveyor then interviewed the LPN who stated, that the resident used the nebulizer twice a day as ordered by the physician. The LPN agreed that the plastic bag was soiled and that it needed to be changed. On 11/19/18 at 2:30 PM, the surveyor spoke to the Administrator and Director of Nursing regarding the above concern. There was no additional information provided. NJAC 8:39-19.4 (a)

Based on observation, interview, policy review and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection. This deficient practice was observed for 1 of 12 residents reviewed, Resident #98, and evidenced by the following: Record review of the facility's policy titled, Isolation Transmission Precaution, updated 5/14/2018, indicated that the facility take all precautions required to prevent transmission of infectious agents. In addition, the policy includes a paragraph titled Use of Personal Protective Equipment (PPE): Don appropriate PPE prior to entering the resident's room. Remove PPE at the doorway or immediately outside the resident's room. On 11/18/18 at 9:40 AM, the surveyor observed a plastic cabinet containing personal protective equipment (PPE) along with a red sign reading See Nurse Before Entering Room, located outside of the room belonging to Resident #98. The surveyor observed the Licensed Practical Nurse (LPN) enter the resident's room, without utilizing any PPE garments. The surveyor interviewed the LPN when she exited the resident's room and the LPN informed the surveyor that the PPE was placed in front of the resident's room in error, she was not aware as to why the resident had PPE equipment outside of their room. The surveyor along with the LPN reviewed the medical records belonging to Resident #98 and could not find any indication that a caution in the electronic medical record (EMAR) or a physician's orders [REDACTED]. The LPN informed the surveyor that she was not informed of the need for contact precaution (infection prevention and control interventions that are used in addition to routine practices intended to prevent transmission of infectious microorganisms which are spread by direct or indirect) by the previous shift staff. The LPN presented the surveyor with a sheet used to communicate between nursing shifts which had no documentation alerting the LPN that there was Contact Precaution ordered for Resident #98. The surveyor reviewed the Interdisciplinary Progress Notes written by the Advanced Practice Nurse (APN) and dated 11/14/18 documenting Completed 14 days of Intravenous Meropenem (and antibiotic). Isolation for ESBL. The surveyor also reviewed a Nutrition Assessment sheet that documented Isolation for ESBL of Biliary Drainage. Resident #98 was admitted to the facility on [DATE] and was readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. ESBL is a Gram-negative bacteria that produce an enzyme; beta-lactamase that has the ability to break down commonly used antibiotics, such as [MEDICATION NAME] and cephalosporins and render them ineffective for treatment. The surveyor reviewed the hospital labs dated 10/25/18, which revealed that Resident #98 was positive for ESBL which was susceptible for treatment with Meropenem. On 11/20/18 at 11:21 AM, the surveyor met with the Director of Nursing who informed the surveyor that upon admission there should have been an order for [REDACTED]. The surveyor monitored Contact Precaution facility practices and did not observe any further diversions from infection control practices. N.J.A.C. 8:39-19.4 (a)

Based on observation, interview and record review, it was determined that the facility failed to a. maintain proper kitchen sanitation and food storage practices, b. properly store fresh, frozen and potentially hazardous foods and c. maintain food equipment areas in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 8/21/17 at 6:15 p.m. during the initial tour of the kitchen, in the presence of the Assistant Food Service Director (AFSD) and Cook, the surveyor observed the following: 1. A tray of iced cupcakes stored on an open bakers rack in the walk-in refrigerator was not covered, labeled or dated. 2. A portable serving cart located in the walk-in refrigerator contained covered bowls of assorted condiments/vegetables and 2 trays of cut-up lettuce that were not dated or labeled. 3. Two large, filled containers with cut-up pineapple and cantaloupe were open to air in the walk-in refrigerator. The container of pineapple was not dated or labeled. 4. The produce in the walk-in refrigerator was stacked to within 3-4 inches of the ceiling, which prevented adequate air circulation. 