Every finding on record at United Methodist Communities at Pitman

COMPLAINT#: 404125 Based on interview, medical record review, and review of pertinent facility documentation on 8/13/25, it was determined that the facility failed to ensure a severely cognitively impaired resident's safety when the soup that CNA #1 reheated for Resident #4 and served to the resident without checking the soup temperature, spilled onto the resident's lap. This resulted in a second-degree and third-degree burns to Resident #4's right inner thigh which had an open area that measured 1 centimeter x 1 centimeter (CM), and reddened area that measured 0.5 cm x 11.4 cm from the edges of open area. This deficient practice was identified for 1 of 5 residents (Resident #4) reviewed and was evidenced by the following: A review of the Facility Reportable Event (FRE) sent to the New Jersey Department of Health (NJDOH), indicated that on 5/2/25 at 5:30 P.M., During dinner [Resident #4] sustained a burn injury to [their] right inner thigh when soup spilled on [their] lap. Burn injury noted with open area 1 cm x 1 cm, redness extending 0.5 cm x 11.4 cm beyond edges of open area. The FRE further indicated that staff was to anticipate the resident's needs and that the Resident's care plan includes cognitive impairment and risk for skin injury. The FRE also revealed that, . CNA failed to take temperature of soup prior to serving resident. The surveyor reviewed the Conclusion section of the Addendum to AAS-45: 5/2/25, submitted by the Director of Nursing (DON) which indicated the following:- Resident was seen by wound nurse practitioner and assessed with second degree burn to right inner thigh and third degree burn to right anterior thigh.- [CNA #1] immediately disclosed that he had not used the thermometer to ensure safe temperature of soup prior to resident being served. Resident #4 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #4 was admitted to the facility with diagnoses that included but were not limited to: dementia, cognitive communication deficit, and peripheral vascular disease (reduced blood circulation in the limbs). Review of Resident #4's comprehensive Assessment Minimum Data Set (MDS), an assessment tool dated 5/20/25, indicated that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating that the resident's cognition was severely impaired. Further review of the MDS revealed that the resident required, Setup or clean-up assistance when eating. A review of Resident #4's care plan (CP) indicated a focus related to the resident having an Assisted Daily Living (ADL) self-care deficit that was initiated on 11/13/24. Interventions for this focus included, Assist me with my meals, initiated on 2/13/25. Further review of the CP revealed a focus related to the resident having the potential for the development of pressure ulcers that was initiated on 12/5/24. Interventions for this focus included that staff were to, Follow facility policies/protocols for the prevention/treatment of skin breakdown, that was initiated on 12/5/24. A review of Resident #4' progress notes (PN) revealed a nursing note dated 5/2/25, at 9:56 P.M., Around [5:20 P.M.]; it was brought to this nurse attention by aide that resident had a acquired a burn noticed after resident was placed in bed. Skin assessed right upper inner thigh to noted to have a 1 cm x 1 cm circular opening, redness area 0.5 cm x 11.4 cm. resident stated [they] pulled the bowl and it spilled. NP called informed of incident and [treatment] ordered. DON and POA notified]. Further review of the resident's PNs revealed a wound care note dated 5/5/25, at 4:48 P.M., that indicated that the purpose of the visit was a subsequent encounter for skin and wound care. The Nurse Practitioner (NP) additionally noted, Staff requested [Resident #4] have a wound/skin consult of patient's right thigh burns, which were caused by hot soup. On evaluation right inner thigh with 70% slough and right anterior thigh with closed blisters. Her assessment further indicated that the resident had a burn of second degree of right thigh and a burn of third degree of right thigh. The NP then proceeded to update the resident's course of treatment. A review of Resident #4's Order Summary Report for May 2025, indicated an active order that was initiated on 5/2/25 for a Silvadene cream to be applied topically, to right upper inner thigh topically two times a day for wound treatment . A review of the resident's Medication Administration Record for May 2025 revealed a corresponding medication to reflect the order. Further review revealed that the resident's Treatment Administration Record was updated to reflect the NP's recommended course of treatment. The surveyor attempted to contact Certified Nurse Assistant (CNA) #1 for an interview without success. A review of his personnel file revealed a facility Performance Enhancement Form dated 5/5/25, which indicated that CNA #1 was suspended 3 days for did not temp food before giving to a resident. the resident was injured as a result. Further review of the personnel file revealed that CNA #1's most recent training on Microwave Use for Heating and Reheating, prior to the incident, occurred on 5/25/23. During an interview with CNA #2 on 8/13/25, at 11:18 A.M., she stated that she had been in-serviced on re-heating food in the microwave. A review of CNA #2's personnel file revealed an electronic Transcript which included two dates for Reheating food/drinks in microwave, 05/07/25 and 06/02/2025. Further review of the personnel file did not include any training that was completed prior to the date of the incident (5/2/25). During an interview with the Nurse Educator (NE) on 8/13/25, at 4:35 P.M., she stated that competencies should be completed at the time of hire and annually. She stated annual trainings were important to ensure that staff were up to date on their skills. She further stated that the reheating food training should be completed annually. Surveyor further explained that CNA #2's personnel file only revealed trainings on this topic that occurred after the incident. When asked if CNA #2 had any additional trainings on reheating foods the NE stated that CNA #2 should have had the training at the time of her hire. No additional documentation was received. The Director of Nursing (DON) stated during an interview with the surveyor on 8/13/25 at 2 P.M., that she was contacted by the resident's nurse on the day of the incident (5/2/25) and was told that CNA #1 served Resident #4 soup that spilled, and that the resident was burned as a result. She stated that she immediately contacted the manager on duty who confirmed that the sign was on the microwave and that the thermometer was also there. She then stated that she spoke with CNA #1 via phone that day and that the following conversation occurred: I said did you heat up the soup, he said yes. I said did you take the temperature, he said no I forgot. I asked if the sign and thermometer were there, he said yes but I forgot. The DON further stated, It is important that staff follow reheating policies and procedures to prevent injuries such as this. During an interview with the Licensed Nursing Home Administrator (LNHA) on 8/13/25, at 4:48 P.M., she stated that she expected that any competencies that were required annually and/or at the time of hire should have been done. She further stated, I'm not sure what happened in these two cases, and that they would double check. No additional documentation was received regarding additional trainings for CNA #1 and CNA #2. A review of the facility's Microwave Use for Heating and Reheating policy, dated 5/25/23, revealed that the facility, Established methods for safe heating and reheating of foods in the microwave by staff will be followed to minimize the risk of food borne illness, and residents will be served food, soups. that are handled safely. The policy further revealed under the Procedure section, . 4. Use a thermometer to check the temperature of the food, soups .6. Soups and hot cereals need to be reheated/heated to 165 degrees F and the temperature will be taken prior to serving the residents. The temperature prior to serving soups and hot cereals shall not exceed 150 degrees F. Cool as needed prior to serving the resident, 7. Staff are required to assist residents and visitors with heating or re-heating food, soups. in the microwave. The surveyor reviewed the facility's Clinical Teammate Competency policy, effective 11/26/19, revealed under the Procedure section, Skill competency will be evaluated at hire, annually and with identified need. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and review of facility documentation it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain kitchen utensils in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 07/06/23 from 9:11 AM to 9:45 AM, the surveyor, accompanied by the Executive Chef (EC), observed the following in the kitchen: In the dry storage room: 1.) There was a rolling metal cart that contained 12 plastic-wrapped, circular baked items, that the EC identified as apple cakes, with no label or date. The EC stated they were made today and were good for three days. The EC further stated they should be labeled with today's date and the use-by date. In the main kitchen walk-in refrigerator: 2.) On a middle shelf, there was a plastic-wrapped metal container of strawberries with a use-by date of 07/04/23. The EC threw away the strawberries. 3.) On a cart, there was a plastic-wrapped metal container of salad mix. The label was incomplete, and the EC was unable to determine the use-by date. The EC threw away the salad mix. 4.) On a middle shelf, there was a plastic-wrapped metal container of meat, that the EC identified as Canadian ham. There was orange-tinted clear liquid pooled on top of the plastic wrap. The EC stated the liquid was possibly drippings from a metal container on the shelf above. The EC threw away the Canadian ham. 5.) On a middle shelf, there was a plastic-wrapped metal container of liquid, that the EC identified as shrimp scampi sauce with a use-by date of 07/05/23. The EC threw away the shrimp scampi sauce. 6.) On a top shelf, there was a plastic-wrapped metal container of meat, that the EC identified as sausage. There was clear liquid pooled on top of the plastic wrap. The EC stated he did not know where the liquid came from and threw away the sausage. In the outside walk-in freezer: 7.) On a middle shelf, there was plastic-wrapped open bag of frozen pierogis that was not labeled with an open or use-by date. The EC removed the bag of frozen pierogis. On 07/07/23 at 11:29 AM, the surveyor, accompanied by the Area Manager (AM), observed the following in the 3rd Floor Dining Room: In the top drawer of a cabinet: 8.) There was an open package of hamburger buns that was re-sealed with a plastic twist tie that was not labeled. The AM stated the dietary staff followed the manufacturer's date on the bread packaging. The manufacturer's use-by date was 07/05/23. The AM threw away the hamburger buns 9.) There was an open package of rye bread that was re-sealed with a plastic twist tie with a use-by date of 07/03/23. The AM threw away the rye bread. 10.) There was an open package of club wheat bread that was re-sealed with a plastic twist tie with a use-by date of 07/03/23. The AM threw away the club wheat bread. In the ice cream freezer: 11.) There was an open container of ice cream without a lid. The AM stated there should be a lid covering the ice cream. 12.) There was metal container next to the freezer with an ice cream scoop that was submerged in a white, opaque liquid. The metal container was open and exposed to air. The AM stated the ice cream scoop must have been used between meal service and should have been sent down to the kitchen to be washed before the lunch service. On 07/10/23 at 11:28 AM, the surveyor interviewed the Area General Manager (AGM) who stated that all prepared or opened food items should have been labeled with a prep and print label which included an open date, use-by date, the shelf life, and the name of the employee who printed the label. The AGM further stated that food items are checked daily for out-of-date items which are thrown away. When asked about the ice cream scoop kept in the dining room, the AGM stated that if the ice cream scoop was used outside of mealtimes, it should have been placed on the dirty cart to be brought to the kitchen for sanitization. Review of the facility's kitchen Daily Cleaning Assignments, dated 07/08/23, included, Check [NAME] for Out of Date Product Daily. Review of the facility's, Date Marking Ready to Eat TCS/PHF Foods policy, dated 04/01/22, included, Refrigerated, ready to eat, TCS/PHF food prepared and held in a food establishment must be clearly marked with a consume by/discard date, and, Food that is required to be date marked must be discarded if it: . is in a container or package that does not bear a date or day. Review of the facility's, Preventing Cross Contamination policy, dated 04/01/22, included, Packaged food may not be stored in direct contact with ice or water if the food is subject to entry of water because of the nature of its packaging, wrapping, or container, Food must be covered/protected from environmental contamination during storage and transportation, and, Utensils and equipment used for both raw and ready to eat foods must be cleaned and sanitized between uses. Review of the facility's In-Use Utensils, Between Use Storage policy, undated, included During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: . In a clean, protected location. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care for 7 of 17 residents, (Resident #9, #22, #43, #44, #46 #56, and #65) reviewed for accurately coding the MDS. This deficient practice was evidenced by the following: 1.) On 07/07/23 at 12:04 PM, the surveyor observed Resident #9 in the main dining room on the third floor seated next to other residents. The resident was unable to tell the surveyor how long he/she resided at the facility but told the surveyor that he/she used to live on a farm and took care of many different animals. The surveyor reviewed the medical record for Resident #9. A review of the residents Admission Record (an Admission Summary) indicated that the resident had resided at the facility since 2016 and had diagnoses which included but were not limited to unspecified dementia, pain, and abnormal weight loss. A review of Resident #9's quarterly MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/10/23 at 11:14 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who told the surveyor that she regularly took care of the resident, and the resident was alert and oriented to person, place with forgetfulness at times. The CNA further stated that the resident's mood was stable, and the resident was happy when she provided care to the resident. On 07/12/23 at 9:29 AM, the surveyor interviewed the residents Licensed Practical Nurse (LPN) who stated that the resident was alert and oriented to person and place with forgetfulness at times. The LPN further stated that the resident's mood was stable, and she was not involved in completing the MDS. On 07/12/23 at 9:47 AM, the surveyor interviewed the Minimum Data Set Coordinator (MDS/C) who stated that, everything fell apart in March because there was no long-term care Social Worker (SW) available to complete the MDS's at that time. The MDS/C told the surveyor that the SW from the communities Assisted Living facility was helping complete the MDS's for the residents and she had minimal experience doing so. The MDS/C further stated that Section C and Section D of the resident's MDS were not completed, and it should have been. The MDS/C told the surveyor that accurate completion of the MDS helped facilitate the management of care for the resident and it was important to fill the information out correctly because it guided in the development of the resident's care plan. 2.) On 07/07/23 at 11:27 AM, the surveyor observed Resident #46 sitting in his/her room in a lounge chair, completing a word search. The resident stated that everything was great, and he/she liked living at the facility. The surveyor reviewed the medical record for Resident #46. A review of the resident's Admission Record reflected that the resident resided at the facility since October 2019 and had diagnoses which included but were not limited to seizures, hyperlipidemia (a condition where there are high levels of fat particles in the blood), nasal congestion, and major depressive disorder. A review of the May 2023, June 2023 and July 2023 Order Summary Report did not reflect a physcian's order for the use of an antipsychotic medication. A review of the resident's quarterly MDS dated [DATE], reveled in Section N0450 - Antipsychotic Medication Review that the resident had a gradual dose reduction of an antipsychotic medication when the resident had never been prescribed or administered an antipsychotic medication. On 07/12/23 at 9:33 AM, the surveyor interviewed the resident's LPN who stated the resident was alert and oriented to person, place, and time with minimal forgetfulness. The surveyor reviewed the resident's medications in the presence of the LPN who stated that the resident was receiving an antidepressant medication, not an antipsychotic medication. The LPN told the surveyor that to her knowledge, the resident had never been perscribed an antipsychotic medication. On 07/12/23 at 9:37 AM, the surveyor interviewed the MDS/C who stated that in March 2023, the facility eliminated the MDS Coordinator position, and she took on a new role with MDS at the facility which made her responsible for only competing the Medicare portion of the MDS's with the assistance from the Regional MDS Coordinator. The surveyor reviewed Resident #46's quarterly MDS dated [DATE], in the presence of the MDS/C who stated that the resident was never on an antipsychotic medication and the MDS had been coded inaccurately. On 07/14/23 at 10:58 AM, the surveyor interviewed the facility's Licensed Nursing Home Administrator (LNHA) who stated that the MDS's were missed. 43308 3.) On 07/06/23 at 10:55 AM, the surveyor observed Resident #44 resting in his/her recliner chair. Resident #44 stated that he/she wasn't feeling well but had informed the nurse and that the nurse was getting his/her medication. The resident stated they had a history of falls but that the staff was good at assessing and providing care to them. According to the Admission Record, Resident #44 had diagnoses which included, parkinson's disease and major depressive disorder. Review of Resident #43's quarterly MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/10/23 at 10:17 AM, the surveyor interviewed the SW in the presence of the LNHA who stated that she started her position at this facility last Wednesday 07/05/23 but has worked as a SW prior. On 07/10/23 at 10:20 AM, the surveyor continued the interview and the LNHA stated that for a while they did not have a SW and that the facility had to utilize the Assisted Living SW. The LNHA further stated that the Assisted Living SW had covered for three (3) months from April to June of 2023. On 07/11/23 at 10:38 AM, the surveyor and the MDS/C reviewed the MDS for Resident #44. At that time, the MDS/C confirmed Section C and Section D of the resident's quarterly MDS dated [DATE], were not assessed. She stated that she signed off on it but that indicated it was completed but not accurate. She stated that it was important for the MDS to be accurate and complete because it showed a clear and concise record of the resident. The MDS/C acknowledged that the quarterly MDS for Resident #44 should have been completed accurately. 4.) On 07/06/23 at 11:10 AM, the surveyor observed Resident #56 resting in bed with his/her eyes closed. According to the Admission Record, Resident #56 had diagnoses which included, major depressive disorder, adjustment disorder, and insomnia. Review of Resident #56's quarterly MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/11/23 at 10:40 AM, the surveyor and MDS/C reviewed the MDS for Resident #56. At that time, the MDS Coordinator confirmed Section C and Section D of the resident's quarterly MDS dated [DATE], were not assessed. She acknowledged that the quarterly MDS for Resident #56 should have been completed accurately. 41260 5.) According to the Admission Record, Resident #22 had diagnoses which included, but were not limited to, vascular dementia, anxiety, diffuse traumatic brain injury, and depressive episodes. Review of Resident #22's quarterly MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/11/23 at 10:15 AM, the surveyor interviewed the CNA who stated Resident #22 was alert and oriented, and was typically in a pleasant, happy mood. On 07/11/23 at 10:21 AM, the surveyor interviewed the Registered Nurse (RN) who stated Resident #22 was alert and oriented to self and place and was typically pleasant and cooperative. 6.) According to the Admission Record, Resident #43 had diagnoses which included, but were not limited to, Alzheimer's Disease and major depressive disorder. Review of Resident #43's quarterly MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/11/23 at 10:15 AM, the surveyor interviewed the CNA who stated Resident #43 was confused and had a flat affect. On 07/11/23 at 10:21 AM, the surveyor interviewed the RN who stated Resident #43 was alert and oriented to self only and had a flat affect. 7.) According to the Admission Record, Resident #65 had diagnoses which included, but were not limited to dementia and insomnia. Review of Resident #65's admission MDS dated [DATE], revealed that Section C - Cognitive Patterns and Section D - Mood were not completed. On 07/11/23 at 10:15 AM, the surveyor interviewed the CNA who stated Resident #65 was confused and was typically in a pleasant mood. On 07/11/23 at 10:21 AM, the surveyor interviewed the RN who stated Resident #65 was alert and oriented to self only and was typically in a pleasant mood. On 07/11/23 at 10:32 AM, the surveyor interviewed the MDS/C who stated that the SW was responsible for completing Section C and D of the MDS, however, the facility did not have a designated SW since March 2023 and the SW from the Assisted Living facility was assisting the facility during the vacancy. The MDS/C further stated that a nurse could complete Section C and D of the MDS if the SW was unavailable, and that staff interviews could be conducted to compete the sections if the resident was not able to be interviewed. The MDS/C also explained that the importance of a complete and accurate MDS was to show a clear and concise record of the resident. The surveyor and the MDS/C reviewed the aforementioned MDS assessments for Resident #22, #43, and #65 and the MDS Coordinator verified that Sections C and D should have been completed. On 07/11/23 at 12:18 PM, in the presence of the survey team, the surveyor interviewed the Director of Nursing (DON) who stated that she expected her staff to complete MDS assessments in their entirety. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual), dated October 2018, included in Section C: Cognitive Patterns, Attempt to conduct the interview with ALL residents, and, Determine if the resident is rarely/never understood . If rarely/never understood, skip to . Staff Assessment of Mental Status. Further review of the RAI Manual included in Section D: Mood, Attempt to conduct the interview with ALL residents, and, Determine whether the resident is rarely/never understood . If rarely/never understood, skip to . Staff Assessment of Mental Status. A review of the facility's MDS Coordinator Job Description revised 03/29/22, indicated that the MDS Coordinator was responsible for, the accurate and timely completion of all Resident Assessment Instrument documents as required by regulatory agencies. Conducts concurrent MDS review to assure it accurately reflects resident status and maximize reimbursements for Medicare A residents. Monitors the overall process and tracking of RAI/MDS documentation and transmission. The Coordinator will ensure timely, accurate and complete assessment of the resident's health ad functional status during the entire assessment period. He/she will integrate nursing, dietary, social recreation, restorative, rehabilitation and physician services to ensure appropriate reimbursement for Medicare/Medicaid residents. A review of the Facility's Resident Assessment Instrument (RAI) MDS Completion Policy and Procedure last approved and dated 7/11/23, indicated, The Resident Assessment Instrument otherwise referred to as the MDS shall be completed in accordance with the Rules and Regulations set forth in Section 1819(f) (6) (A_B) for Medicare and the 1919 (f) (6) (A-B) for Medicaid in the Social Security Act, As amended by the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987). The facility's Resident Assessment (RAI) MDS Completion Policy and Procedure further indicated that the MDS's purpose was an assessment tool that the facility utilized to identify resident care problems which could be addressed in the residents individualized care plan. NJAC 8:39-11.1

