Every finding on record at United Methodist Communities at Collingswood

Based on interview and record review it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level one assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 1 resident reviewed for PASRR (Resident #2) and was evidenced by the following:On 11/20/2025 at 12:10 PM, the surveyor reviewed Resident #2 Electronic Medical Record (EMR) which showed that the resident had a PASRR completed on entry to the facility. Under section one for diagnoses of mental illness it was marked as NO, meaning Resident #2 did not have any mental illness diagnoses when admitted . The PASRR was dated 2/8/2023.A review of the admission Record face sheet (an admission summary) reflected the resident was initially admitted to the facility in February 2023. Medical diagnoses on admission included but were not limited to pain, anxiety, Parkinson's Disease, diabetes, and muscle weakness. A review of the most quarterly Minimum Data Set (MDS), an assessment tool dated 9/4/25 showed that the resident had a Brief Interview of Mental Status (BIMS) of 00 out of 15, meaning the resident had severe cognitive impairment. Review of section I of the MDS titled active diagnoses revealed the resident had a diagnosis of psychotic disorder.A review of Resident #2 quarterly MDS from 12/15/23 under section I for active diagnoses was marked as No for diagnoses of psychotic disorder.A review of the residents most recent psychiatric note dated 10/22/25 under diagnoses and plan it revealed a diagnosis of psychosis.On 11/21/25 at 10:48 AM, the surveyor interviewed the Director of Nursing (DON) regarding Resident #2 PASRR. The DON told the surveyor the Social Worker was responsible for the PASRR but was currently on a leave of absence.On 11/24/25 at 11:00 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding Resident #2 PASRR. The LNHA said the facility did not have a PASRR policy. The surveyor asked the LNHA when a PASRR should be completed and the LNHA responded, on admission or if the resident gets prescribed an antipsychotic or is given a new psychiatric diagnosis.NJAC 27.1 (a)

Based on observation, interview, and review of pertinent facility documents it was determined the facility failed to revise an individual comprehensive care plan for a resident with a repeated fall history. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #12) and was evidenced by the following: On 11/19/2025 at 10:24 AM, during the initial tour of the facility the surveyor observed Resident #12 in bed with eyes closed. The resident's bed was in the lowest position and there was a fall mat on the right side of the bed.A review of the admission Record face sheet (an admission summary) reflected Resident #12 was admitted to the facility with diagnoses which included but were not limited to depression, low back pain, anxiety, hypertension, and repeated falls.A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/15/25 revealed the resident had a Brief Interview of Mental status score of 4/15, meaning the resident had severe cognitive impairment. Section GG, titled functional status showed the resident required substantial/maximum assistance for sit to stand transfers.A review of incidents, accidents and facility progress notes for Resident #12 revealed the resident had unwitnessed falls on 1/17/25, 2/17/25, and 7/25/25. On 1/17/25, the resident was found on the floor and sustained a small forehead laceration. Neurological assessments were initiated. On 2/17/25 the resident was found on the floor in the bathroom. The resident stated they fell out of bed. The resident complained of knee pain and an Xray was ordered and completed. On 7/25/25, the resident was found laying on the floor next to the bed and sustained a skin tear to the left lower jaw area. The resident was transferred to the hospital for evaluation.A review of Resident #12 Individualized Comprehensive Care Plan (ICCP) included a focus area of fall risk initiated on 10/23/23. The care plan goal was that the resident would be free from falls. The care plan interventions included assess call light ability, do not leave resident alone in the bathroom, educate on calling for assistance, keep items within reach, bedside table within reach, room free of clutter, and ask if the resident needs anything prior to leaving. The care plan did not include new interventions following the 1/17/25, 2/17/25, and the 7/25/25 falls. On 11/24/2025 at 12:17 PM, during an interview with the Director of Nursing (DON), the DON told the surveyor that the facility tries to update the care plans after each fall. The DON acknowledged the care plan was not updated following each of the falls.On 11/25/25 at 9:00 AM, the surveyor reviewed the policy titled Fall Prevention and Management with a revision date of 8/8/25. Under the section post fall management, it included modifying the care plan as indicated.The surveyor reviewed the policy titled Care Plan Policy dated 8/8/25. The policy purpose was to guide the care and treatment provided to each resident. Number 21 of the policy revealed that the care plans would be updated and/or revised for significant changes, change in planned interventions, new diagnoses, medications or abnormal lab work.NJAC 8:30-27.1 (a)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a resident who was dependent on staff for transfers was safely and properly transferred with two staff members via mechanical lift. Instead, the resident was transferred using mechanical lift by one staff member from their chair to their bed. This deficient practice was identified for 1 of 2 residents (Resident #29) reviewed for accidents and was evidenced by the following: On 11/20/25 at 10:30 AM, Resident #29 was observed in the bed and had just received care from the Certified Nursing Assistant (CNA). The surveyor observed the resident had soft padding on the right and left upper side rails of the bed. A review of the admission Record (an admission summary) showed Resident #29 was admitted to the facility with medical diagnoses which included but were not limited to dementia, urinary retention, failure to thrive, and vitamin deficiency.A review of the a Significant Change Minimum Data Set (MDS), an assessment tool, dated 10/12/25 revealed under Section GG-functional abilities that the resident was dependent for bed to chair transfer meaning the helper does all the effort, resident does none of the effort to complete activity, or the assistance of two or more helpers is required for the resident to complete the activity. Resident #29 had a Brief Interview of Mental Status of 4/15, meaning the resident was severely cognitively impaired.On 11/20/25 at 12:22 PM, the surveyor reviewed a Facility Reported Event (FRE). The report included that on 9/30/25 the residents spouse approached the Unit Mentor (UM) regarding pain in the resident's right wrist. An assessment was completed by the physician and an Xray was ordered of right wrist, forearm and elbow.It was documented on the FRE that it was unknown if wrist pain was fall related, and it was an unwitnessed injury. Further review showed that no one witnessed the resident fall. Additional review showed that on 9/29/25 the resident was transferred from the wheelchair to the bed but did not fall. The resident's spouse was in the room at the time of transfer, and it was uneventful. A review of the investigation portion of the FRE showed that the resident was out of bed on 9/29/25. Resident #29 was ordered a mechanical lift with a two person assist to get out of the bed. The investigation revealed that although Resident #29 did not fall, the CNA assigned to Resident #29 did not follow the plan of care or physician orders by using the two persons assist with transfer and was suspended from employment. Review of the FRE conclusion was that the resident did not fall and most likely hit their wrist on the side rail of the bed. On 11/20/25 at 1:14 PM, the surveyor reviewed the physician orders which showed an active order dated 9/15/25 for Hoyer (mechanical) lift transfers with two persons assist.A review of the Individualized Comprehensive Care Plan (ICCP) showed a fall focus, initiated 2/24/24. Interventions included but were not limited to transfer with assist of 2 with mechanical lift.On 1/21/2025 at 10:23 AM, during an interview with the Director of Nursing (DON) the surveyor asked about the incident with Resident #29. The DON told the surveyor that after investigating the incident it was determined the resident did not fall and the arm injury occurred when resident punched the bed rail. The DON said, The CNA did not follow the policy, meaning the CNA transferred resident alone, not with two people.On 11/25/25 at 9:40 AM, the surveyor reviewed the policy titled, Safe Handling, dated 8/8/25. Under the mechanical lift usage guidelines it was written that lifts required two persons to use.NJAC 8:39-27.1(a)

Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide a safe and sanitary environment to prevent the potential spread of infection and cross-contamination to both residents and staff by failing to: adhere to proper handwashing techniques, clean and sanitize medical equipment in accordance with the facility policy and manufacturer's recommendation and maintain appropriate infection control practices during the medication administration observation for 1 of 2 nurses observed on 1 of 3 nursing units ([NAME] Unit). This deficient practice was evidenced by the following: On 08/14/24 at 8:20 AM, the surveyor met with Registered Nurse (RN) #2 at the medication cart. RN #2 wore gloves as she swept debris from the top of the medication cart with her gloved hands. RN #2 then doffed (removed) her gloves and failed to perform hand hygiene before she reached into her pocket and obtained the keys to the medication cart, unlocked the cart, and then returned an unsampled resident's eye drops into the medication cart. RN #2 then proceeded to access the computer that was mounted on top of the medication cart and after medication review, she stated that she needed to obtain vital signs (blood pressure, heart rate and pulse oximetry reading (the amount of oxygen circulating in the blood determined by placing a pulse oximeter probe on a finger) from Resident #23. At 8:22 AM, RN #2 wheeled the blood pressure machine into Resident #23's room. RN #2 greeted the resident and the resident complained of an aching sensation in the fingers of their right hand. RN #2 placed a blood pressure cuff on the resident's left upper arm, and placed a pulse oximeter probe on the resident's left index finger. RN #2 wore a surgical mask and pulled the mask out and away from her face when she spoke with the resident. RN #2 then proceeded to remove the blood pressure cuff and pulse oximeter probe from the resident, and then rubbed the resident's right hand and arm in an effort to comfort the resident. RN #2 then obtained the blood pressure machine and left the resident's room without first performing hand hygiene. At 8:29 AM, RN #2 failed to clean the blood pressure machine and pulse oximeter after use and placed it in the hallway. RN #2 then returned to the medication cart, accessed the computer, reached into her pocket and obtained the keys to the medication cart and opened it. RN #2 then performed hand hygiene using alcohol based hand rub (ABHR) before she prepared medications for Resident #23. At 8:39 AM, after RN #2 administered medications to Resident #23 with a spoon, she proceeded to wash her hands under the stream of running water for 22 seconds. At 8:43 AM, RN #2 obtained the blood pressure machine and proceeded into Resident #111's room. At that time, RN #2 adjusted the resident's oxygen cannula (plastic prongs that are placed in the nostrils to deliver oxygen) to ensure that the tubing made contact with both of the resident's nostrils. RN #2 then placed the blood pressure cuff on the resident's left upper arm and placed the pulse oximeter probe on the resident's right middle finger. RN #2 then removed the blood pressure cuff and pulse oximeter from the resident, touched the resident's blankets and patted the resident's legs and exited the resident's room without first performing hand hygiene. At 8:49 AM, RN #2 stated that Resident #111 had a new order to have their blood sugar checked and proceeded to remove a glucometer from the medication cart. At 8:50 AM, RN #2 donned (put on) gloves before she placed a test strip into the glucose meter (device to measure blood sugar levels of persons with diabetes). RN #2 then cleaned Resident #111's right middle finger with an alcohol prep pad, then used a lancet to [NAME] the resident's finger and drew a drop of blood which was placed on the test strip within the glucose meter. RN #2 then placed pressure on the resident's right middle finger to stop the bleeding and cleansed the area. At 8:52 AM, RN #2 doffed her gloves and removed the used test strip from the glucometer with her bare hand. RN #2 then proceeded to dispose of her gloves. At 8:53 AM, RN #2 went into Resident #111's bathroom and laid the lancet and test strip on the bathroom counter while she washed her hands under the stream of running water for 20 seconds. RN #2 then returned to the medication cart and disposed of the used lancet and test strip into the sharps disposal system (device used to contain needles and sharp instruments until disposal) on the side of the medication cart. RN #2 failed to clean the blood pressure machine, pulse oximeter, and glucometer after usage. RN #2 then began to prepare medications for Resident #111 which included but were not limited to: a single dose vial of Budesonide Suspension 0.5 mg (milligrams) per two milliliters (nebulizer (inhaled respiratory treatment), and Ueclidinium-Vilanterol (hand held inhaler) and glycolax powder 3350 17 grams (a powder that is mixed with water treat constipation). At 9:08 AM, RN #2 returned to Resident #111's room and donned gloves. The resident's breakfast tray was present on the overbed table in front of the resident. RN #2 placed the single dose vial of Budesonide and the Ueclidinium-Vilanterol (hand held inhaler) on the resident's overbed table while she administered the oral medications to the resident. The resident declined to take the glycolax and requested to take both the budesonide nebulizer treatment and the Ueclidinium-Vilanterol hand held inhaler after breakfast. At that time, RN #2 proceeded to take Resident #111's budesonide nebulizer treatment and the Ueclidinium-Vilanterol hand held inhaler into the resident's bathroom and placed the medications directly on the resident's bathroom counter that surrounded the sink while she washed her hands under the stream of running water for 21 seconds. At 9:14 AM, RN #2 returned to the medication cart and returned the budesomide to a multi-foil pack container and returned the Ueclidinium-Vilanterol hand held inhaler into the drawer of the medication cart. RN #2 then proceeded to sign out Resident #111's medications in the computer and then proceeded to review medications for the next resident. At 10:11 AM, during an interview with the surveyor, RN #2 stated that she had not performed any additional blood sugars with the glucose meter after the medication pass observation and had wiped it down with an approved disinfectant wipe. RN #2 then stated that she still had to wipe the glucometer down again with a disinfectant wipe since it was placed in the case during the observation prior to being cleaned. RN #2 stated, I am supposed to wipe it down before I placed it in the case, because the case might get bacteria on it. RN #2 then stated, I still have to wipe it down and get a new one. At that time, the surveyor asked RN #2 to describe the process for handwashing. RN #2 stated, I wash my hands under running water for 15 to 20 seconds. RN #2 stated that if the proper handwashing technique were not followed, it may attract microorganisms and the hands were not cleaned. RN #2 further stated that if the handwashing policy were not followed, it could spread infection and viruses. At that time, the surveyor asked RN #2 to describe the process for cleaning the blood pressure machine and pulse oximeter. RN #2 stated it was ideal to clean between residents with a disinfectant wipe. RN #2 stated if the blood pressure machine and pulse oximeter were not cleaned between residents, it might transfer microorganisms and can spread bacteria. At that time, the surveyor asked RN #2 what could happen if she handled a used glucometer test strip without gloves and RN #2 stated that the blood or bacteria could get on the skin and be transferred onto her. At that time, RN #2 stated that she should have cleaned the tip of the nebulizer treatment and inhaler before she returned it to the multi-use package in the medication cart. At that time, RN #2 stated that if she touched her mask while speaking with a resident and then touched the resident, medication cart, and computer there could be problems because, my hands could have been contaminated. At 10:24 AM, RN #3 approached the surveyor and RN #2 at the medication cart as the surveyor began to interview RN #2 about the proper technique for cleaning both the glucose meter and the glucose meter case. RN #3 stated, we can get a new case or attempt to replace the whole unit. At 10:29 AM, the surveyor interviewed RN #3 who stated, we are required to wipe the blood pressure machine down between residents with a disinfectant wipe. RN #3 stated, we were stricter during COVID, but there is a potential for contamination if it were not cleaned. At that time, RN #3 stated that either hand sanitizer or handwashing should have occurred after gloves were doffed. RN #3 stated that there was a risk of spreading anything infectious if hand hygiene was not performed after each resident. RN #3 stated that hands must be washed for 20 to 30 seconds out of the stream of running water. At 10:47 AM, the surveyor interviewed the Director of Nursing (DON) who stated she recently served in the role of the previous Infection Preventionist (IP) prior to becoming the DON three weeks ago. The DON stated that the current IP was not available for interview. The DON stated that once gloves were doffed, staff were supposed to wash their hands, because if it were not done, it was an infection control breach. At that time, the DON stated, we informed the staff that they were not supposed to touch the outside of their masks because it was not clean. At that time, the DON stated the blood pressure machine and pulse oximeter were supposed to be cleaned between residents with a disinfectant wipe or it was an infection control issue if it were not done. At that time, the DON stated that, RN #2 shared with us after your observation that she did not clean the glucose meter after she used it. The DON explained that she asked RN #2 what was observed by the surveyor, and, she told me that she did not do it. The DON stated, it was a problem and against our policy. The DON stated that RN #2 should not have handled the test strip and lancet without gloves and should not have placed them or the inhaler and nebulizer on the bathroom counter. The DON stated that it was an infection control issue if the glucose meter, nebulizer, and inhaler were returned to the medication cart without cleaning them first. The DON stated it was her expectation that nursing cleaned the glucometer after use and RN #2 did not properly clean the glucometer after use as required. At that time, the DON stated that hands were require to be washed outside the stream of water for 30 seconds. The DON stated, If hands were washed under the stream of water, then you are not lathering and ensuring that all surfaces were washed. At 12:12 PM, the surveyor interviewed the Staff Educator (SE) who stated that hand sanitizer should be used both before and after glove use per facility policy. The SE stated that hands were required to be lathered with soap for 20 seconds outside of the stream of running water. The SE stated that hands were not effectively washed if they were washed under the stream of water and could infect anyone because that was not effective handwashing. The SE stated it was unacceptable to touch the outside of your mask, because the outside was the dirtiest. The SE stated staff should wash their hands after they touched equipment. The SE stated that there could be contamination if the medication cart was accessed and hand hygiene was not completed prior to use. The SE stated that the medication cart and the keys to the cart were the dirtiest part, because everyone touched them. At that time, the SE stated the blood pressure and pulse oximeter should be cleaned before and after use and were considered contaminated if they were not cleaned between residents. At that time, the SE stated RN #2 should have cleaned the glucose meter, blood pressure cuff, and pulse oximeter with the approved disinfectant wipes which have a kill time (contact time required to kill germs) of two minutes. The SE stated the test strip for the glucometer should have been placed in a glove when doffed, then discarded in the trash and the lancet should have been discarded in the sharps container. The SE stated gloves should have been donned before the glucose meter was sanitized with disinfectant wipes. The SE stated, test strips should never have been handled with bare hands, because you could have blood transmission or an infection waiting to happen. The SE stated when RN #2 placed the glucometer back in the case after use, she contaminated the whole case. The SE stated RN #2 should have cleaned the glucose meter per protocol prior to returning it to the storage case. At that time, the SE stated when RN #2 placed the nebulizer container and the inhaler on the sink it would have contaminated them, as well as everything in the cart where the medications were stored. The SE stated RN #2 should have wasted the inhaler and nebulizer and reordered both of the medications. The SE provided the surveyor with RN #2's Hand Hygiene Competency dated 01/24/24, Medication Pass Observation Tool dated 01/31/24, and a Glucometer Competency Checklist dated 01/30/24. On 08/15/24 at 10:15 AM, the DON provided the surveyor with the Manufacturer Technical Brief (Reviewed 10/23) for the glucose meter used by the facility which was reviewed by the surveyor and revealed the following: To minimize the risk of transmitting bloodborne pathogens, the cleaning and disinfecting procedures should be performed as recommended in the instructions below .The [trademark] glucometer (glucose meter) may only be used for testing multiple patients when standard precautions and manufacturer's disinfecting procedures are followed . -The meter should be cleaned and disinfected after use on each patient. -The cleaning procedure is needed to clean dirt, blood and other bodily fluids off of the exterior of the meter before performing the disinfecting procedure. -The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens. Cleaning and Disinfecting FAQ: -Why is cleaning and disinfecting of blood glucose monitors a high priority? Blood glucose meters are at high risk of becoming contaminated with blood borne pathogens such as Hepatitis B Virus (HBV, a serious liver infection), Hepatitis C Virus (HCV, an infection caused by a virus that attacks the liver) and Human Immunodeficiency Virus (HIV, the virus that causes acquired immunodeficiency syndrome (AIDS). Transmission of these viruses from resident to resident has been documented due to contaminated blood glucose devices. According to the Centers for Disease Control and Prevention, cleaning and disinfecting of meters between resident use can prevent the transmission of these viruses through indirect contact. Review of the facility policy, Medication Management Program Guidelines (RS-10) (11/6/23) revealed the following: Cleanse hands using antimicrobial soap and water or community-approved hand sanitizer before beginning a med pass, before handling medication, and before and after contact with resident. Hand hygiene is performed before putting on examination gloves and upon removal for administration of topical, ophthalmic (relating to the eye), injectable, enteral (passing through the intestine either naturally through the mouth or through an artificial opening), rectal and vaginal medications. Review of the Hand Hygiene (RS-26) Policy (Effective 03/19/18) revealed the following: Purpose: To prevent the transmission of pathogenic micro-organism from resident to resident and from inanimate surfaces to residents by the hands of all healthcare providers. Hand hygiene procedure with soap and water: Turn on water, adjust temperature. Wet hands and wrists with running water before applying soap. Keep hands with fingers downward so water will run into sink and not down arms. Apply soap to hands, use only community approved liquid soap, rub the soap on all surfaces of the hands and wrists using friction, friction can be obtained by rubbing hands rapidly and firmly together, wash all surfaces for at least 20-30 seconds: back of hands palms, wrists, between fingers, including thumbs, under fingernails and around cuticles, rinse hands thoroughly under running water keeping hand downward, avoid touching the sink. Dry hands thoroughly with paper towel(s) .Turn off faucet with a clean paper towel. Discard Paper towel. Hand hygiene should be done (even when gloves are used): At the beginning of work. Before and after contact with each resident. After contact with blood, bodily fluids, mucous membranes, secretions, excretions . Before administering medication. After body fluid exposure. Review of the facility policy, Cleaning & Disinfecting Resident Equipment (RS-29) (Last approved 03/23/23) revealed the following: Blood Pressure Cuffs/machines .Before use on each resident .with a low level disinfectant. Glucose monitors .Before use on each resident and before going into storage .with a low level disinfectant. NJAC 8:39-19.4 (n)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to maintain medical records that were complete by not documenting the completion of treatments for 1 of 1 resident (Resident # 42) reviewed for accidents. This deficient practice was evidenced by the following: On 08/13/24 at 10:56 AM, the surveyor observed Resident #42 sitting outside his/her room in a wheelchair. The resident had a wander guard (a device that alarms if the resident attempts to exit the facility) on his/her left wrist. According to the Admission Record, Resident #42 had diagnoses which included, but were not limited to, unspecified dementia and mood disorder. Review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/21/24, included the resident had a Brief Interview for Mental Status score of 3, which indicated the resident's cognition was severely impaired. Review of the Elopement Risk Scale assessment, dated 07/16/24, included the resident could move without assistance while in a wheelchair and had a history of wandering. Further review of the assessment revealed the resident was a High Risk to Wander. Review of the Care Plan, initiated 07/21/23, included the resident was at risk for wandering related to impaired safety awareness and a history of wandering with an intervention to ensure that the wander guard is on the left wrist. Review of the Order Summary Report, as of 08/15/24, included physician's orders for Wander guard function check every shift, and Wander guard placement check left wrist every shift for elopement precaution. Review of the May 2024 Treatment Administration Record (TAR) revealed the two wander guard treatment orders were not signed out, and left blank, on the following dates: -05/09/24 Evening Shift -05/22/24 Evening Shift -05/23/24 Evening Shift Review of the June 2024 TAR revealed the two wander guard treatment orders were not signed out, and left blank, on the following dates: -06/05/24 Evening Shift Review of the August 2024 TAR, revealed the two wander guard treatment orders were not signed out, and left blank on the following dates: -08/01/24 Evening Shift -08/02/24 Evening Shift -08/16/24 Evening Shift During an interview with the surveyor on 08/15/24 at 10:53 AM, the Certified Nursing Assistant (CNA) stated that the facility used wander guard devices and that everyone was responsible for checking to ensure they were in place. The CNA further stated that it was important to check the wander guards to prevent confused residents from leaving the facility. During an interview with the surveyor on 08/15/24 at 10:55 AM, the Licensed Practical Nurse (LPN) stated Resident #42 had a wander guard. The LPN further stated that the nurses check the placement and function of the wander guard every shift and document completion of the treatment on the TAR. The LPN added that if there is a blank on the TAR it meant the treatment was not completed, and that it was important to ensure the TAR was signed so everyone knows the treatment was completed. The LPN also stated the importance of checking the wander guard for placement and function was to prevent residents from eloping. During an interview with the surveyor on 08/15/24 at 11:01 AM, Registered Nurse (RN) #1 stated the nurses were responsible for checking the placement and function of wander guards every shift and documenting the treatment in the TAR. The RN further stated that it was important to document the wander guard checks so everyone knows the wander guard is on and functioning. The RN further stated that a blank on the TAR meant the nurse did not document the completion of the treatment. During an interview with the surveyor on 08/15/24 at 11:13 AM, the Director of Nursing (DON) stated the nurses were responsible for checking the placement and function of the wander guards every shift and documenting the completion of the treatment in the TAR. The DON further stated that a blank on the TAR meant the nurse did not sign the treatment as completed. When notified of the blanks in Resident #42's TAR, the DON stated the nurses should have signed the TAR and not left it blank. The facility was unable to provide a policy related to medical documentation or documenting in the TAR. Review of the RN Job Description, modified 03/29/22, included, Administers and documents administration of medications, enteral nutrition, and treatments per the physician's order and accurately records all care provided in the EHR [electronic health record]. NJAC 8:39-35.2 (d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop a comprehensive person-centered care plan for 1 of 2 residents (Resident #36) reviewed for oxygen. This deficient practice was evidenced by the following: On 8/13/24 at 10:11 AM, the surveyor observed Resident #36 in bed receiving oxygen via a nasal canula (tubing that delivers oxygen to the body through the nose). A review of the Admission Record (an admission summary) revealed Resident #36 had diagnoses which included, but were not limited to, presence of cardiac pacemaker, chronic atrial fibrillation (heart arrhythmia), chronic pulmonary edema (lungs fill with fluid), other heart failure, and obstructive sleep apnea (blockage in airway while asleep). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the managment of care, dated 07/31/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed in Section O: Special Treatments, Procedures and Programs that the resident was on continuous oxygen therapy on admission and while a resident at the facility. A review of the Order Summary Report, as of 08/15/24, included the following active physician's order: Oxygen: 2 L/min (liters per minute) via nasal canula every shift, with a start date of 07/24/24. A review of the individualized comprehensive care plan, initiated 07/25/24, did not include the resident's use of continuous oxygen via nasal canula. On 08/14/24 at 2:02 PM, during an interview with the surveyor, Registered Nurse (RN) #1 stated care plans are initiated upon admission and updated as needed if the resident's condition changes. She continued by stating that if a resident was prescribed oxygen, it should be included on the care plan so that everyone knows the resident's needs. She also stated that it was important that oxygen was on the care plan in the event that the resident needs to leave the unit for an appointment, so he/she doesn't leave the unit without it. She also added that if there was an agency nurse, he/she needs to know the resident's needs. During that interview, RN #1 reviewed Resident #36's care plan and confirmed that continuous oxygen via nasal canula was not included. The RN stated, No, I don't see it. On 08/15/24 at 9:35 AM, during an interview with the surveyor, the MDS coordinator stated that upon admission, the care plan is initiated and that oxygen should have been included on Resident #36's care plan. On 08/16/24 at 09:00 AM, during an interview with the surveyor, the Director of Nursing (DON) stated oxygen should have been included in Resident #36's care plan and that it was normally included as per the facility's policy and procedure. A review of the facility policy titled, Care Plans, dated 11/9/23, revealed, POLICY The Interdisciplinary Team shall develop a comprehensive, individualized plan of care for each resident that integrate all elements of needed medical, clinical, and community living supports PROCEDURE 1. Development of the Care Plan begins at admission, utilizing information gathered from the resident, family, admission assessments completed by each discipline, and records from the transferring facility or referral source.19. The Care Plan is to be reviewed and updated by all staff providing care or services for the resident. The Care Plan includes a statement of the problem; reasonable, measurable, and time-limited goals; and specific interventions, along with the discipline responsible. NJAC 8:39-11.2(3)h