5. The frozen food items in the walk-in freezer were stacked to within 1 inch of the ceiling, which prevented adequate air circulation. Review of the facility's Purchasing: Policy and Procedure (P&P) revised on 3/2010 revealed Items are stored a minimum of 18 inches from the ceiling and 6 inches from the floor. 6. One large, closed and filled, plastic bin was located on the lower shelf of a utility table, with a measuring cup stored inside the bin. At 6:30 p.m. the AFSD identified the product inside the bin as food thickener. The interior sides and bases for 4 mini hot boxes were heavily soiled with liquid debris. 7. One white 30 pound (lb) opened container of beef base located on the bottom shelf of the reach-in refrigerator, was open to air. 8. The blade of the manual can opener was soiled with a build-up of food debris and metal chard. 9. One of 3 kitchen hand wash sinks located in the back of the kitchen, was filled with discarded ice. 10. The underneath area of a shelf directly above the 5 bay steam table, was visibly soiled with a build-up of food debris and was in direct contact with ready-to-serve foods. 11. The water inside the filled 5 bay steam table was soiled. 12. The right lower section of the sandwich refrigerator felt warm when opened and contained a tray of raw chopped meat on the top shelf, with an open box of hot dogs on the shelf directly below. The left lower side of the unit was also warm when opened and contained an opened jar of Dijon mustard, 2 opened packages of sliced cheese and a deep container with partially melted butter. The opened jar of mustard felt warm to touch and there was no thermometer inside the unit. At 6:50 p.m. the surveyor placed a calibrated thermometer inside the lower section of the unit and after 5 minutes it registered +58 degrees Fahrenheit (F). At 6:55 p.m. the Cook stated that the top section of the refrigerated sandwich unit was turned off after the evening meal service, but the lower refrigerator section stayed on all day and night. At 7:00 p.m. the Food Service Director (FSD) arrived and joined the surveyor for the balance of the kitchen tour. 13. Nine 5 lb opened to air containers of ice cream in the ice cream freezer chest, were soft to touch with visible signs of melted product on the inside top sections of each container. In the presence of the FSD the surveyor placed a calibrated thermometer inside the ice cream freezer and after 5 minutes it registered +16 degrees F. The FSD stated the ice cream should be frozen solid. 14. Four closed mini hot boxes stored on the left side of the kitchen were soiled and each contained a soiled sheet pan on the interior base. 15. A garbage pail was not observed under or around the area of the hand wash sink in the pantry. 16. The top section of the sandwich refrigerator in the pantry felt warm when opened and the thermometer inside the unit registered +40 degrees F. The surveyor placed a calibrated thermometer inside the unit and after 5 minutes the unit registered +44 degrees F. 17. The entire back splash area behind the dish machine was soiled with splattered food debris and black mold-like substance. On 8/21/17 at 7:00 p.m., the surveyor reviewed the kitchen's County Risk-Based Inspection Report dated 8/11/17, which revealed that the facility was out of compliance with the cold food holding regulations and proper temperature guidelines for food items stored in refrigerated areas. Review of the facility's HACCP/Food Safety Program Policy and Procedure dated 1/27/12 and revised on 8/17/16 revealed to Verify that frozen food is hard to the touch and does not show signs of thawing or refreezing .all refrigeration equipment must be maintained at 40 degrees F or below and freezer equipment at 0 degrees F .all foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers. NJAC 8:39-19.7 (d), 17.4 (e)

Based on observation and interview, it was determined that the facility failed to ensure proper handling and storage of medications. This deficient practice was identified for 1 of 15 residents reviewed for medication regimen, Resident #10 and was evidenced by the following: On 8/23/17 at 1:50 p.m. the surveyor observed 6 poured medications in a plastic cup on top of a medication cart in the Bender Unit hallway. The Medication cart was unlocked and unattended by nursing staff. At 1:53 p.m. the surveyor observed the Registered Nurse (RN) responsible for administering the medications leaving room [ROOM NUMBER] with the RN mentor following behind. The RN told the surveyor she was in the middle of the medication pass when she was informed that a resident was out of control and needed to be redirected. The RN identified that the medications on top of the cart were for Resident #10. The surveyor asked the RN why she didn't secure the medications in the cart before tending to the resident. The RN responded I should have, I know I was wrong and made a big mistake. NJAC 8:39- 27.1 (a)