Based on observation, interview and record review it was determined that the facility failed to notify a representative from the Office of the State of Long-Term Care Ombudsman about a resident's emergency transfer to the hospital. This deficient practice was identified for 1 of 1 resident, (Resident #16) reviewed for hospitalization as was evidenced by the following: On 07/06/23 at 10:51 AM, during the initial tour the surveyor observed Resident #16 sitting in a wheelchair in their room. At that time, the surveyor interviewed Resident #16 who stated that he/she was doing good and had no concerns. A review of the progress note dated 04/19/23 at 21:54 (9:54 PM), reflected that Resident #16 was sent to the hospital and admitted with a diagnosis of acute urinary retention (the inability to voluntarily pass urine) and acute cystitis (bladder infection). A review of the facility's Notice of Emergency Transfer signed by a nurse dated 04/26/23, revealed that the resident was sent out to the emergency roiagnom on [DATE] for abdominal pain. A further review revealed, 1. A copy of this notice must be provided to the resident/resident representative, as well as the Office of the Ombudsman. A review of the resident's medical records and pertinent facility documents reflected that there was no documentation that a representative from the Office of the New Jersey Long-Term Care Ombudsman was notified in writing regarding the hospitalization . On 07/07/23 at 12:30 PM, the surveyor inquired about the notification of the emergency transfer to the hospital for Resident #16. At that time, the Licensed Nursing Home Administrator (LNHA) stated that the notification to the Ombudsman's office was not completed for the resident. On 07/10/23 at 10:17 AM, in the presence of the LNHA, the surveyor interviewed the Social Worker (SW) who stated that she started her position at this facility last Wednesday, 07/05/23, but had worked as a SW prior. The surveyor continued to interview the SW who stated that when a resident was transferred out to the hospital, there was an assessment that should have been filled out by social services and then sent out to the family and the Ombudsman's office. She explained the assessment form was the Notice of Emergency Transfer and that the form documented the reason for the transfer. The SW stated that it was important that the form was completed and sent to the family representative to ensure the family knew of the transfer, and to the Ombudsman's office to see if there was anything that needed to be followed up on. On 07/10/23 at 10:20 AM, the surveyor continued the interview and the LNHA stated that for a while they did not have a SW and that the facility had to utilize the Assisted Living (AL) SW. The LNHA further stated that the AL/SW had covered for three (3) months from April to June of 2023. When asked who was responsible for ensuring the notification was sent out, the LNHA stated that the SW was responsible for sending out the notifications. At that time, both the SW and the LNHA acknowledged that the notice of transfer should have been completed. On 07/10/23 at 10:44 AM, the surveyor interviewed the Registered Nurse (RN) who stated that when a resident was transferred to the hospital the form called Notice of Emergency Transfer should have been completed. She explained that with their old Electronic Medical Record (EMR) it was easier to know what needed to be completed but in November of 2022 they switched over to a new EMR and they were learning the new system and honestly forgot about it because it did not remind them that it needed to be completed like the old system. The RN stated that they started the form and gave it to the SW to be completed. She further stated that if they forgot, the SW would also remind them that it needed to be started. The RN then stated that since they did not have a full time SW for a while, they simply forgot that it needed to be done and were just reminded on Friday [07/07/23] that it should be getting done. On 07/11/23 at 12:13 PM, in the presence of the Acting Director of Nursing (DON), the Infection Preventionist (IP), the Contracted Administrator and the survey team, the surveyor interviewed the LNHA who stated that the Notice of Emergency Transfer form was completed and the family was notified but it was missed a few times and that it was not sent to the Ombudsman's office. She further stated that the SW was responsible for sending the form to the Ombudsman's office and that it should have been sent out the next day or within the next few days. The LNHA stated that the AL/SW was not educated on notifying the Ombudsman's office of the emergency transfer. The LNHA acknowledged that a notification of the emergency transfer was not sent out and that it should have been sent to the NJ Ombudsman Office. A review of the facility's, Discharge and Transfers Policy, revised 07/10/23, included, Written notice will be provided by nursing/social work to the NJ [New Jersey] OOIE (Office of the Ombudsman for the Institutionalized Elderly) of all emergency leave of absence (LOA)/transfer of residents to an acute care setting on an emergency basis. A copy of this notice must be provided to the resident/resident representative, as well as to the Office of the Ombudsman Confirmation of the fax transmission to the ombudsman shall be noted in the resident's chart .A copy of the notices for Emergency Transfers to the hospital may be sent when practicable to the office of ombudsman on a monthly basis as long as list meets requirements. List of all discharges and leave of absences must be sent to the NJ Ombudsman office monthly via fax or email by the social worker/designee of each community. NJAC 8:39-4.1(a)(32)