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to: a) properly label and date food products stored in the walk-in refrigerator/freezer and the dry goods storage room; b) properly discard food products on or before the expiration date; c) handle, prepare, and distribute food to residents in a manner that prevents foodborne illness. This deficient practice was evidenced by the following: On [DATE] from 9:20 AM to 11:20 AM the surveyor, accompanied by the Food Service Director (FSD), observed the following in the walk -refrigerator of the main kitchen: 1. There were three unopened 32-ounce Jennie-O Turkey Breast lunchmeats with no expiration or use by dates. 2.There were multiple packages of thawed ground beef on a free-standing metal cart with pull dates of [DATE]. The FSD stated that the meat must be used with-in three days of being pulled. The FSD stated that pulled referred to being removed from freezer and allowed to thaw in the refrigerator. The FSD stated that the ground beef was on the menu to be served [DATE]. 3. There was a large can of crab meat, unlabeled and with no identifiable received or use by date. 4. There was a bin of diced celery covered in plastic wrap with no open or use by date. 5. There was two bags of sundried tomatoes wrapped in plastic wrap with no open or use by dates. The FSD stated that the facility policy required labeling indicating received, expiration, use by and opened dates. On [DATE] at 10:00 AM, the surveyor who was accompanied by the FSD, observed the following in the walk-in freezer: 1. There were multiple vanilla shake cartons with no expiration, use-by, or received dates. 2. There was a metal bin covered with foil with the date of [DATE]. Inside the metal bin there were multiple crab cakes wrapped individually in plastic wrap. The FSD stated that [DATE] is the date the crab cakes were prepared. The FSD acknowledged that the crab cakes were expired. 3. Underneath the freezer condenser there was an open box of soft pretzels that was covered with ice. There was condensation on the ceiling and ice formations hanging from the condenser. The FSD stated that they have had problems with the pipes and some leakage in the past. 4. There were three frozen meats found on a bottom shelf, partially covered by boxes on the floor. A large pork tenderloin had a supplier expiration date of [DATE]. A large beef tenderloin and a large corn beef brisket were unlabeled, no expiration, received or use by dates. When interviewed, the FSD stated that frozen meats cannot be used after 6 months. 5. There was an open undated box containing sealed bags of chicken nuggets without labeling. The FSD stated that the facility policy required labeling indicating received dates, use by or expiration dates as well as open dates. On [DATE] at 10:22 AM, in the presence of the FSD in the dry storage room, the surveyor observed the following: 1. A large opened container of American Chocolate Sprinkles that was undated. 2. Multiple undated cans of Sysco Classic Sliced Strawberry Topping. 3. Multiple undated boxes of Bakers Basic Muffin Mix. 4. Multiple undated cans of(NAME)Classic Coconut Milk. 5. Multiple undated bottles of Sysco Reliance Pancake and Waffle Syrup. 6. Multiple undated containers of seasoning including Sysco Montreal Chicken Seasoning, Italian Seasoning, Sysco Green Onion, and Sysco Thyme. 7. On a bottom shelf there was 25 lb. bag of Kikkoman Panko in a paper sack that was torn and open at the top side of the bag and open to air. The FSD stated that at that time that the Panko should be stored in a closed bag or container. 8. A 10 lb. bag of Arborio White Rice was torn at the top and open to air. The FSD stated at that time that the rice should be stored in a closed bag or container. 9. There were multiple unopened, undated containers of caramel topping. 10. There were multiple unopened, undated containers of undated jelly. 11. There were multiple unopened, undated containers of Maraschino Cherries. 12. There were multiple unopened, undated containers of apple sauce. 13. There were multiple unopened, undated bottles of soy sauce. 14. There were multiple unopened, undated boxes of cornstarch. 15. There were multiple unopened, undated bottles of chili sauce. 16. There were multiple unopened, undated containers of mustard. 17. There were multiple unopened, undated bottles of vinegar. On [DATE] at 12:10 PM, the Licensed Nursing Home Administrator (LNHA), provided the surveyor with a policy and procedure for Food Safety Management System, dated [DATE], that indicated hamburger/ground beef was to be used within one to two days of refrigeration or stored in the freezer for no longer than three to four months. The Product Labeling and Guide Policy dated [DATE], indicated that all food prepared in operation must be covered and labeled as to contents, date of preparation, use by date and employee name/initial prior to storage in refrigerators, freezer and dry storage. The policy also indicated that items received from vendors were to be labeled with a received date utilizing a label gun and stored properly using first in first out (FIFO) procedures. On [DATE] at 3:15 PM the surveyor's findings in the kitchen were reviewed with the administration: The LNHA, Corporate Nurse, and Executive Director. On [DATE] at 12:48 PM the surveyor observed the following inside the(NAME)Unit nourishment refrigerator: 1. There were eight containers of nectar thick apple juice had use by dates ranging from [DATE] through [DATE]. 2. There were two containers of nectar thick orange juice had use by dates of [DATE]. 3. There were 16 containers of nectar thick water stamped with use by dates ranging from [DATE] through [DATE]. On [DATE] 01:14 PM the Registered Nurse (RN) verified that the expired nectar thick liquids needed to be discarded and stated that Dining Services were responsible for monitoring the refrigerator temps and stocking the nourishment refrigerator with food and beverage items for the residents. Upon review, the Medication Refrigerator / Staff Refrigerators Policy dated [DATE] indicated that assigned staff were responsible for monitoring the food products retained in the nourishment refrigerators as per product expiration date. In a follow up interview on [DATE] at 9:43 AM, the Licensed Nursing Home Administrator verified that the dietary dept was responsible for removing outdated items from the fridge. On [DATE] at 11:40 AM on the 5th floor Long Term Care Kitchen, in the presence of the FSD, the surveyor observed a food service worker taking the temperatures of multiple hot and cold food items intended for use at lunch service that day. The cold food temperatures were as follows: 1. Pureed Turkey Sandwich: 47 degrees Fahrenheit (F). 2. Ground Turkey: 43 degrees F. 3. Pureed Pasta: 60 degrees F. The FSD immediately took these food items out of service. On [DATE] at 1:15 PM, the FSD and LNHA provided the Daily Service and Hazard Analysis and Critical Control Points (HACCP) Record, that indicated cold foods must be held at 40 degrees F or below. On [DATE] at 10:30 AM, the area manager for the facility's food service company confirmed that cold product holding temperatures were to be maintained at 40 degrees F or below while holding and serving. NJAC 8:,[DATE].2 (g).