Based on observation, interview, and record review it was determined that the facility failed to perform a wound treatment according to proper infection control procedure, to 1 of 2 residents reviewed for wound care, Resident #4, as evidenced by the following: On 8/21/17 at 6:30 p.m. the surveyor observed Resident #4 in bed on an air mattress, with air boots applied to bilateral lower extremities. On 8/23/17 at 10:00 a.m. the surveyor reviewed the medical record of Resident #4,which revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a physicians progress note dated 7/27/17 revealed that the resident's left anterior foot wound culture was positive for Serratia and Pseudomonas Bacteria. On the above date, the Physician ordered [MEDICATION NAME] 250 mg (an antibiotic), 1 tablet to be taken daily for 30 days. On 8/23/17 at 10:30 a.m., an Infectious Disease note dated 8/7/17, identified Resident #4's left heel stage 4 pressure ulcer as improving with good granulation tissue measuring 3x2.5x0.4 cm. The left anterior wound was noted as deteriorating, measuring 6x 2.5x 1cm, infected with the bacteria Serratia and Pseudomonas, and had an exposed tendon to the wound base. On 8/24/17 at 11:20 a.m. the surveyor observed a wound treatment for [REDACTED]. The surveyor observed the RN wash her hands, don gloves and remove the dressing from the infected wound first, then touch the second dressing to the non-infected wound with the contaminated gloves. The RN cleansed both wounds with the contaminated gloves and did not remove the gloves to perform hand hygiene. After completing the treatment to both wounds, which she treated concurrently, she applied tape to secure the dressing. The RN used a marker to date and initial the dressing after it had been applied to the Resident. After the treatment, the surveyor asked the RN why she didn't treat the wounds separately. The RN told the surveyor it was difficult because they were in close proximity. The RN Infection Control (IC) nurse who also observed the dressing change, responded that the nurse didn't follow correct procedures and risked cross contamination of the infected wound to the non infected wound. On 8/24/17 at 12:20 p.m. the surveyor reviewed the facility's policy on Aseptic Technique for a Clean Dressing Change, which indicated that the Nurse should remove gloves, wash hands and apply new gloves after removing soiled dressings. On the above date and time, the surveyor also reviewed the Wound Care/ Dressing Change Education that was provided to the RN by the Infection Control Nurse on 8/25/17. The education included to wash hands after removal of the soiled dressing and to treat each wound separately. It also instructed the nurse not to write on the tape after it had been applied on the resident. NJAC 8:39-27.1 (a)

Based on observation, interview and documentation, it was determined that the facility failed to maintain a safe, functional and sanitary environment in the kitchen. in the kitchen. This deficient practice was evidenced by the following: On 8/21/17 at 6:15 p.m., during the initial tour of the kitchen, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. The rubber seals around 4 lids on the ice cream freezer were soiled. One of 4 lids did not close properly which resulted in an exchange of ambient air and a build-up of water/condensation around the outside of each lid. 2. One of 4 hood lights on the back hood were not working. 3. Under the hand wash sink behind the back hood there was a large area of standing water with visible signs of water leaking from the U bend pipe under the sink. 4. Three of 3 light bulbs on a ceiling mounted light fixture next to the back hood were not working. 