Based on observation, interviews, and review of facility documentation, it was determined that the facility failed to follow appropriate infection control practices for hand hygiene. This deficient practice was identified during a dining observation on 1 of 2 units, (2nd floor dining room) and was evidenced by the following: On 07/07/23 the surveyor observed the following: At 12:09 PM, a Certified Nursing Aide (CNA) in the second floor dining room was handed a plate of food at the door of the kitchenette. The CNA held the plate with her thumb on top of the plate and her fingers on the bottom of the plate and served it to Resident #61. The CNA then went to the small refrigerator in the dining room and touched the door handle, then returned to the door of the kitchenette and was handed another plate of food. The CNA held the plate with her thumb on top of the plate and her fingers were observed on the bottom of the plate. The CNA served the plate to Resident #39. The CNA then went back and opened the small refrigerator with the door handle, removed a small foil wrapped butter, unwrapped the butter and handed it to Resident #61. The CNA then asked Resident #8 for a beverage choice, went to the beverage dispenser area, grasped a plastic cup, went to the counter area where there was a metal bin of ice covered with plastic wrap, removed the plastic wrap, grasped the handle of the scoop that was resting on the ice, filled the cup with ice, replaced the scoop back on the ice, and then replaced the plastic wrap over the ice. The CNA then filled up the cup with juice from the beverage dispenser and handed the cup to Resident #8. Upon resident request, the CNA then returned to the small refrigerator, opened the door, removed coffee creamer, and placed them on the table in front of Resident #58. There was no hand hygiene observed at any time during the surveyors observations. On 07/07/23 at 12:13 PM, the surveyor interviewed the CNA who acknowledged she did not perform hand hygiene when she served the residents in the dining room. She stated that hand hygiene should have been performed before and after serving each resident their plated food or drink. The CNA further stated that it was important to perform hand hygiene between each resident to prevent cross contamination. On 07/07/23 at 12:27 PM, the surveyor interviewed the second floor Registered Nurse (RN) and informed her of the dining room observation. The RN stated that the CNA did not perform hand hygiene correctly during meal pass and that the CNA should have performed hand hygiene between each resident, when handling the butter, when touching the refrigerator handle, and any time touching plated food. The RN stated that it was important to perform hand hygiene when food was served to decrease transmission of any infection. On 07/07/23 at 12:37 PM, the surveyor interviewed the second floor Unit Manager (UM) who stated that in the dining room, the homemaker prepared and plated the meals and handed them to the CNA who delivered the meal to the residents. She stated that hand hygiene should have been performed before the meal service and in between each resident's meal pass. The surveyor informed the UM of the CNA dining room observation. The UM acknowledged that the CNA did not perform hand hygiene correctly and that she should have washed her hands between residents, when she touched the refrigerator, and that she should have worn gloves when she touched the butter for the resident. The UM stated that it was important to perform hand hygiene correctly for the safety and wellbeing of the residents and the staff. On 07/07/23 at 12:50 PM, the surveyor interviewed the Acting Director of Nursing (DON) who stated that in the dining room the homemaker plated the food, and the CNA served the residents. The DON stated that hand hygiene should have been performed in the dining room if the staff touched anything dirty before they touched anything clean. The surveyor informed the DON of the CNA dining room observation. The DON acknowledged that the CNA did not perform hand hygiene correctly and that she should have cleaned her hands after touching dirty areas such as the refrigerator handle. The DON stated that it was important to use proper hand hygiene when in the dining area for the prevention of sickness. On 07/11/23 at 12:01 PM, the Licensed Nursing Home Administrator was made aware of the 07/07/23 second floor CNA dining room observation. Review of facility documentation, Orientation Competency Checklist-Healthcare CNA, signed and dated by the CNA on 04/27/23, revealed Hand Washing Competency with return demonstration, was completed on 04/27/23, and the Dining and Serving Process with lecture/discussion, was completed on 04/28/23. The Staff Development Coordinator signed and dated the document on 5/18/23. Review of facility policy, Hand Hygiene, last revised 03/23/2023, revealed, 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. Procedure: Clean hands before and after routine resident care activities, including entering and exiting the resident care areas and after hand-contaminating activities. Hand hygiene should be done (even when gloves are used): Before and after contact with each resident. After contact with an inanimate object that is potentially contaminated. Before handling food or eating. Indications for hand antisepsis with an alcohol based hand rub: After touching a patient or the patient's immediate environment. Each associate must utilize the 5 moments of hand hygiene approach recommended to clean their hands: 5. After touching resident surroundings. NJAC 8:39-19.4 (m)(n)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide nail care to a resident that was dependent on the staff for activities of daily living. This deficient practice was identified for 1 of 2 residents, (Resident #3) reviewed for Activities of Daily Living (ADLs) and was evidenced by the following: On 07/06/23 at 11:02 AM, the surveyor observed Resident #3 lying in bed. The resident's nails were observed to be long with debris under them and nails on the right hand were observed to be broken, jagged, and unfiled. On 07/07/23 at 10:33 AM, the surveyor observed the resident lying in bed, dressed, clean and appeared comfortable. The surveyor observed that the residents nails on both hands were long, jagged and some were broken. The resident was pleasant and confused to specific details regarding time and place. The resident stated that his/her memory was not what it used to be. The resident showed the surveyor his/her hands and when the surveyor asked the resident the last time, he/she had their nails cut the resident stated that he/she did not know when the last time that their nails were cut but that they were a mess. The surveyor asked the resident if he/she would like his/her nails cut and cleaned and the resident stated, Sure. On 07/07/23 at 10:40 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) and asked the CNA if ADLs were performed for Resident #3, and she stated that ADLs were performed that morning and the resident was washed and dressed but did not want to get out of bed. The CNA then got called to another room and could not be further interviewed that that time. On 07/07/23 at 10:59 AM, the surveyor interviewed CNA #2 who stated that she had been employed through the agency and added that she worked at the facility frequently and was familiar with Resident #3. CNA #2 stated that when she performed ADLs, the resident was washed and dressed. She stated that Resident #3 preferred to wear pajamas and refused to get out of bed. She also added that the resident was incontinent and wore protective briefs for vanity and hygiene. She stated that all residents in the facility were provided with baths or showers twice a week. She stated that residents had the option of having a bath or a shower. She stated that baths were put on the schedule every morning. She further stated that CNAs cleaned the resident hands, but did not clip the nails. CNA #2 told the surveyor that the nurses do that. She explained that nails were done in activities where the residents nails were filed and painted. She stated that the staff did not touch the toenails. On 07/07/23 at 11:10 AM, the surveyor observed residents in the activities room and the Activities Assistant (AA) was filing and painting resident nails. The AA explained to the surveyor that resident nails were filed and painted every Friday by the AA in the activity room. She also stated that the AA were not allowed to cut the resident nails and that it was the responsibility of the nurses to cut the resident nails. She continued to explain that she made rounds in the morning to visit every resident in their room to find out if they needed anything. She stated at that time, she would inform the residents that she was filing and painting nails. She stated that if a resident was not able to leave their room and wanted their nails done, she would go to the resident's room and file and paint their nails. On 07/10/23 at 11:30 AM, the surveyor observed Resident #3 in bed. The resident showed the surveyor his/her hands and the residents nails continued to be long, some were observed jagged with debris under the nails. CNA #3 was in the hallway and the surveyor conducted an interview with her at that time. CNA #3 stated that the resident always had long nails however they should not be jagged or broken. The CNA went to the nurse and asked the Licensed Practical Nurse (LPN) if she could cut Resident #3's nails. The LPN stated that there was a change in the nail policy and that resident nails were not to be cut only filed. The LPN stated that the CNAs that had been caring for Resident #3 should have told the nurse that the resident's nails were broken or jagged so that the nurse could have filed them. On 07/11/23 at 10:12 AM, the surveyor attempted to telephone interview the Responsible Party (RP). There was no answer, so the surveyor left a message. On 07/11/23 at 10:16 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that she had been employed in the facility for approximately six years. She stated that nail care was part of showering or bathing, and nails care should be done on a needed basis. She stated that the nail care process included cleaning and filing of nails. She continued to add that residents' nails were a part of the ADLs that were performed daily. On 07/11/23 at 10:26 AM, the surveyor interviewed the Household Coordinator who identified herself as the lead CNA. The lead CNA stated that she saw Resident #3's nails and agreed that the nails needed to be filed and cleaned. She stated that she filed and cleaned the resident's nails as much as the resident would allow her to do. She stated that she educated the CNAs on proper nail care. She added that she would continue to check on Resident #3's nails and would file the resident's nails if the resident allowed her to do so. On 07/11/23 at 12:16 PM, the surveyor interviewed the Acting Director of Nursing (DON) who stated that resident nails should be observed daily to assure that they were clean and filed. The DON stated that residents were bathed two times a week and that their nails should have been cleaned and filed during bath time. The DON stated that she would provide the nail care policy to the surveyor. The surveyor reviewed the medical record for Resident #3. According to the Admission Record, Resident #3 was admitted to the facility with diagnoses that included but were not limited to macular degeneration (visual impairment), scoliosis (curvature of the spine), and chronic ischemic heart disease. The quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 04/24/23, indicated that Resident #3 had cognitive impairment and required extensive assistance with activities of daily living. The surveyor reviewed Resident #3's Care Plan (CP) which indicated that the resident had a self-care performance deficit related to limited mobility and cognitive deficits. The CP was initiated on 12/08/22 and was revised on 05/22/23. The CP indicated that the resident required extensive assistance with personal hygiene. On 07/12/23 at 8:52 AM, the surveyor was provided with a copy of Resident #3's CP. A further review of the care plan included an intervention for ADLs dated 07/11/23, that indicated that the resident would have their nails cleaned and filed on bath days (Monday and Thursday on the 6:00 AM - 2:00 PM shift). On 07/14/23 at 10:30 AM, the DON did not have any additional information to provide. The facility policy, Resident Nail Care, with a last revised date of 07/11/23, indicated that residents would receive nail care when needed to maintain good grooming, hygiene, and skin integrity. The policy also indicated that the purpose for nail care was to help a prevent the spread of infection, prevent bodily injury, maintain integrity of the nail and to prevent the accumulation of dirt and microorganism underneath the nail. The policy also indicated that resident nails are to be kept short and were to be inspected on bath/shower days and file the nails often. NJAC 8:39-27.1(c),27.2 (g)