Based on observation, interview and record review, it was determined that the facility failed to ensure that a resident's urinary catheter drainage bag was covered in a manner to maintain the resident's dignity. This deficient practice was identified for Residents #47, 1 of 14 residents reviewed and was evidenced by the following: On 04/30/19 at 2:46 PM, the surveyor observed from the hallway that Resident #47 was in his/her room. Resident #47's urinary catheter drainage bag, which was hung on the left side of the resident's bed rail, was in full view from the hallway. From the hallway, the surveyor saw that the drainage bag contained yellow urine and was not covered with a privacy bag. Review of the resident's initial Minimum Data Set (MDS), an assessment tool dated 03/10/19, showed the resident had a Brief Interview for Mental Status (BIMS) score of 12, (moderate impairment in cognition). The MDS also showed the resident required two person assistance for care, was non ambulatory, and had limited Range of Motion on both upper and lower extremities. The MDS showed the resident was admitted with [DIAGNOSES REDACTED]. On 05/02/19 at 07:40 AM, the surveyor observed the resident's urinary catheter drainage bag again from the hallway and there was no privacy bag covering the drainage bag. The surveyor observed Resident #47 who was in bed, but did not want to be interviewed. At that time, the surveyor interviewed the resident's Registered Nurse (RN) who stated they used a privacy bag only when the resident was out of the room. The surveyor reviewed the Resident #47's (MONTH) 2019 Flow Sheet which reflected an intervention, dated 05/02/19, to cover the urinary drainage bag with a dignity (privacy) bag while the resident is in bed and when in the wheelchair. Resident #47's care plan, dated 04/30/19, reflected to cover the urinary drainage bag with a privacy bag. The surveyor reviewed the Catheter Care, Indwelling policy dated 02/19/19. The policy did not address privacy for the urinary catheter drainage bag. NJAC8:39-2.2 (d)