5. One of 3 light bulbs in the ceiling mounted light fixture located above the manual can opener was not working and the light cover was soiled with splattered food debris. On 8/21/17 at 7:00 p.m., the FSD stated the facility had an in-house computerized work order system for maintenance issues called Big Foot. The FSD further stated that a work order is filled out on-line and then emailed internally to the Maintenance Director (MD), who scheduled the assignment based on a priority level. If service was needed immediately, the FSD would call the MD directly. The FSD also stated that no work order was placed for the hood light or ceiling light fixtures because she was not aware of the problem and was not informed of the needed repairs by any of the staff. On the above date and time, the surveyor reviewed the facility's Safety and Security, Preventative Maintenance Policy and Procedure revised on 11/2002. The policy indicated that it was the General Manager's responsibility to document and report problems to the MD. The policy further indicated that the system was designed to pinpoint problem areas, control equipment maintenance and repair expenses, by avoiding repetitive maintenance and excessive parts replacement. NJAC 8:39-31.2b,e

Based on observation and interview on 08/23/17, it was determined that the facility failed to ensure that staff were trained annually to respond to non-fire disasters as evidenced by the following: On 8/23/17 at 10:00 a.m., the surveyor reviewed the facility's annual disaster drill reports for the last 12-month period which revealed that a disaster drill was not conducted within this period. This was confirmed in an interview on the above date and time, with the facility's Maintenance Director who indicated that a disaster drill was not conducted within the last 12 months. NJAC 8:39-31.6(a)

Based on observation, interview and record review, it was determined that the facility failed to supervise a confused resident who fell out of bed resulting in a head laceration and fractured finger; and failed to provide supervision for a confused resident in the activity area resulting in bilateral nasal bone fractures, cervical strain (whiplash), and a closed head injury requiring 7 sutures and left elbow contusion with a skin tear. This deficient practice was identified for 2 of 9 residents, Residents #7 and #13, reviewed for falls and was evidenced by the following: 1. On 07/07/15 at 8:40 a.m. the surveyor observed Resident # 7 out of bed in a geri-chair sitting in the hallway. S/he had a red sore on the forehead and 2 black eyes. A Certified Nursing Assistant (CNA) who was nearby said that the resident fell out of bed recently. Resident # 7 was confused and disoriented when the surveyor spoke to him/her. He/she was pleasant and smiling. On 07/08/15 at 7:30 a.m., the surveyor observed the resident in bed with eyes closed and a bandage on his/her forehead. The bed was in a low position, the right side of the bed was against the wall and there was a floor mat on the left side of the bed. The room was at the end of the hall, the room furthest away from the closest nursing station. On 07/08/15 at 7:40 a.m. the surveyor reviewed the medical record for Resident #7 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/28/15 the Interdisciplinary (IDC) team assessed that the resident was severely cognitively impaired utilizing a Quarterly Minimum Data Set (MDS), an assessment tool. The IDC team further assessed that the resident required extensive assistance with all activities of daily living. The MDS indicated that the resident moved about the facility in a wheelchair. The team further assessed that during moving from a seated to standing position or surface to surface transfer, Resident #7 was not steady and was only able to stabilize self with staff assistance. The surveyor reviewed the Hendrich ll Fall Risk Model completed on 06/08/15 that revealed Resident #7 was a high fall risk due to confusion, disorientation, impulsivity and the inability to rise from a chair without assistance. The resident had a care plan in place with interventions that included: keep area free from obstructions to reduce the risk of falls/injury; place call bell in reach; and use alarm to monitor attempts to rise. Although the care plan prior to the fall indicated the use of an alarm, the Director of Nursing (DON) said that the facility was no longer using alarms at that time. Further review of the medical record revealed that Resident #7 had 1 fall and sustained a head laceration and fractured left fifth finger. A review of the facility Falls Investigation form indicated that on 06/28/15 at 2:30 a.m. the resident was found lying on the floor next to the bed. S/he had a gash approximately 4 cm by 2 cm which was actively bleeding on the forehead. The physician was notified and the resident was transferred to the hospital at 3 a.m. for evaluation and treatment. The resident had 5 sutures placed to close the gash on the forehead and was returned to the facility at 7 