C#: NJ 6 Based on interviews, medical record review, and review of other facility documents on 11/22/2021 and 11/23/2021, it was determined that the facility failed to promptly refer a resident for needed dental services within three (3) business days after the resident dentures were identified as being partially broken and document the circumstance that lead to the delay, for 1 of 3 residents reviewed (Resident #2). The facility also failed to follow its policies titled Activities of Daily Living (RS-65) and Dental Service (RS-41), and theSocial Worker -HC (Health Care) and Clerical Assistant job description. The deficient practice was evidenced by the following: Review of a facility policy dated 7/15/2021, titled Activities of Daily Living (RS-65), revealed the following: Under Procedure: included .The community will provide care and services for the following activities of daily living: . Communication, including . Making appointments, . Review of the facility policy titled Dental Service (RS-41) last revised 9/10/2019 revealed the following: Under Policy included All (facility) shall provide oral assessments and dental care to its residents. Under Purpose included .To Ensure that each (facility) has incorporated a system for ensuring proper oral assessment, dental care, and assistance in obtaining necessary dental services for the residents served. Under Procedure included .6. Each (facility) will obtain an outside dental resource or dental services to meet the needs of its residents .7. When emergency dental problems arise, the (facility) must make a referral to a dentist promptly within 3 days which includes time of onset, describe the dental problem and document . 9. The Executive Director and the Director of Nursing must be aware of all emergent dental problems or loss of dentures to ensure a dental plan of care has been implemented for the resident and that the resident has been provided prompt dental service. Review of the facility Social Worker -HC job description revealed the following: Under Position Summary revealed, The Healthcare Residence Social Worker oversees the residents, in the skilled nursing setting, by identifying their psychosocial, mental and emotional needs along with providing, developing and/or aiding in the access of services to meet those needs . Review of the facility Clerical Assistant job description revealed the following: Under: Position Summary revealed Provides clerical services to Assisted Living/Healthcare as directed by the DRL/DON. Under Essential Functions (Specific Tasks/Duties) included: .5. Schedules all resident appointments with doctors, dentists, and other professional, as well as for any diagnostic studies A review of the Electronic Medical Record (EMR) were as follows: According to the Face Sheet, Resident #2 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS), an assessment tool dated 5/19/2021, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 9/15, indicating the resident was moderately cognitively impaired. The MDS also showed the resident required extensive assistance with most Activities of Daily Living (ADLs). Review of the Care Plan Report dated 8/1/2021 through 8/31/2021, with an effective date of 3/19/2021, included under Problems: Resident #2 needed assistance with my care due to cognitive and physical limitations, under: Goals included: I will participate in my care as much as I can. Under Interventions: . I have dentures but do not fit well, I usually do not wear them . A review of the Progress Notes (PNs) dated 02/19/2021 at 1:05 p.m., written by the Registered Nurse (RN #1), revealed Resident #2 broke part of his/her upper dentures on the a.m. (morning) shift, and the broken piece was placed in the denture cup. During an interview on 11/23/2021 at 9:43 a.m., RN #1 stated she notified the Social Worker (SW) about Resident #2's dentures, and she did not recall what happened with the dentures or if the resident saw the Dentist. RN #1 further stated that the Medical Records person (Clerical Assistant) arranged the transport for dental appointments. Review of a second PN titled IDT (Interdisciplinary Team) Conference and Care Plan Review Summary dated 5/26/2021 written by the IDT Team: SW, MDS Coordinator/RN, Dietician and DON (Director of Nursing) revealed that Resident #2 was not wearing his/her dentures because they did not fit well. A review of Resident #2's PNs dated 7/16/2021 at 3:09 p.m., written by the Administrator, revealed they were in the process of getting his/her teeth addressed, .dentures had a change in fitting since the last hospitalization SW to follow up However, further review of the EMR showed Resident #2 went out to the hospital on June 9th and returned on June 25th, 2021. During an interview on 11/23/2021 with the SW at 8:57 a.m., she stated she does not handle dentures/dentist issues. The Medical Records/ Clerical Assistant person scheduled the Dentist. She further stated that the nurses told her or the Medical Records person about seeing the Dentist. During an interview on 11/23/2021 at 9:14 a.m., the Medical Records / Clerical Assistant stated she schedules transport for appointments and appointments if the Dentist comes to the facility. The Medical Records / Clerical Assistant also stated when residents were admitted , they talked to the SW and completed a Health Drive Enrollment form, it listed if they wanted dental care at the facility, and then they were added to the list for the Dentist who comes monthly for an annual exam, and problem visits. During a phone interview on 11/23/2021 at 12:45 p.m., RN #2 stated she notified the SW of Resident #2's dentures. She further stated SW was the person who reached out to the family and the Dentist to schedule an appointment. However, the RN stated she does not remember if Resident #2 was seen by the Dentist. During a second interview on 11/23/2021 at 2:00 p.m., the Medical Records/Clerical Assistant stated she did not have any records on file for Resident #2 being scheduled for the Dentist. During an interview on 11/23/2021 at 2:08 p.m., the Executive Director stated Resident #2 had to be refitted for dentures, she could recall the conversation, and the SW investigated the issue. However, she did not remember the date or if the resident saw the Dentist. During the survey, the Administrator was unavailable for an interview. At the time of the survey, there was no documentation in the EMR that Resident #2 was scheduled for a dentist appointment. The SW and the Medical Records/ Clerical Assistant were unable to provide documentation or verify that Resident #2 had a Dental appointment scheduled or saw the Dentist. N.J.A.C.: 8:39-15.1

C#: NJ 6 Based on interviews, medical record review, and review of other facility documents on 11/22/2021 and 11/23/2021, it was determined that the facility's Social Worker failed to ensure that the Health Drive Enrollment Form was competed on admission to ensure the resident received required dental services for 1 of 3 residents reviewed (Resident #2). The facility also failed to follow its policy titled Activities of Daily Living (RS-65) and the Social Worker -HC (Health Care). job description. This deficient practice was evidenced by the following: A review of the Electronic Medical Record (EMR) were as follows: According to the Face Sheet, Resident #2 was admitted on [DATE], with Diagnoses which included but were not limited to Urinary Tract Infection, Site Not Specified, Type 2 Diabetes Mellitus without Complications, Unspecified Anxiety Disorder, and Unspecified Lack of Coordination. According to the Minimum Data Set (MDS), an assessment tool dated 5/19/2021, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 9/15, indicating the resident was moderately cognitively impaired. The MDS also showed the resident required extensive assistance with most Activities of Daily Living (ADLs). Review of the Care Plan Report dated 8/1/2021 through 8/31/2021, with an effective date of 3/19/2021, included under Problems: Resident #2 needed assistance with my care due to cognitive and physical limitations, under: Goals included: I will participate in my care as much as I can. Under Interventions: . I have dentures but do not fit well, I usually do not wear them . A review of the Progress Notes (PNs) dated 02/19/2021 at 1:05 p.m., written by the Registered Nurse (RN #1), revealed Resident #2 broke part of his/her upper dentures on the a.m. (morning) shift, and the broken piece was placed in the denture cup. During an interview on 11/23/2021 at 9:43 a.m., RN #1 stated she notified the Social Worker (SW) about Resident #2's dentures, and she did not recall what happened with the dentures or if the resident saw the Dentist. RN #1 further stated that the Medical Records person (Clerical Assistant) arranged the transport for dental appointments. Review of a second PN titled IDT (Interdisciplinary Team) Conference and Care Plan Review Summary dated 5/26/2021 written by the IDT Team: SW, MDS Coordinator/RN, Dietician and DON (Director of Nursing) revealed that Resident #2 was not wearing his/her dentures because they did not fit well. A review of Resident #2's PNs dated 7/16/2021 at 3:09 p.m., written by the Administrator, revealed they were in the process of getting his/her teeth addressed, .dentures had a change in fitting since the last hospitalization SW to follow up However, further review of the EMR showed Resident #2 went out to the hospital on June 9th and returned on June 25th, 2021. During an interview on 11/23/2021 with the SW at 8:57 a.m., she stated she does not handle dentures/dentist issues. The Medical Records/ Clerical Assistant person scheduled the Dentist. She further stated that the nurses told her or the Medical Records person about seeing the Dentist. During an interview on 11/23/2021 at 9:14 a.m., the Medical Records / Clerical Assistant stated she schedules transport for appointments and appointments if the Dentist comes to the facility. The Medical Records / Clerical Assistant also stated when residents were admitted , they talked to the SW and completed a Health Drive Enrollment form, it listed if they wanted dental care at the facility, and then they were added to the list for the Dentist who comes monthly for an annual exam, and problem visits. During a phone interview on 11/23/2021 at 12:45 p.m., RN #2 stated she notified the SW of Resident #2's dentures. She further stated SW was the person who reached out to the family and the Dentist to schedule an appointment. However, the RN stated she does not remember if Resident #2 was seen by the Dentist. During a second interview on 11/23/2021 at 2:00 p.m., the Medical Records/Clerical Assistant stated she did not have any records on file for Resident #2 being scheduled for the Dentist. During an interview on 11/23/2021 at 2:08 p.m., the Executive Director stated Resident #2 had to be refitted for dentures, she could recall the conversation, and the SW investigated the issue. However, she did not remember the date or if the resident saw the Dentist. At the time of the survey, there was no documentation in the EMR that Resident #2 was scheduled for a dentist appointment. The SW was unable to provide the Health Drive Enrollment form or verify that Resident #2 had a Dental appointment scheduled. Dentist. Review of a facility policy dated 7/15/2021, titled Activities of Daily Living (RS-65), revealed the following: Under Procedure: included .The community will provide care and services for the following activities of daily living: . Communication, including . Making appointments, . Review of the facility Social Worker -HC job description revealed the following: Under Position Summary revealed, The Healthcare Residence Social Worker oversees the residents, in the skilled nursing setting, by identifying their psychosocial, mental and emotional needs along with providing, developing and/or aiding in the access of services to meet those needs . N.J.A.C.: 8:39-27.1 (a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 5/17/2021 from 9:51 AM to 10:36 AM, the surveyor, accompanied by the Executive Chef (EC) and Food Service Director (FSD), observed the following in the kitchen: 1. The fan in the dry storage room has a substantial buildup of what appeared to be dust on the external wire frame that encloses the fan blade. The fan faces a box that contained plastic forks used for resident meals. The surveyor held their hand in front of the fan and determined that the fan was blowing in the direction of the box of plastic forks and the fan was blowing onto the cutlery boxes on the top shelf of a multi-tiered storage rack. 2. The fan in the dish room had an excessive dust buildup on the metal grill surrounding the fan blade. The fan was determined to blow air in the direction of the dry rack that contained cleaned and sanitized dishware, potentially contaminating the cleaned and sanitized dishware. On interview the FSD stated, Yeah they're dirty, we'll get them cleaned right away. 3. (2) stacks of cleaned and sanitized plates used to serve resident meals were on a middle shelf of the drying rack in the dish room. The plates were not stored in the inverted position and were exposed with the fan blowing. On interview the FSD stated, I think they were in transition between tasks and forgot to invert them. We will have them re-cleaned. 4. During observation of the milk box, the surveyor, EC and FSD were unable to find an internal thermometer to determine the internal refrigerated temperature. A review of the milk box temperature log revealed that the recorded AM temperature for the milk box on 5/17/2021 was 36 degrees Fahrenheit. The EC removed several crates of milk boxes and was unable to find an internal thermometer. The EC stated, Let me go get a new one (internal thermometer). 5. On a lower shelf of the pot drying rack, a stack of approximately 9 full baking pans were stacked on top of each other. The surveyor lifted the top pan and observed that the pan below was wet to the touch (wet nesting). This was also felt by the FSD. The FSD stated, They're wet. The FSD instructed the EC to rewash the baking pans. 6. In the Chef's prep area, a box of Plastic Food Wrap was observed on top of a prep counter. The lid had been removed from the box and the plastic wrap was exposed. A second box of Plastic food wrap was also opened and had the cardboard lid removed, exposing the plastic wrap on an additional work top next to the steamers. On interview the FSD stated, I guess they are exposed but it would only be the top of the plastic wrap and shouldn't touch the food. The surveyor reviewed a facility policy titled Washing Pots and Pans, with an updated date of 4/2006. Under the Activity 1 heading, the answer key defined the following six steps of cleaning and sanitizing pots, pans, other equipment, and utensils in a three-compartment sink. Step 1: Prepare the pot washing area. Step 2: Pre-rinse, scrape or soak. Step 3: Wash. Step 4: Rinse. Step 5: sanitize. Step 6: Air dry. In addition, under Activity 2 at #6 the following was revealed: 6. Air-dry all items; never use towels or aprons for drying. Remind employees to stand cutting boards and sheet pans upright and apart for quick drying. Never stack wet pots and pans on storage shelves. The facility did not provide a policy/procedure pertaining to a cleaning schedule for the fans in the kitchen, use of internal thermometers or protecting the plastic wrap from exposure to contamination. NJAC 8:39-17.2 (g)