Based on observation, interview and record review, it was determined that the facility failed to clarify medication orders regarding route and sequencing of administration, in accordance with professional standards of practice. This deficient practice was identified for Resident #49, 1 of 3 residents reviewed during the medication pass observation and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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. During the medication pass observation on 05/02/19 at 8:15 AM, the surveyor observed a Registered Nurse (RN) as she administered medication to Resident #49. The RN first prepared the tablets and then brought out a bottle of [MEDICATION NAME] nasal spray from the medication cart and set it on top of the medication cart. At that time, Resident #49 wheeled self through the hallway and parked next to the medication cart. The nurse administered the resident's tablets and then stated she would not administer the [MEDICATION NAME] until after the resident finished his/her breakfast. The surveyor reviewed the (MONTH) and (MONTH) 2019 Medication administration Record (MAR) and noted the order for [MEDICATION NAME], ordered on [DATE], reflected: Fluiticasone ([MEDICATION NAME]) 50 mcg (microgram) nasal sprays, suspension two sprays daily. There was no indication for which nostril to spray the medication. The surveyor noted nurses' initials on the MAR daily which meant the [MEDICATION NAME] was being administered daily since it was ordered. On 05/02/19 at 8:20 AM, the surveyor interviewed the RN regarding the route of administration for the [MEDICATION NAME]. The RN reviewed the MAR, in the presence of the surveyor, and acknowledged the order was incomplete and did not indicate which nostril to place the [MEDICATION NAME] for Resident #49. Further review of the physician's orders [REDACTED].#49 had a physician's orders [REDACTED]. Both orders were reflected on the (MONTH) 2019 MAR and there was no delineation for when to give which medication. On 05/02/19 at 1:20 PM, the surveyor interviewed Resident #49's RN who stated she would give [MEDICATION NAME] first because [MEDICATION NAME] was milder than [MEDICATION NAME]. The RN did not offer an explanation for why the orders were not clarified with the physician. The surveyor reviewed the medication administration policy, dated 8/2018, which reflected that staff would review residents' medications. N.J.A.C 8:39-27.1(a), 29.2 (d)