a.m. Later that day, the nurse noted that the resident's left pinky finger was bruised and swollen. The Physician ordered an x-ray which was done at the facility on 06/29/15. The x-ray revealed a fracture involving the fifth digit head, middle phalanx with displacement and associated soft tissue swelling. Based on the x-ray report the physician ordered the finger to be splinted with a tongue depressor and gauze for 1 week and then to reassess. The resident refused to keep the splint in place and kept removing it and throwing it on the floor. The surveyor reviewed the statement given by the CNA who was assigned to Resident #7 at the time of the fall. The CNA documented that the resident was fidgety all night due to a storm and rainy weather. The resident got up several times during the night and was redirected. At 2:30 a.m. the CNA answered a call bell on the opposite side of the hallway and heard Resident # 7 yelling. When she entered the room the resident was on the floor bleeding from the forehead. Further review of the Fall Investigation form revealed that the facility identified possible factors that may have contributed to the fall which included: the resident had poor cognition; had a history of [REDACTED]. The investigation revealed that this was the second time that the resident had become anxious during a storm. Although this fact was indicated in the report, the DON was unable to provide written documentation regarding the prior occurrence, nor was the fact incorporated into the resident's care plan. The facility's conclusion of the fall revealed that a restless resident was left in bed, attempted to get out of bed from a low bed and when s/he rolled off the mattress, hit their forehead on the bedside table. Final review of the fall by the facility determined that Resident #7 displayed restless behavior and was left in bed after making multiple attempts to get up. It was further stated that staff should have offered resident the opportunity to get up and be brought to the nurse's station. The CNA was educated about getting direction from a nurse on how to handle restless residents. On 07/10/15 at 10 a.m. the surveyor spoke with the Director of Nursing (DON) regarding this fall. The surveyor asked the DON why the CNA did not get Resident # 7 out of bed when s/he displayed restless behavior. The DON said that the CNA admitted she did not use good judgement when she did not get the resident out of bed and bring the resident out to the nurse's station for closer observation. 2. On 7/9/15 at 9:38 a.m. the surveyor observed Resident # 13 sitting in a Geri-chair in the activity room with his/her eyes closed. Oxygen was in use via nasal canula. On 7/9/15 at 9:50 a.m. the surveyor reviewed the resident's medical record. The resident had [DIAGNOSES REDACTED]. The IDC team assessed the resident on 3/31/15 utilizing an Annual MDS, an assessment tool, as being cognitively impaired, dependent on 2 staff members for transfers and toilet use, not ambulatory, and having behaviors that included behavior symptoms not directed towards others which significantly interfered with the residents participation in activities and social interactions. This behavior also disrupted the care or living environment. The IDC team also assessed that the resident had trouble concentrating and had a fall with injuries which were not major. The resident's fall risk score at the time using the facility's scoring system was 20, with 9 being a high fall risk. On 7/9/15 at 1:14 p.m. the surveyor observed the resident awake in a Geri-chair, with legs elevated, in the hall outside of his/her room. The resident looked at the surveyor when the surveyor spoke to him/her, but did not respond. The surveyor could not locate any staff in the area of the resident. On 7/9/15 at 1:25 p.m. the resident's nurse said that she did not know if the resident still tried to get up by him/herself. The nurse also said that the resident was confused, required total care for activities of daily living, was Hoyer- lifted for transfers, and occasionally would respond when spoken to. On 1:29 p.m. the resident's CNA said that the resident required total care, occasionally answered when spoken to, and would hold on to the side rail when receiving care. The CNA also said that she was on duty 2 days after the resident sustained [REDACTED]. On 7/09/15 at 1:40 p.m. the surveyor reviewed the resident's fall investigations. The resident had 2 falls. The first fall occurred on 2/19/15 when the resident was found on the floor next to his/her bed. The resident did not