COMPLIANT: NJ 9 Based on observation, interview, and review of facility provided documentation on 4/26/2021, it was determined that the facility failed to maintain its hot water Baseboard Heating Units in a safe and optimal working condition for 3 of 8 rooms (Room #202, 215 and 218) reviewed for temperatures. This deficient practice was evidenced by the following: During a tour of the second and third floor on 4/26/2021 in the presence of the Director of Environmental Services (DES), the surveyor inspected 8 rooms and identified the Baseboard Heating Units were not functioning as follows: 1. At 12:40 p.m., the surveyor observed Room #202 Baseboard Heating Unit (BHU) was missing the high, medium, and low fan speed control buttons. The BHU had a toggle switch installed in place of a temperature control knob. There was no temperature adjusting control turn knob, and this BHU had no means to control the fan speed. During Room #202 tour, the DES stated that the high, medium, and low buttons control the fan speed. The DES also stated that the toggle switch was installed to replace a temperature adjusting knob. The DES explained when the toggle switch is in the on position, it is full heat, and when the switch is turned off, there is no heat. 2. At 12:45 p.m., the surveyor observed Room #215, the BHU was missing the high, medium, and low fan speed control buttons. This unit had no temperature adjusting control turn knob. This BHU had no means to control the heat or fan speed. 3. At 12:58 p.m., the surveyor observed Room #218, the BHU was missing the high, medium, and low fan speed control buttons. This unit had no temperature adjusting control turn knob. The unit had a toggle switch to provide either heat or no heat. This BHU had no means to control the fan speed. There were no means to control the temperatures and the amount of air movement in the rooms. The facility failed to maintain its heating equipment in proper working conditions. N.J.A.C. 8:39 -31.2 (e).

Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 7/30/19 from 8:07 AM to 9:05 AM, the surveyor observed the following in the presence of the of the Dining Services Director (DSD) and Executive Chef (EC): 1. In the dry storage area on a multi-tiered rack, two cans of prunes were dented. The DSD removed the cans to the designated dented can area. 2. The surveyor observed the EC perform handwashing at the designated hand washing sink. The EC proceeded to wet hands under running water, applied soap and washed hands vigorously for 10 seconds. The EC then proceeded to turn off faucet with bare hands prior to grabbing a hand towel. The EC then proceeded to dry hands with the hand towel and threw the towel into the trash receptacle. A poster on the wall at eye level and to the right of the handwashing sink indicated that hands were to be washed for at least 15 seconds. The surveyor reviewed the facility policy titled Hand Hygiene (RS-26), last revised 7/2/2019. The Purpose noted the following: 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. In addition, To educate staff in proper hand washing technique. Under the Procedure section the policy stated the following: 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. The policy further stated, Rinse hands thoroughly under running water keeping hand downward, avoid touching the sink. Dry hands thoroughly with paper towel(s). Hands that are not dried properly can become dry and cracked, leading to an increased risk of harboring microorganisms. Turn off faucet with a clean paper towel. Discard paper towel. 3. In the walk-in refrigerator on a lower shelf, a 1/4 pan contained a raw salmon filet wrapped in clear plastic wrap. The salmon filet had a open date of 7/23/19. The salmon had a use by date of 7/25/19. The EC stated, that was a birthday meal, the resident didn't come down so we didn't use it. The EC threw it in the trash. On interview the EC stated, I am responsible for monitoring the use by dates. 4. On a shelf, in the outside walk-in freezer, a frozen Chef Pierre pie had a use by date of 5/8/19. The EC threw the pie in the trash. 5. Observation of the hot table/steam service table revealed the splash guard was splattered with an unidentifiable, brown food debris, along the interior length of the splash guard. The surveyor interviewed the EC in regards to how often the hot table/steam service table was cleaned. The EC stated, This is our hot serving area. We try to clean it as often as possible, usually once a week. It's dirty, fair enough. On interview 7/30/19 at 9:22 AM the EC stated, Listen, this is what we do. We look around and if something looks dirty we clean it. We don't have a daily cleaning schedule in place. The surveyor reviewed the facility procedure titled Labeling & Dating Procedure, undated. The procedure did not indicate what the facility is to do with food products that are past their use by date. NJAC 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 8:29 AM to 9:17 AM, the surveyor observed the following in the kitchen in the presence of the Dining Services Director (DSD) and Executive Chef (EC): 1. In the walk-in refrigerator, there were two previously opened containers of sour cream on a shelf that were dated [DATE] and [DATE]. The DSD stated, We throw it away after 3 days. 2. Located on a shelf, a container of nectar thickened cranberry juice was opened had an unidentifiable brown substance on the cap. The juice was labeled with a received date on [DATE]. No use by date was noted on the container. 3. Located on a shelf, a plastic bag of shredded orange cheddar cheese was opened and not dated. On the same shelf, an opened bag of mozzarella cheese was labeled with a use by date of [DATE]. 4. A plastic bin on a shelf, contained four (4 ounce) cartons of fat free milk that were labeled with an expiration date of [DATE]. 5. Located on an upper shelf, a tray contained individually portioned containers of tartar and cocktail sauce that was labeled with a use by date of [DATE]. The EC removed them from storage. 6. Located on a shelf, there were two ¼ pans. One of the pans contained sliced tomatoes and the other contained lettuce. Both containers were undated. The EC removed them from storage. 7. Located on a shelf, a plastic bag that contained carrots was labeled with a use by date of [DATE]. On the same shelf, an opened bag of romaine lettuce was not labeled with received or use by dates. The EC removed both items from storage. 8. Located on a shelf, a plastic container of diced celery was not labeled with a received or use by date. 9. Located on a shelf, a ,[DATE] pan of chicken gravy contained a use by date of [DATE]. The EC stated, I'll throw that away. Located on the same shelf, a four-inch half pan contained ricotta cheese and had a use by date of [DATE]. The EC stated, That should have been thrown away. 10. During observation of the high temperature dish machine, the surveyor observed wash temperatures of 154 and 152 degrees Fahrenheit on consecutive trials. The machine data plate indicated that the temperature requirement for the wash was 160 degrees Fahrenheit. According to the facility document entitled, Form# ,[DATE] (revised ,[DATE]), on [DATE] at the breakfast meal period, the machine wash temp was recorded at 165 degrees Fahrenheit. The DSD then proceeded to test the wash tank temperature manually and determined that wash tank water temperature was 167 degrees Fahrenheit. The DSD stated that he would immediately contact the Ecolab service representative to have the dish machine serviced due to a suspected improperly functioning wash temperature gauge. The DSD provided the surveyor with a service invoice dated [DATE], which revealed that an element in the machine was replaced due to it having a bad leg, after such, the temperature remained constant. On [DATE] the DSD provided the surveyor with an additional Ecolab service invoice dated [DATE] which revealed that the machine required replacement of a missing rod for short curtain and replaced blue tube between wash arm and pump assembly, Adjusted wash thermostat, added vent dampeners and replaced rinse gauge. 11. A wall at the opening of the dish room area that was adjoined with the dirty dish counter contained a thick buildup of a blue substance that the DSD identified as pre-soak solution. The DSD further stated that the pre-soak solution splashed onto the wall when poured by Food Service Worker (FSW) which had caused the paint to peel away from the wall. On [DATE] from 10:21 AM to 10:52 AM the surveyor observed the following in the kitchen in the presence of the DSD: 12. Upon entry to the kitchen, a food service worker (FSW) was observed with a hair net that only partially covered their hair, allowing the front ,[DATE] of hair to be exposed. 13. In the walk-in freezer located on a shelf, 2 bags of frozen green beans had been removed from their original container and were not dated. 14. On a lower shelf, a large clear plastic bag containing Kaiser rolls was undated. 15. Located on a shelf, 3 frozen pies removed from their original container had no dates. On [DATE] from 11:55 AM to 12:05 PM, the surveyor observed the following in the Healthcare 3 Unit refrigerator in the presence of the DSD: 16. Seven containers of cherry flavored gelatin had an expiration date of [DATE]. 17. Four containers of vanilla pudding had an expiration date of [DATE]. 18. A total of eight dairy drink nectar thickened beverages were expired. Six cartons contained an expiration date of [DATE] and two cartons had an expiration date of [DATE]. The DSD discarded them all. The surveyor reviewed the facility's policy titled, Food Safety Product Labeling & Dating Guide-US (Revised ,[DATE]) which revealed the following labeling requirements: Date cartons, cases, boxes, etc., with date received (Not needed, if products remain in master cases already dated by manufacturer.) Further review of the policy indicated that product storage labeling for storing prepared food must include: Name of product (unless clearly identifiable) and date of preparation and/or use-by date. The surveyor reviewed the facility policy, Grooming and Appearance Standards (HR-14) (Last Revised [DATE]), which noted the following: Associates who handle food must confine their hair by wearing a hair net or hat issued by their supervisor and according to applicable health department standards. NJAC 8:,[DATE].2(g)