Based on observation, interview and record review, it was determined that the facility failed to a.) ensure that as needed psychoactive medications (PRN) drugs are limited to 14 days unless reviewed by the attending physician or prescribing practitioner and with documented rationale for continuing use; and b.) provide appropriate specific [DIAGNOSES REDACTED]. This deficient practice was identified for Residents #38 and #22, 2 of 14 residents reviewed for psychoactive medication use and was evidenced by the following: 1. On 04/30/19 at 2:31 PM, the surveyor observed Resident #38 who was in the day room and self propelling his/her wheelchair (w/c). The surveyor attempted to interview the resident but the resident presented with a disorganized thought process and moved the w/c back and forth. The resident was not able to be interviewed due to impaired cognition. A review of the significant change Minimum Data Set (MDS), an assessment tool, dated 03/27/19, showed the resident had a Brief Interview of Mental Status (BIMS) score of 7 (severe cognitive impairment). The MDS also showed the resident had no mood problem but had behaviors that included: kicking, scratching and pacing. The resident required a one person assist with transfer and walked in the corridor and room. The MDS reflected the resident was admitted with diagnoses that included: [MEDICAL CONDITION] and depression and on psychoactive medications. The POS showed the resident had diagnoses that included; dementia with behavioral disturbances. The surveyor reviewed the physician's orders [REDACTED].#38 had a physician's orders [REDACTED]. A review of the clinical notes from 01/14/19 until 05/01/19 revealed that there was no documentation that indicated the reason the [MEDICATION NAME] had been in use since 01/14/19. According to the resident's care plan dated 01/17/19, the facility staff would attempt gradual dose reduction. A review of the psychological (psych) consult note, dated 01/15/19, indicated Resident #38 had target symptoms of anxiety/apprehension and to continue with the treatment. The 02/13/19 psych consult note also indicated to continue with the medications. On 05/02/19 at 1:22 PM, the surveyor interviewed the resident's Registered Nurse (RN) who stated that Resident #38's behavior had improved and that the resident had occasional aggressive behaviors. The RN did not offer an explanation for why the [MEDICATION NAME] remained an active order beyond the 14 days as required. On 05/03/19 at 10:00 AM, the Administrator informed the surveyor that she had no further documentation/information regarding why the PRN [MEDICATION NAME] remained an active order beyond 14 days. The surveyor reviewed the medication administration policy dated 8/2018 which reflected that staff would review residents's medications, including review for need for continuation. 2. On 04/30/19 at 12:01 PM, the surveyor reviewed the resident's electronic medical chart which reflected a consent form, dated 04/05/19, and signed by the resident to receive antipsychotics. On the consent form, [MEDICATION NAME] ([MEDICATION NAME]) was checked off as an antipsychotic. The section labeled, targeted symptoms and diagnosis, were left blank and no [DIAGNOSES REDACTED]. The Admission Record reflected that Resident #57 was admitted to the facility on [DATE] with medical diagnoses that included; chronic [MEDICAL CONDITIONS] and collapse, essential hypertension, restless leg syndrome, and [MEDICAL CONDITION]. The resident's admission Minimal Data Set, an assessment tool dated 04/18/19, showed Resident #57 had a Brief Interview of Mental Status score of 8 (moderate cognitive impairment). The MDS reflected the resident exhibited no signs of delusions or hallucinations and had zero verbal, physical or other behavioral symptoms. There was no psychiatric [DIAGNOSES REDACTED]. The MDS showed the resident required limited assistance for transfer, ambulation, bed mobility, and dressing. Review of the physician orders [REDACTED]. The surveyor reviewed the physician orders [REDACTED]. The surveyor reviewed the pharmacy consultation note dated 04/10/19. The pharmacy consultant documented that Resident #57 was on [MEDICATION NAME] and [MEDICATION NAME]-[MEDICATION NAME] (a [MEDICAL CONDITION] medication) and that the two medications represented an off-label use for Resident #57. The pharmacist recommended that the physician update the [DIAGNOSES REDACTED]. A review of the resident's care plan reflected that the resident was at risk for falls related to impaired mobility secondary to use of antipsychotics. On 05/03/19 at 09:20 AM, the surveyor interviewed the Director of Nursing (DON) regarding the [MEDICATION NAME] and the DON stated it was for the resident's [MEDICAL CONDITION]. There was no evidence the facility clarified the [DIAGNOSES REDACTED]. The psychopharmacological Medications policy, dated 11/2017, showed that psychoactive medications would be evaluated for continued use and would be used to treat specific condition. NJAC 8:39- 33.2

Based on observation, interview and review of medical record, it was determined that the facility failed to remove expired medications from the medication refrigerator where current use medications were stored and b.) failed to ensure that expired medications were not administered to residents in accordance with appropriate professional standard of practice. This deficient practice was identified in 1 of 1 medication room inspected and for 2 of 13 residents reviewed (Residents #35 and #36) and was evidenced by: 1. On 06/25/18 at 08:40 AM the surveyor inspected the medication room on the fifth floor in the presence of the unit Registered Nurse (RN) and found a bottle of liquid [MEDICATION NAME] (medication used to treat acid reflux) in the med refrigerator. The pharmacy label on the bottle had an instruction which read: do not use after 6/21/18. The surveyor noted that the bottle was about three-quarters full. There were two other unopened bottles of the [MEDICATION NAME] inside a clear plastic bag which were still at the full line, with a use by date of 7/15/18. Further review of the medication bottle revealed that the [MEDICATION NAME] belonged to Resident #35, who, according to the admission's record, was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 5/24/18, indicated that Resident #35 had moderate impairment in cognition. At that time, the surveyor reviewed the physician's orders [REDACTED]. The surveyor noted that the [MEDICATION NAME] was administered daily and was administered four days past the expiration date written on the bottle. On 6/25/18 at 8:54 a.m., the surveyor interviewed the RN medication nurse for Resident #35. The RN stated that she administered the [MEDICATION NAME] the morning of 6/25/18. When asked to identify which bottle she poured the medication from, the RN pointed to the expired bottle and stated that she poured the [MEDICATION NAME] out of the bottle that expired on 6/21/18. The nurse stated that she normally checked medication bottles for expiration before med administration but it escaped her mind today and she did not check for expiration. A review of the medical record did not reveal any adverse effect/harm to the resident from using the expired medication. 2. On 06/25/18 at 08:40 AM the surveyor inspected the medication room on the fifth floor in the presence of the unit RN and found a bottle of liquid Firvanq also known as [MEDICATION NAME] (antibiotic used to treat infections) in the medication refrigerator. The pharmacy label on the bottle had an instruction which read: discard after 6/15/2018. Further inspection of the medication bottle revealed that the [MEDICATION NAME] belonged to Resident #36, who according to the admission record, was admitted with a [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated that Resident #36 was also admitted with a urinary tract infection. On 06/25/18 at 10:11 AM, the surveyor reviewed Resident #36's Medication Administration Record [REDACTED].Diff, stool infection). A review of the MAR indicated [REDACTED]. The [MEDICATION NAME] bottle in the refrigerator was not supposed to be used beyond 6/15/18. A review of the physician's orders [REDACTED]. Per the nurses note written on 6/14/2018 at 2:15 PM, a Licensed Practical Nurse (LPN) obtained a verbal order from the physician to continue the [MEDICATION NAME] for extra 3 days until 6/17/2018. On 06/28/18 at 10:31 AM, the Director of Nursing and the Administrator confirmed that when the LPN received the order from the physician to continue the [MEDICATION NAME] for three days, the nurse did not request for new medication from the pharmacy and that they used the [MEDICATION NAME] which was already in use for the resident. The Administrator provided a printout showing that the nurse chose the option to not fill for a new bottle of [MEDICATION NAME]. A review of the medical record did not reveal any adverse effect/harm to resident #36 from using the expired [MEDICATION NAME]. According to the facility policy with an original date of 1/15/04 and revision date of 5/1/15, expiration dates of medications would be checked. NJAC 8:39-29.1 (e) NJAC8:39-11.2 (b)

Based on observation, interview and record review, it was determined that the facility failed to follow appropriate infection control protocols and causing potential cross-contamination when providing care for residents on contact isolation precaution. This deficient practice was identified for Residents #16 and Resident #15. The evidence included the following: 1. During the initial unit tour on 4/25/17, the Unit Registered Nurse Mentor stated that Resident #16 was on isolation for infection. He did not state the type of infection. The surveyor observed the resident lying in bed. At the entrance into the resident's room, the surveyor observed an isolation cart that contained personal protective equipment (gloves, gown, goggle). The surveyor reviewed the medical record which revealed that Resident #16 was admitted with [DIAGNOSES REDACTED]. A review of the resident's April 2017 Physician order [REDACTED].#16 had an infectious bacteria in the urine and had an order for [REDACTED]. equipment.) On 4/26/17 at 8:30 a.m., the surveyor observed a Certified Nursing Assistant (CNA) in Resident #16's room assisting the resident. The CNA was not wearing gloves or protective gown. The surveyor observed the CNA pick up the resident's urinal which contained urine with her bare hands. She then went into the resident's bathroom and dumped the urine into the toilet. During interview with the CNA on 4/28 at 8:55 a.m., the CNA stated that she was aware that Resident #16 was on isolation precautions and that she should wear protective gown and gloves when caring for the resident. When asked why she did not wear the protection the previous day, she stated: I was not doing care for the resident, only dumping the urine out of the urinal. When asked if she knew where the infection was located, she stated that it was in either the urine or in the resident's stool. 2. During the initial unit tour on 4/25/17, the Unit Registered Nurse Mentor told the surveyor that Resident #15 was on contact isolation precaution due to an infection in the eyes. The surveyor observed the resident seated in the wheelchair. At the entrance into the the resident's room, the surveyor observed an isolation cart that contained personal protective equipment. On 4/26/17 at 8:45 a.m., the surveyor observed a Laboratory Technician (LT) as she went into Resident #15's room for a lab draw. The surveyor noted that the LT was wearing a plastic disposable coat over her clothes. When the LT finished with Resident #15, she left the resident's room with the disposable coat on and did not wash her hands. The LT also went to the dining room to speak to another resident and then went to other resident's room still wearing the same disposable coat. The surveyor reviewed the resident's care plan that reflected staff should follow isolation precaution as ordered by the physician. On 4/28/17 at 10:55 a.m., the surveyor interviewed the facility Administrative staff. The Executive Director stated that the LT should know the proper infection control protocols because it was included in their contract with the provider Laboratory company. NJAC8:39-19.4 (a)