sustain any injuries. On 5/19/15 at 3:15 p.m., the Licensed Practical Nurse (LPN) found the resident lying face down on the floor in the activity room. As per the investigation report, prior to the fall, the resident had sat in his/her wheelchair in front of an active sensory stimulation device (Snoozellen). The foot rests of the wheelchair were fully extended with the resident's feet properly placed on them. The investigation report revealed that the resident had the behavior of attempting to grab/reach for things that s/he saw in front of him/her which may or may not have existed. Prior to the fall the resident displayed this reaching behavior. The wheelchair tipped forward as the resident reached out and the resident fell forward on his/her face. The nurse was called to the area and saw the resident lying on the floor face down with blood. The resident was turned over by 2 nurses who observed the resident had a laceration to his/her right forehead approximately 3 centimeters with a moderate amount of bleeding. The bridge of Resident #13's nose had bruising, and bleeding was noted from the left nostril. The resident also had a left elbow skin tear. The resident was sent to the emergency room for evaluation. According to the investigation report there were no staff present in the lounge area where the resident sat in his/her wheelchair. An Activity Aide wrote a statement and documented that she ran an activity in the day room from approximately 2:15 p.m. to 2:55 p.m. She was in the office with another staff member when they heard the resident yell and then went to the sensory room. The statement did not include that another activity person took her place when she left the room. On 7/10/15 at 8:30 a.m. the Director of Nursing said that it was her understanding that there had been an aide in the area of the snoozellen area but she could not pinpoint that person. The physician's notes dated 5/19/15 from the emergency room revealed that the resident sustained [REDACTED]. A CT Scan showed comminuted bilateral nasal bone fractures with overlying soft tissue swelling. The resident was sent back to the facility. The facility failed to provide staff supervision in the activity area for a confused resident at high risk for falling who had behaviors known to the facility of reaching out and trying to grab at things. NJAC 8:39-27.1(a)

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices; observe proper thawing procedure for potentially hazardous frozen food; maintain food equipment in a safe and sanitary environment to prevent the development of food borne illness; and failed to follow the facility's established policy and procedure on food thawing. This deficient practice was evidenced by the following: On 7/7/15/at 7:30 a.m. during the initial tour of the kitchen, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. The interior sides and bases for 4 mini and 1 tall hot boxes were heavily soiled with liquid debris. At 7:35 a.m. the FSD stated that the hot boxes were used for lunch and dinner services and cleaned daily after dinner service. 2. The rubber seals around the 4 lids on the ice cream freezer were soiled and 1 of 4 lids did not close properly which resulted in an exchange of ambient air and a build-up of water around the outside of each lid. 3. The clear, sliding, plastic lids of 3 large, filled, portable condiment containers that contained rice, sugar and flour were soiled with splattered food debris. 4. Access to the hand wash sink behind the large kettle was blocked by 2 large, portable bakers racks. 5. The back splash of the tilt-top kettle was heavily soiled. 6. Three packages of frozen chicken breasts were defrosting in a utility sink without any running water. At 7:55 a.m. the cook stated he had pulled the chicken out of the freezer at about 7 a.m. so it could be thawed out for a cold Caesar salad for tomorrow's lunch. When asked, the cook acknowledged that the proper procedure to defrost the chicken should have been for it to be placed under running water. 7. On 7/8/15 at 2:30 p.m. the facility's Operation Manager was observed in the kitchen without wearing a hair restraint. On 7/7/15 at 12 Noon, the surveyor reviewed the facility's Policy and Procedure (P&P) titled HACCP/Food Safety Program dated 1/27/12 and revised on 3/13/15. The P&P stated foods must be thawed only under refrigeration, never at room temperature. For emergency thawing only: under cold running water or in a microwave oven. Compliance with the facility's above P&P was not observed by the surveyor. NJAC 8:39-19.7 (d)