Based on observation, interview and record review, it was determined that the facility failed to implement identified safety measures for 2 of 6 residents reviewed for falls, Resident #1 and #5. Resident #1 fell on [DATE] and required 2 sutures for a facial laceration; and again on 6/19/16, and sustained a fractured nose. This deficient practice was evidenced by the following: 1. The surveyor reviewed the medical record of Resident #1 on 7/19/16 at 10 a.m. which revealed the resident had [DIAGNOSES REDACTED]. On 7/21/16 at 9:30 a.m., the Certified Nurses Aide (CNA) told the surveyor that the resident had a history of [REDACTED]. Further review of the medical record revealed that Resident #5 was assessed on the Initial 2/5/16 and Quarterly 5/6/16 Minimum Data Set ( MDS), an assessment tool as moderately impaired- decisions poor; cues/supervision required and had a severe cognitive impairment. Review of the 2/5/16 and 5/6/16 MDS' revealed that Resident #5 was assessed as requiring limited assistance of one person for bed mobility and transfers. The resident was non-ambulatory and utilized a wheelchair for mobility. The surveyor reviewed Residents #1 Care Plan which revealed on 6/1/16, Resident #1 was identified as being at risk for falls related to a history of falls, agitation and no safety awareness. Review of interventions for the risk of falls included but were not limited to: Ensure floor mat is next to bed when the resident is in bed; All transfers via Hoyer lift with assistance of 2; Side of bed against the wall with plugs inserted in outlets; Resident out of bed daily to a high back wheelchair with bilateral leg rests and a cushion under his buttocks for comfort and pressure reduction; and Lay resident down for a nap when he/she appears restless, Generally after meals. The surveyor observed Resident #1 on 7/19/16 at 9:30 a.m. sitting in the hallway in front of the nurses station in his/her high-back wheelchair. The resident was observed to have a seat cushion and a calf pad and a pillow under his/her legs. Review of the facility's Occurrence Reports (OR)/fall investigation reports revealed that from 4/6/16 to 6/24/16 the resident sustained [REDACTED]. A). On 4/6/16 at 22:16 (10:16 p.m.) the resident was found on the floor in his/her bedroom laying on the right side. The injury sustained was an old scab that reopened. According to the OR, the bed was not in the lowest position and the floor mat was not in place. B). On the above mentioned date and time, the surveyor reviewed an Occurrence Report (OR) dated 6/17/16 at 17:25 (5:25 p.m.), which revealed that Resident #1 fell from the wheelchair while seated in front of the nursing station. The OR indicated that the resident was found on the left side with a large amount of blood from Left temple. The OR also indicated that Resident #1 complained of pain and had sluggish pupils. The resident was sent to the emergency room for evaluation and returned with 2 sutures to the left side of the face. C). The OR dated 6/19/16 that indicated Resident #1 had a fall from the wheelchair on 6/19/16, two days after the previous fall, and sustained a fractured nose and a two inch laceration over the eye brow. The OR Conclusion completed by the Director of Nurses (DON) revealed that the Resident's feet got caught under the wheelchair and (he/she)fell forward. In the conclusion of the facility's investigative report, it was noted by the Director of Nurses' (DON), that Resident #1's wheel chair did not have the leg rests on. A review of a CNA witness statement revealed that the resident leaned forward then fell face first onto the floor. C). On 6/24/16 at 7:30 a.m., the nurse was called out to the hallway by another resident's family member and was informed that the resident was on the floor in the hallway. The resident was observed lying on his/her right side in front of the wheel chair. No apparent injury was documented. According to the OR, prior to the fall the resident was sitting in the wheelchair. In addition, the OR reflected, After the resident was repositioned in the w/c (wheel chair) the resident was observed trying to scoot self out of the chair. The resident was reminded to call for assistance. The Follow-up Report indicated all appropriate interventions were in place. There were no fall interventions added to Resident #1's Care Plan. 2. The surveyor reviewed the admission record of Resident #5 on 7/21/16 at 9:30 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The surveyor reviewed Resident #5's care plan that revealed on 2/1/16, the resident was identified to be At risk for falls related unsteady gait and history of multiple falls prior to admission; poor safety awareness. Interventions for fall risk included but were not limited to: Keep areas free of obstruction to reduce the risk of falls or injury; Place call bell/light within easy reach; Remind (resident) to call for assistance before moving from bed-to-chair and from chair-to-bed; Respond promptly to calls for assist to the toilet; Make sure (resident) is wearing non-skid footwear/non-skid socks; Keep resident up until he/she is ready to go to bed. On 7/21/16 at 1:30 p.m., the resident was observed out of bed to wheelchair in the hallway near his/her room. Review of fall investigation reports that were provided by the facility revealed that from 2/19/16 to 6/14/16, the resident sustained [REDACTED]. A review of the facility's Occurrence (OR)/fall investigation reports revealed the following incidents: A). On 2/19/16 at 8:20 p.m., Resident #5 was heard calling out. The resident was found sitting on the floor between two beds in the resident's room facing the wall holding on to the side rails of the beds. The resident stated that he/she was trying to get into bed, pointing to his/her roommates bed. The section of the investigation report under Conclusion noted Resident is not to be left in (his/her) room until staff is able to assist into bed. Keep at nurses station or in an activity. Wheelchair was locked. Review of the resident's care plan revealed that the intervention was not implemented until it was updated three days later on 2/22/16. B). On 3/10/16 at 2:40 p.m., the resident was observed sitting on the floor in his/her room. The resident stated I was trying to get to the wheelchair and slid of of bed. Review of the Conclusion revealed Staff to assist (resident) into his/her wheelchair after his/her afternoon nap. Review of the care plan revealed that the intervention was implemented five days later. C). On 3/20/16 at 8 a.m., the resident was found sitting on his/her buttocks in front of his/her bed. Resident #5 stated at that time missed the wheelchair, wanted to transfer to wheelchair. Review of the Conclusion revealed Continue with current plan of care. Ongoing education to resident regarding the need to call for assistance prior to transferring; already on care plan. The resident's care plan was not further revised. D). On 4/4/16 at 7:30 p.m., the resident was witnessed transferring from bed to wheelchair and fell on to the floor. The resident sustained [REDACTED]. Resident was reminded to call with call bell for assistance. Review of the Conclusion revealed Staff to keep (resident) up until he/she is ready for bed. He/she takes an afternoon nap and may not be ready to go to bed until later in the evening. There was no documented evidence that the causal factors of the fall were determined, or the resident's care plan was updated and/or revised after the 4/4/16 fall. E). On 4/18/16 at 6:20 p.m., the resident was sitting on floor by the side of the bed with his/her head against side rail. The Resident stated that he/she was transferring to bed and got dizzy and fell . Review of the Conclusion revealed Staff review of care plan; resident is not to be in room until ready for bed. Keep at nurses station or in activities. Review of the care plan revealed that the above intervention was developed on 2/22/16. The care plan was not updated and/or revised after the 4/18/16 fall. F). On 5/9/16 at 1:30 p.m., the resident was found sitting on the floor next to bed; was previously in wheelchair. Resident stated he/she wanted to take a nap and fell . Review of the Conclusion revealed Resident to be assisted to bed for nap after lunch. Review of the care plan revealed that this intervention was implemented on 5/23/16 which was 14 days after the 5/9/16 fall. G). On 5/11/16 at 1:00 p.m., Resident #5 was observed sitting on the floor. The resident stated he/she wanted to go to bed. Review of the Conclusion revealed Resident to be assisted to bed after lunch for a nap. Review of the care plan revealed that this intervention was implemented on 5/23/16 which was 12 days after the 5/11/16 fall. H). On 5/21/16 at 1:30 p.m., the resident was lying on the floor on their right side between the bed and the wheelchair. The resident told the staff that he/she was trying to go from his/her bed to the wheelchair and lost his/her balance. Instructed resident to call for assistance before attempting to transfer self. Resident shown how to use call bell. Review of Conclusion revealed Resident was referred to therapy. Staff is to follow resident as he/she exits the dining room after lunch and anticipate his/her wanting to lay down. Review of the care plan revealed that the intervention was implemented on 5/24/16 which was 5 days after the 5/21/16 fall. I). On 5/31/16 at 2:15 p.m., the resident was found sitting on the floor in his/her room. Review of the Conclusion revealed Resident continues on therapy caseload. A floor mat has been added to his/her care plan. There was no evidence that the care plan intervention developed on 5/23/16, was not followed. J). On 6/6/16 at 4:20 p.m., the resident was found sitting on the floor next to the bed by a family member of another resident. Review of the Conclusion revealed Resident is currently on therapy caseload. Anti-roll backs will be added to his/her wheelchair. New goal will be for no injuries to be sustained. Review of the care plan revealed an absence of dates to indicate when this intervention was added. K). On 6/14/16 at 10:30 a.m., the resident was found sitting on his/her buttocks. Previous to this fall the resident was in his/her wheelchair. The resident stated that he/she wanted to go to bed. Review of the Conclusion revealed Continue with plan of care. Remains on therapy caseload. Again, the implementation of the care plan was not followed. L). On 6/14/16 at 6:05 p.m., while attempting to self transfer to bed, the resident did not lock the wheels on the wheelchair. Review of theConclusion revealed On therapy caseload for wheelchair management. Anti-roll backs ordered for his/her wheelchair. On 7/21/16 at 1:10 p.m., the CNA told the surveyor that the resident was unable to consistently utilize the call bell to call for assistance, due to poor decision making ability. On 7/22/16 at 9:30 a.m., the Director of Nursing (DON) stated that measures to increase supervision were needed. NJAC 8:39-27.1