Based on observation, record review and interviews during the initial tour of the kitchen on 6/21/2016 in the presence of the Assistant Dining Director, it was determined that the facility failed to ensure that the kitchen was maintained in a clean and sanitary manner in order to prevent the potential for any outbreak of foodborne illnesses. This deficient practice was observed on 6/21/2016 between 8:07a.m. and 9:07a.m. and was evidenced by the following: 1. A large capacity/industrial-size Hobart food mixer was noted with an accumulation of dried-on food particles and debris from an indeterminate meal both on the back splash as well as the mixing blade. The mixer was covered with a clear plastic wrap and stored as clean. 2. The hood directly above the cooking area had an accumulation of lint and grease and was sticky to the touch. The Assistant Dining Director stated that the hood was cleaned weekly by the staff and the mixer was supposed to be cleaned after each use. There was no evidence provided to the surveyor at that time to show that the cleaning was done. 3. The refrigerator in the Bistro/Cafeteria had 3 quart-sized plastic whole milk containers that had expired. Two full containers had expiration dates of 6/14/06 and 6/16/06 respectively and the third half full container had an expiration date of 6/14/16. The Assistant Dining Director stated that dietary staff were supposed to check dates prior to placing items in the refrigerator for use. On 6/24/16 the administrator provided the survey team with a blank 'weekly cleaning schedule ' stating that staff has been re-inserviced on sanitation procedures. NJAC 39:17.2 (g)

Based on observation, interview and record review, it was determined that the facility failed to initiate a comprehensive care plan (CCP) for the use and monitoring of psychoactive medications. This deficient practice was identified for Resident #10, 1 of 15 residents reviewed and was evidenced by the following: During the initial unit tour on 6/21/16, the Director of Nursing (DON) told the surveyor that Resident #10 had the behavior of screaming and was on Psychoactive medications. On 6/23/16, the surveyor reviewed the medical record for Resident #10 who was admitted to the facility with [DIAGNOSES REDACTED]. A review of the June 2016 Physicians Order Sheet (POS) revealed the resident had an order dated 3/24/16 for [MEDICATION NAME] 0.5 mg every six hours as needed for anxiety; [MEDICATION NAME] sprinkle 250 mg dated for 4/7/16, two times a day to treat anxiety; and [MEDICATION NAME] 0.5 mg dated 4/23/16 daily to treat dementia with behavioral disturbance. On 6/23/16 at 9:50 a.m., the surveyor observed the resident seated in the wheelchair in the hallway near the nurses' station with his/her head down and eyes closed. The surveyor reviewed the resident's CCP and could not find any documentation that addressed the use of psychoactive medications. When interviewed on 6/23 at 2 p.m., the DON and the Administrator stated that they would look into that. There was no evidence that the facility developed a care plan for the use of these medications till after surveyor inquiry. NJAC 8:39-11.2 (e)

Based on observation, interview and record review, it was determined that the facility failed to apply physician-ordered TED stockings (anti embolism) as ordered and in accordance with appropriate professional standards of practice. This deficient practice was identified for Resident #1, 1 of 1 residents reviewed for the use of TED stockings and was evidenced by the following: The surveyor reviewed the medical record for Resident #1 who was admitted to the facility with [DIAGNOSES REDACTED]. A review of June 2016 physician's orders [REDACTED]. On 6/22/16 at 12:30 p.m., the surveyor observed Resident #1 lying in bed, dressed with no TED stockings on. The surveyor reviewed the Treatment Administration Record (TAR) at 1 p.m. and noted that it had been signed as if the TED stockings were applied as ordered. On 6/23/16 at 10:55 a.m., the surveyor reviewed the TAR and noted that the slot for TED stockings had been signed to indicate that it was applied on the resident. At 11 a.m., the surveyor observed the resident in bed dressed and had no TED stockings on. At 11:20 a.m., the surveyor took the unit Registered Nurse to the resident's room and inquired about the TED stocking. The nurse pulled the blanket off the resident's legs and stated oh, he/she doesn't have them on. 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. NJAC 8:39-11.2 (b)

Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain a clean, sanitary environment in the kitchen and related areas. This deficient practice was evidenced by the following: On 6/17/14 from 9:10 a.m. to 9:20 a.m., the surveyor observed the following in the presence of the Director of Dining Services (DDS) and the Executive Chef (EC): 1. The paper towel dispenser, which was wall mounted above the hand washing sink, dispensed paper towels which touched the running water and faucet. 2. Two open boxes of pan bags used for cooking foods and an open box of plastic wrap were visibly soiled with substances of unknown origin were observed on a shelf. 3. The heavy duty blender base and the meat slicer were observed on a food preparation counter top. When interviewed, the EC stated neither piece of food service equipment had been used that morning. Debris of unknown origin was visible on the blender base. An opened can of food thickener was observed on the base of the meat slicer. 4. The dish machine was in operation for clean-up of the breakfast meal. One Food Service Worker (FSW) was working at the dish machine. The FSW loaded soiled dishes into the dish machine, then removed clean, sanitized plates from the clean end of the dish machine and stacked the plates on a clean storage rack. When interviewed, the DDS stated the FSW should have washed her hands after working on the soiled end before going to the clean end of the dish machine. On 6/18/14 from 7:40 a.m. to 9:05 a.m., the surveyor observed the following in the presence of the Director of Dining Services (DDS) and the Executive Chef (EC): 1. In the walk-in refrigerator, 30 lbs. of partially frozen raw ground meat was observed in an open bag on a sheet pan (not in a pan to collect meat drippings.) 2. In the walk-in refrigerator, a package of sliced deli turkey and sliced ham were observed on a shelf. Both packages had a facility label which gave the sliced deli turkey and sliced deli ham a 5 day shelf life. When interviewed, the DDS and EC stated the facility policy for shelf life of sliced deli meats was 3 days, not 5 days. The EC stated the deli meats had been incorrectly labeled. 3. In the walk-in refrigerator, an opened piece of hickory smoked ham wrapped in plastic wrap and a sealed piece of hickory smoked ham were observed on a shelf. The manufacturer's refrigeration shelf life/date of expiration was found on the ham. The DDS and EC were unable to identify the manufacturer's refrigeration shelf life/date of expiration for the hickory smoked ham. 4. In the walk-in refrigerator, an opened box of unfrozen raw bacon was observed on a shelf. When interviewed, the DDS and EC stated the box of bacon had been frozen and pulled to thaw. The DDS and EC stated the box of raw bacon should have been labeled to identify the " pull date" from the freezer, the date the box of raw bacon had been opened and the "use by date." The DDS and EC were unable to identify the refrigeration shelf life of the bacon. 5. In the walk-in refrigerator, a box which contained 4 packages of sliced bologna was observed on a shelf. The supplier label indicated the bologna was received on 5/8/14. No other dates were found on the bologna or the box which contained the bologna. A code was observed on the bologna. The DDS and EC were unable to identify what the code meant and the manufacturer's refrigeration shelf life/date of expiration. 6. In the walk-in refrigerator, 3 raw, unfrozen beef rounds, 20 lbs. each, were observed on a shelf. The facility labeled the meat with a receiving date of 6/12/14. No other information was found on the 3 beef rounds. The EC brought the box for the beef rounds back into the kitchen from outside. The supplier's label indicated the beef rounds was received on 6/10/14, 2 days earlier than labeled by the facility. The label on the box indicated the beef rounds had been packed on 5/7/14. The EC stated the beef rounds were placed in the refrigerator after delivery. The DDS and EC were unable to identify the manufacturer's refrigeration shelf life of the beef rounds. NJAC 8:39-17.2(g)