Based on observation, interview and record review, it was determined that the facility failed to implement and/or revise interventions to address the safety of residents who were identified at risk for falls. This deficient practice was identified for Resident #1 and #5, 2 of 6 residents reviewed for falls. Resident #1 fell on ,[DATE] and 6/19/2016 and sustained a fractured nose and a facial laceration requiring sutures. This deficient practice was evidenced by the following: 1. The surveyor reviewed the medical record of Resident#1 on 7/19/16 at 10 a.m. which revealed the resident had a [DIAGNOSES REDACTED]. Review of the resident's initial Care Plan dated 6/12/15, indicated that Resident #1 was at risk for falls r/t (related/ to) a history of falls and agitation; no safety awareness. The surveyor reviewed interventions for the risk of falls that included, but were not limited to: Ensure floor mat is next to bed when the resident is in bed; All transfers via Hoyer lift with assistance of 2; Side of bed against the wall with plugs inserted in outlets; Resident out of bed daily to a high back wheelchair with bilateral leg rests and a cushion under buttocks for comfort and pressure reduction; and Lay resident down for a nap when he/she appears restless. generally after meals. The responsible staff, per the care plan, were the Certified Nurse's Aides (CNAs) and nursing. On 7/18/16 at 11 a.m., the surveyor observed Resident #1 sitting in the hallway in front of the nurse's station, in a high back wheelchair with leg rests on, and a seat cushion and a calf panel/pad under his/her legs. On the above mentioned date and time, the surveyor reviewed an Occurrence Report (OR) dated 6/17/16 at 17:25 (5:25 p.m.), which revealed that Resident #1 fell from the wheelchair while seated in front of the nursing station. The OR indicated that the resident was found on the left side with a large amount of blood from Left temple. The OR also indicated that Resident #1 complained of pain and had sluggish pupils. The resident was sent to the emergency room for evaluation and returned with 2 sutures to the left side of the face. The Follow-up Report, dated 6/27/16, indicated All current interventions were in place. Remains on therapy caseload to determine appropriate and safest seating arrangement. The Follow-up Report also noted that No staff interviews were available and, under the heading of 'Recommendations', None Noted. There was no evidence of documentation in the OR or the Follow-Up Report, of how the resident fell from the wheelchair. The surveyor reviewed the OR dated 6/19/16 that indicated Resident #1 had a fall from the wheelchair on 6/19/16, two days after the previous fall, and sustained a fractured nose and a two inch laceration over the eye brow. The OR revealed that the Resident's feet got caught under the wheelchair and (he/she)fell forward. In the conclusion of the facility's investigative report, it was noted by the Director of Nurses' (DON), that Resident #1's wheel chair did not have the leg rests on. A review of a Certified Nursing Assistant (CNA) witness statement revealed that the resident leaned forward then fell face first onto the floor. In addition, the resident's care plan was not revised after the fall and reflected staff were re-educated on the resident's plan of care. On 6/22/16 (3 days later) the care plan was updated to reflect resident was to be out of bed to a high back wheelchair kneed (sic - knee) pommel, neck cushion and calf pad added to chair for positioning. A review of an OR dated 6/24/16 at 15:13 (3:13 p.m.), reflected the nurse was informed by a family member that the resident was on the floor in the hallway, laying on his/her right side, in front of his/her wheelchair. No apparent injury was documented. After the resident was repositioned in the wheelchair, the resident was observed inching his/her body forward in the wheelchair. The resident was reminded to call for assistance. Review of the conclusion portion of the OR revealed all appropriate interventions were in place. No injuries. Resident continues on therapy caseload. The 'Root Cause' of the OR indicated that the fall was, Due to residents action or internal risks factors. There was no evidence that the resident's careplan was updated. 2. The surveyor reviewed the medical record of Resident #5 on 7/21/16 at 9:30 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. Further review of the medical record revealed that Resident #5 was assessed on the Initial 2/5/16 and Quarterly 5/6/16 MDS, as moderately impaired- decisions poor; cues/supervision required. Review of the 2/5/16 and 5/6/16 MDS' revealed that Resident #5 was assessed as requiring limited assistance of one person assistance for bed mobility and transfers. The resident used a wheelchair for mobility. On 7/21/16 at 1:30 p.m., the resident was observed out of bed to wheelchair in the hallway, near his/her room. The surveyor reviewed the Care Plan of Resident #5, which revealed that on 2/1/16, the resident was identified to be At risk for falls related unsteady gait and history of multiple falls prior to admission; poor safety awareness. Interventions for fall risk included but were not limited to: Keep areas free of obstruction to reduce the risk of falls or injury; Place call bell/light within easy reach; Remind (resident) to call for assistance before moving from bed-to-chair and from chair-to-bed; Respond promptly to calls for assist to the toilet; Make sure that (Resident #5) is wearing non-skid footwear/ non-skid socks; and Keep resident up until (he/she) is ready to go to bed. Review of fall investigation reports that were provided by the facility revealed that from 2/19/16 to 6/14/16, the resident sustained [REDACTED]. A.) Further review of the fall investigation dated 2/19/16 revealed that the resident was observed sitting on the floor between two beds. The investigation revealed that the resident stated he/she was trying to get into bed. Review of the At risk for falls care plan dated 2/1/16, revealed that the care plan was updated on 2/22/16, (3 days later) with an intervention stating Resident is not to be left in (his/her) room until staff is able to assist (him/her) into bed. Keep at the nurses station or in an activity program. B.) Review of the 3/10/16 fall investigation revealed that the resident was observed on the floor sitting on his/her bottom. The resident stated they were trying to get to wheelchair and slid out of bed. Review of the resident's care plan related to falls revealed that the careplan was updated on 3/15/16, 5 days after the fall, and indicated that Staff to assist (Resident #5) up into his/her chair after his/her afternoon nap. C.) The resident fell on [DATE] at 8 a.m. The fall investigation indicated Resident #5 stated he/she missed the wheelchair when attempting to get out of bed. The facility's fall investigation indicated that the current care plan interventions would continue and Resident #5 was to call for assistance. D.) Resident #5 fell again on 4/4/16 at 7:40 p.m. while transferring from bed to wheelchair. The resident fell on to their buttocks and sustained 3 small bruises. There were no added care plan interventions. The Follow-up Report dated 3/24/16 indicated, ongoing education to resident regarding the need to call for assistance prior to transferring; already on care plan. E.) The resident again fell on [DATE] at 6:20 p.m. while attempting to transfer self to bed. The facility's conclusion reflected resident is not to be in room until ready for bed. There was no documentation that indicated the facility staff implemented the care plan intervention dated 2/22/16 of not to leave the resident alone in the room and to assist the resident to bed. F.) At 1:30 p.m. on 5/9/16, Resident #5 fell from the wheelchair attempting to go to bed. The Follow-up Report dated 5/23/16 (14 days after the fall) indicated, Resident to be assisted to bed for nap after lunch. The care plan was updated to reflect this intervention on 5/23/16 (14 days later). G.) On 5/11/16 at 1 p.m., the resident fell from the wheelchair. The resident stated he/she wanted to go to bed. The Follow-up Report dated 5/23/16 (12 days after the fall) indicated, Resident to be assisted to bed for nap after lunch. H.) On 5/21/16 at 1:30 p.m. the resident fell from bed to wheelchair. The Follow-up Report of 5/24/16 indicated resident was referred to therapy and staff were to follow the resident when exiting dining room after lunch. Resident #5 had 3 similar falls (5/9, 5/11, 5/21) before the care plan was updated. I.) Review of the 5/31/16 fall (4:15 p.m.) investigation revealed that the resident was observed sitting on the floor in his/her room. A review of the care plan reflected that a floor mat was added on 6/1/16. The resident's care plan was evaluated on 6/1/16. The evaluation included that Resident #5 continued to attempt independent transfers resulting in falls. Staff now report that (he/she) gets (his/her) feet caught between one another. Goal remains for decreased falls and no injury. There was no documented evidence that an intervention was added to the care plan to address this issue. J.) On 6/6/15 at 4:15 p.m. Resident #5 fell in the bedroom while attempting to transfer independently. Anti-rollbacks were added to the wheelchair. There was no documentation that reflected care plan interventions were implemented. A 6/13/16 care plan evaluation note indicated that Resident #5 will continue to fall due to (his/her) poor safety awareness and impulsivity. Current interventions remain appropriate. K.) Resident #5 fell at 10:30 a.m. on 6/14/16 while independently transferring from wheelchair to bed. The care plan was not updated to reflect new interventions. L.) Resident #5 fell again on 6/14/16 at 6 p.m., again attempting to independently transfer from wheelchair to bed. No interventions were added to the careplan and there was no documentation that care plan interventions were implemented. On 7/21/16 at 1:10 p.m., the Certified Nurses Aide (CNA) told the surveyor that due to the resident's poor decision making abilities, the resident was unable to consistently utilize the call bell to call for assistance. On 7/22/16 at 9:30 a.m., the Director of Nursing (DON) told the surveyor that measures to increase supervision were needed. The DON was unable to state how the supervision would be provided. Review of the Policy provided by the facility, titled Fall Prevention and Management, under the Skilled Nursing section revealed: 6. The fall preventive measures implemented in the EMR and care plan shall be initiated and documented. and 7. Document resident's response to these interventions shall be initiated and documented. NJAC 8:39-27.1(a)

Complaint # NJ Based on interviews, review of personnel files, and pertinent facility documentation on 7/6/16, it was determined that the facility failed to consistently follow their own policy titled, Abuse Prevention/Accidents, Incidents for 1 of 5 sampled residents (Resident #3) that sustained an injury. In addition, the facility failed to consistently follow their own policy titled, Performance Evaluation for 1 of 2 Registered Nurses (RN #1). This deficient practice is evidenced by the following: 1. According to the Face Sheet, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), an assessment tool dated 3/8/16, indicated that the resident was cognitively impaired and required assistance with activities of daily living (ADLs). The Clinical Notes Report dated 4/29/16, indicated that Resident #3 received a skin tear at 11:30 p.m. to the left upper forearm; that measured 4 X 0.5 centimeters (cm). The resident hit his arm on the radiator in the bedroom. There were no complaints of pain. The nurse cleaned the area with Normal Saline Solution (NSS), applied 3 steri-strips, [MEDICATION NAME], an [MEDICATION NAME] dressing, an abdominal pad, and a stretch conforming gauze to the area. There was no incident report created after the injury on 4/29/16. There was no documentation indicating that the physician, or responsible party were notified of the injury on 4/29/16. On 7/7/16 at 3:41 p.m., the surveyor received a faxed letter from the Administrator, indicating that the facility was unable to locate an incident report for the skin tear that Resident #3 had on 4/29/16. An interview was conducted by the surveyor on 7/6/16 at 2:15 p.m., with the Director of Nursing (DON). The DON stated that an incident report was not completed for the skin tear that Resident #3 received on 4/29/16. 2. A review of RN #1's personnel file showed the date of hire as 3/31/15. There were no performance evaluations in the personnel file. The surveyor conducted an interview on 7/6/16 at 1:15 p.m., with the DON. The DON stated that the Administrator was responsible for completing the performance evaluation for RN #1. On 7/7/16 at 3:41 p.m., the surveyor received a letter from the Administrator that stated the facility was unable to locate the performance review for RN #1. The facility policy titled, Abuse Prevention/Accidents, Incidents included but was not limited to: Definition of accident/incident: Any unusual event or circumstance that is not consistent with the normal routine of the community, its staff, visitors, etc .Procedure/Responsibilities: 1 .Nursing observations, such as skin tears or hematomas, will also be considered unusual occurrences .An Incident/Accident Report will be completed by the involved staff member to record all actions taken. State all information about the incident; the extent of the injury, who was notified, what interventions were implemented to address the incident, and when they were implemented. The facility policy titled, Performance Evaluation, included but was not limited to: Formal performance evaluations shall be conducted at a minimum annual basis from the associate's hire date .Managers are held accountable for completing the performance review no later than two (2) weeks beyond the due date, or performance counseling for the manager may result .The Associate Resource Director (ARD) and the Executive Director at each community with support of Home Office Vice President of Human Resources is responsible for the implementation and communication of this policy. There was no evidence that the policy was consistently followed. NJAC 8:39-9.3(a)2