Based on interview, it was determined that the facility failed to provide evidence that a bedtime snack was verbally offered to the residents on a consistent basis. This deficient practice was identified for 5 of 8 residents at a group meeting and was evidenced by the following: On 6/19/14 at 11:20 a.m., a meeting was held with a group of 8 residents identified by the facility as being alert and oriented. When asked, 5 of 8 residents said they were not offered a bedtime snack. One of the residents who attended the meeting stated he/she was offered a bedtime snack one night in the past week. When interviewed on 6/23/14 at 11:55 a.m., the Licensed Nursing Home Administrator (LNHA) stated snacks were available on the nursing unit. The LNHA said there was a cart with snacks and the nurses or certified nursing assistants were responsible for offering bedtime snacks to the residents. NJAC 8:39 - 17.2 (f) 1

Based on interview, observation and record review it was determined that the facility failed to: implement care plan interventions for one resident (Resident #11); update a resident's care plan (Resident #6) with interventions following a fall; and initiate a care plan for two residents at risk for depression (Resident #3) and falls (Resident #8). This deficient practice was noted for 4 out of 12 residents reviewed for care plans and was evidenced by the following: 1. Resident #11 had a history of [REDACTED]. The Care Plan noted an intervention that was started on 3/4/13 to place Resident #11 within sight of staff during the night due to an earlier fall (3/4/13). Resident #11 had a fall on 4/18/13 at 1:50 a.m. and fell from a wheelchair. According to the Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) statements, the fall was unwitnessed and it could not be determined if Resident #11 was within sight of staff. 2. Resident #6 had a history of [REDACTED]. The Care Plan was initiated on 11/16/12 and last reviewed on 6/13/13. The last added intervention to the Care Plan was 12/11/12. Resident #6 had a fall on 5/11/13. According to the "Occurrence Report" it was concluded that the following interventions were to be implemented on 5/14/13: a.) staff to stay with resident while in bathroom; b) resident not to be left alone while toileting; and c) supply resident with non-skid stockings when walking. The above interventions were not on the current care plan when reviewed by the surveyor on 7/3/13. 3. Resident #3 was admitted to the facility in 2010 with the [DIAGNOSES REDACTED]. The surveyor reviewed Resident #3's July 2013 Physician order [REDACTED]. The surveyor reviewed the psychiatrist's consultation sheet dated 5/8/13 on 7/2/13 at 12:30 p.m. The psychiatrist noted that Resident #3 had a long history of depression and it "took long time to treat it." The psychiatrist also noted not to change medications as Resident #3 "requires lifelong treatment because of severe, chronic psychiatric illness, with high risk of relapse" and "current medications improve function." The surveyor reviewed Resident #3's current Care Plan on 7/3/13 at 9 a.m. Resident #3 had no care plan for mood/depression. 4. Resident #8 was confused and admitted on [DATE] after a fall and fractured clavicle. The surveyor reviewed Resident #8's electronic medical record on 7/2/13 at 10:20 a.m. Resident #8 was assessed as a high risk for falls on the Fall Risk Assessment form. The surveyor reviewed Resident #8's current Care Plan on 7/3/13 at 9 a.m. Resident #8 had no care plan for falls or for risk of falls. N.J.A.C. 8:39-11.1

Based on interview, observation and record review it was determined that the facility failed to adequately supervise a resident, Resident #11, who had a history of [REDACTED]. During the initial tour on 7/1/13 the Licensed Practical Nurse (LPN) stated Resident #11 was confused and had several falls. The surveyor observed Resident #11 throughout the survey (7/1/13-7/3/13) calmly seated in a wheelchair within view of the staff. The surveyor reviewed Resident #11's electronic medical record (eMR) on 7/2/13 at 10:20 a.m. It was noted in the Progress Notes that Resident #11 had multiple falls since 12/2/12 (admitted ). The surveyor requested and received the "Occurrence Reports" from the Administrator on 7/3/13 at 9 a.m. The following information was noted for 2 of the falls: Resident #11 had a fall on 3/4/13 at 1:50 a.m. Resident #11 attempted to get up from a wheelchair and bed multiple times and was placed by the nurse's station to be monitored. The nurse at the nurse's station left the area and Resident #11 fell from the wheelchair. The Interdisciplinary Fall Meeting met later that day and implemented the following interventions: 1. Frequent checks while in bed; 2. Place within sight of staff if up during the night; 3. Offer a snack; and 4. Give resident something for distraction. The above interventions were added to Resident #11's Care Plan. Resident #11 had a fall on 4/18/13. The surveyor could not find any description of the fall in the progress notes except that the resident was not in any pain or discomfort after a fall. According to the "Occurrence Report," the fall occurred at 1:50 a.m. in the hallway by the nurse's station. Resident #11 was restless in bed and was seated in a wheelchair and brought to the nurse's station for supervision. According to the LPN's statement, the LPN was notified by a Certified Nursing Assistant (CNA) that Resident #11 was on the floor. The LPN was with another resident at the time. The CNA statement only noted that s/he heard a loud sound and upon getting up saw Resident #11 on the ground next to the wheelchair. According to the "Occurrence Investigation Report" signed by the Administrator, it was noted Resident #11 appeared to have leaned forward in the wheelchair and fell . The surveyor and Administration could not locate any further information as to where the CNA was in relation to Resident #11 and what the CNA was doing at the time. The surveyor reviewed staff statements that indicated Resident #11 was not within sight of staff. N.J.A.C. 8:39-27.1(a)

Based on interview, observation and record review, it was determined that the facility failed to document according to their policy on "Abuse Prevention/Accidents, Incidents" for a fall investigation for 1 of 12 residents, Resident #11. The facility also failed to complete documentation of a death pronouncement for 1 of 1 residents, Resident #13. This deficient practice was evidenced by the following: 1. During the initial tour on [DATE] the Licensed Practical Nurse (LPN) stated Resident #11 was confused and had several falls. The surveyor observed Resident #11 multiple times from 9 a.m. through 2 p.m. throughout the survey ([DATE]-[DATE]) calmly seated in a wheelchair within view of staff. The surveyor reviewed the electronic medical record (eMR) on [DATE] at 10:20 a.m. Resident #11 had a [DIAGNOSES REDACTED]. The surveyor reviewed the eMR Progress Notes and reviewed a [DATE] (timed 11:45 a.m.) entry that noted Resident #11 had a fall. The surveyor requested and received the incident report for Resident #11's [DATE] fall from the Administrator, and the facility's Accident and Incident Policy and Procedure on [DATE] at 9 a.m. According to the "Abuse Prevention/Accidents, Incidents" Policy and Procedure, it noted that all accidents were to be "thoroughly investigated" and included the following procedures that were missing from Resident #11's eMR: The nurse was to document the assessment, plan of action and follow-up evaluation of the resident in the interdisciplinary clinical progress notes in the eMR including a "detailed description of findings, observations, and interventions" and "any resident observations or comments." The surveyor could only locate the following progress note in Resident #11's eMR: [DATE] at 11:15 a.m; "No complaints of pain/discomfort related to fall. OOB (out of bed) to w/c (wheelchair). Propelling self on unit. W/C Alarm functioning. (Name of attending physician)/POA (Power of Attorney) made aware." N.J.A.C. 8:,[DATE].1(b) NJSA 26:8 -24.1 Complaint #NJ 2. The surveyor reviewed the closed medical record for Resident #13. The resident, who had been on Hospice services, expired at the facility on [DATE]. The surveyor reviewed the electronic Progress Notes dated [DATE]/ 10:52 p.m. which indicated that the resident's death was pronounced by the Registered Nurse (RN). The RN did not save the death pronouncement information to the Electronic Death Registration System as required.