Complaint # NJ Based on interview, review of personnel files, and pertinent facility documentation on 7/6/16, it was determined that the facility failed to consistently ensure that the performance evaluation was completed every 12 months for 1 of 1 Certified Nurse Assistants (CNA#1). This deficient practice is evidenced by the following: 1. A review of CNA #1's personnel filed showed the date of hire as 10/4/10. The annual performance evaluation was dated 1/28/15. There were no current annual performance evaluations in the personnel file. The surveyor conducted an interview on 7/6/16 at 1:15 p.m., with the Director of Nursing (DON). The DON stated that the DON was responsible for ensuring that the annual performance evaluations were completed. The DON further stated that the facility was in the process of transferring the performance evaluations to a computer system. On 7/7/16 at 3:41 p.m., the surveyor received a letter from the Administrator that stated the facility was unable to locate the current annual performance evaluation for CNA #1. The facility policy titled, Performance Evaluation, included but was not limited to: Formal performance evaluations shall be conducted at a minimum annual basis from the associate's hire date .Managers are held accountable for completing the performance review no later than two (2) weeks beyond the due date, or performance counseling for the manager may result .The Associate Resource Director (ARD) and the Executive Director at each community with support of Home Office Vice President of Human Resources is responsible for the implementation and communication of this policy. There was no evidence that the policy was consistently followed. NJAC 8:39-43.17(b)

Complaint # NJ Based on the review of the medical records, and pertinent facility documents on 7/6/16, it was determined that the facility failed to notify the responsible party and physician when 1 of 5 sampled residents (Resident #3) fell and/or sustained an injury. This deficient practice is further evidenced by the following: 1. According to the Face Sheet, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), an assessment tool dated 3/8/16, indicated that the resident was cognitively impaired and required assistance with activities of daily living (ADLs). The Occurrence Report dated 4/22/16, indicated that Resident #3's alarm sounded and the resident was found sitting up on the floor; parallel to the bed, with his hands on the floor. The Occurence Report dated 4/22/16, did not specify the type of alarm.The Fall Type section of the Occurrence Reportdated 4/22/16, indicated that the resident fell getting into or out of the bed. The wheelchair locks were not activated. The Director of Nursing (DON) documented the conclusion on 7/6/16, which indicated that the resident attempted to independently transfer. Therapy will order anti-rollbacks. The new intervention was not documented on the Care Plan Report. The Clinical Notes Report dated 4/23/16, indicated that the nurse was called into Resident 3's room by the Certified Nurse Assistant (CNA) at 3:15 p.m. to observe Resident #3 sitting on the floor, parallel to the bed, with both hands on the floor. The resident was unable to recall the event. The resident denied pain. There were no injuries. The wheelchair locks were not activated. The resident was wearing well fitted shoes. The Physician was notified. The resident's family will be notified in the morning. There was no documentation in the medical record indicating that the responsible party was notified. The Clinical Notes Report dated 4/29/16, indicated that Resident #3 received a skin tear at 11:30 p.m. to the left upper forearm; that measured 4 X 0.5 centimeters (cm). The resident hit his arm on the radiator in the bedroom. There were no complaints of pain. The nurse cleaned the area with Normal Saline Solution (NSS), applied 3 steri-strips, [MEDICATION NAME], an [MEDICATION NAME] dressing, an abdominal pad, and a stretch conforming gauze to the area. There was no incident report created after the injury on 4/29/16. There was no documentation indicating that the physician, or responsible party were notified of the skin tear on 4/29/16. On 7/7/16 at 3:41 p.m., the surveyor received a faxed letter from the Administrator, indicating that the facility was unable to locate an incident report for the skin tear that Resident #3 had on 4/29/16. The facility policy titled, Abuse Prevention/Accidents, Incidents included but was not limited to: Definition of accident/incident: Any unusual event or circumstance that is not consistent with the normal routine of the community, its staff, visitors, etc .Procedure/Responsibilities: 1 .Nursing observations, such as skin tears or hematomas, will also be considered unusual occurrences. The resident's responsible party and physician will be promptly notified when the resident is involved in an accident or incident. There was no evidence that the policy was consistently followed. NJAC 8:39-4.1(a)2 NJAC 8:39-13.1(d)3

Based on observation, interview and record review, it was determined that the facility failed to dispose of wasted, non controlled medications, in a safe and secure manner. This deficient practice was observed during the medication pass, as evidenced by the following: During the Medication Pass observation of 4/9/15 at 8:15 a.m., the surveyor observed the nurse drop two medications, Raloxifen and Vitamin D, while being poured prior to offering them to residents. The nurse proceeded to discard each medication in a plastic cup in the side trash bin of the medication cart. At 8:20 a.m., the surveyor observed a resident drop two medications out of a cup while attempting to take them. The nurse picked them up from the floor and discarded the pills in the plastic cup of the side trash bin on the medication cart. When the nurse completed the medication pass at 9:00 a.m., the surveyor asked her how she was going to dispose of the pills. The nurse stated that she did not know what the facility policy was, and she was going to throw them in the trash. At 11:15 a.m., the surveyor reviewed the facility policy dated 1/00 that was provided titled "Destroying Controlled (Medications) Substances." The policy did not address the disposition of non-controlled medications. At 1:15 p.m., the same day, the facility provided the surveyor with a "draft" policy, titled "General Guidelines for Safe and Appropriate Handling of Medications." Under the section of "Waste and Disposal Procedure," #8., " medications must be destroyed beyond the possibility that they could ever be used again by utilizing the "drug buster" solution obtained through the pharmacy, or kitty liter." On 4/9/15 at 2:00 p.m., the Director of Nurses told the surveyor that the policy was in draft awaiting approval from the corporate office and that staff had not been inserviced on the new policy. NJAC 8:39-29.4, 4(i)

Complaint # NJ 124 Based on interview and record review, it was determined that the facility failed to investigate incidents of resident to resident abusive behaviors and injuries of unknown origin, to determine causal factors and prevent recurrence. This deficient practice was identified for 5 of 7 residents reviewed for abuse/mistreatment and injuries of unknown origin, Residents #1, #3, #5, #7, #8, and #9, as evidenced by the following: 1. The surveyor reviewed the medical record of Resident #1 on 6/12/14 at 11:00, which revealed that the resident had [DIAGNOSES REDACTED]. Review of the medical record revealed that from 1/1/14 to 6/9/14, the resident had 16 incidents of resident to resident altercations. On 6/13/14 at 1:00 p.m., the Director of Nurses told the surveyor that none of the incidents had been investigated. 2. On 6/11/14 at 1:30 a.m., during the initial tour of the facility, the nurse told the surveyor that Resident #9 was verbally and physically aggressive toward staff. The nurse also stated that Resident #9 had attempted to hit and kick other residents. On 6/12/14 at 11:10 a.m., the surveyor reviewed the medical record of Resident #9, which revealed that the resident had [DIAGNOSES REDACTED]. Review of the progress notes from 5/4/14 to 6/13/14 revealed that Resident #9 displayed behaviors including face to face altercations and inappropriate behaviors toward other residents. On 6/13/14 at 11:30 a.m., the DON provided references for "Occurrence Report" to the surveyor. There was inconsistent incident documentation to include a physical confrontation which occurred on 5/4/14. 3. During the initial tour on 6/11/14 at 10 a.m., the unit nurse told the surveyor that Resident #7 was totally dependent on staff for care and was currently receiving Hospice services. The surveyor observed the resident in bed, sleeping. On 6/12/14 at 10:00 a.m., the surveyor reviewed Resident #7's medical record. The resident had a Certified Nurse Aide (CNA) care plan which included that the resident was "forgetful" and "confused." According to the Nursing Progress Notes on 3/26/14 the resident was noted to have a skin tear on the left leg and on 5/15/14 the resident was noted to have a "skin tear/open hematoma" on the right knee. According to the notes, both of those injuries were of unknown origin. On 6/12/14 at 1 p.m., the surveyor reviewed the Occurrence Report (the facility investigative tool) for the injuries. The 3/26/14 report indicated that the resident was "noted with an unknown skin tear on front left leg" measuring 3 cm. by 0.25 cm. The report also revealed that "the resident can not recall how he/she got the skin tear." The section on the Occurrence Report for staff interviews indicated "No Staff Interviews available" and there were no staff statements attached to the report. The Occurrence Report, written on 5/15/14, revealed "noted skin tear/open hematoma on resident's right knee 2 cm. by 1 cm. triangular shape." The report indicated "resident could not recall how obtained skin tear." The section on the report for staff interviews included "No staff interviews available." There were no staff statements attached to the report. 4. On 6/12/14 at 9:45 a.m., the surveyor reviewed the medical record for Resident #3 which revealed the resident had [DIAGNOSES REDACTED]. The surveyor reviewed the progress notes for Resident #3 which revealed multiple behavior incidents including face to face confrontations and inappropriate behavior toward other residents from 10/13 to 5/14. On 6/12/14 at 1:00 p.m., the surveyor asked the Director of Nursing (DON) for all investigations for Resident #3 that had been done in the prior 6 month period. The surveyor reviewed the investigative reports provided by the DON and found that there were no investigative reports for: -10/15/13 the following documented occurrences: On 10/15/13 at 8:52 p.m., Resident #3 was involved in a physical confrontation. On 10/19/13 at 8:54 p.m., Resident #3 was involved in a physical confrontation. On 3/9/14 at 9:59 p.m., Resident #3 went into another resident's room and unplugged that resident's oxygen machine while it was in use. On 3/20/14 at 3:34 p.m., Resident #3 went onto another resident's room and started grabbing at that resident's belongings. The other resident attempted to escort Resident #3 out of his/her room at which time Resident #3 hit the other resident. On 6/12/14 at 1:45 p.m., the surveyor asked the DON if there were any other investigative reports for the prior 6 months for Resident #3 to which the DON responded that she had provided all completed investigations as requested for Resident #3. 5. On 6/11/14 at 12:30 p.m. the surveyor reviewed the medical record for Resident #8, which revealed the resident was admitted to the facility on [DATE],with [DIAGNOSES REDACTED]. On initial tour with a staff nurse, Resident #8 was identified as being confused with behaviors of becoming combative with staff and other residents. The resident was observed sitting in a wheelchair with a Wanderguard attached to the wheelchair. The surveyor reviewed the progress notes for Resident #8 which revealed that on 3/23/14 at 2:30 p.m., Resident #8 was grabbed on the arm by another resident. Resident #8 then hit the other resident with a closed fist multiple times in the left arm. On 6/12/14 at 9:30 a.m., the surveyor asked the DON for all investigative reports for the prior 6 months for Resident #8. The surveyor received and reviewed an Occurrence Report for the incident noted above that occurred on 3/23/14. The report indicated that the incident was witnessed by other residents and housekeeping and maintenance staff members. There were no statements from these witnesses attached to the Occurrence Report. The surveyor asked the DON if the entire investigative report was received for this incident, and the DON responded that the report was complete. On 6/13/14 at 1:00 p.m., the surveyor reviewed the facility policy for Prevention of Abuse, which included on page 7, Section V. Protection/Investigation: Residents will be protected from harm by the following measures: -Any individual, who observes signs of possible abuse, notifies the nurse immediately so an assessment can be performed. -As the primary investigator, the department manager , Care Coordinator, Director of Nursing, Director of Wellness, Administrator or designee begins to conduct an investigation of the event. -Written statements are obtained of the individual who suspects/observed the allegation of abuse. -Statements are obtained from the victim. There was no documented evidence this policy was consistently followed. NJAC 8:39-4.5(a)5

Complaint NJ # 124 Based on observation, interview and record review it was determined that the facility failed to report incidents of resident to resident behaviors including face to face altercations and inappropriate behaviors from Resident #3 toward other residents to the state agency. This deficient practice was identified for 4 of 6 residents (Residents #1,#3,#8 and #9) reviewed for resident to resident abuse/behaviors as evidenced by the following:1. On 6/11/14 at 9:45 a.m. during the initial tour, the nurse stated that Resident #3 was confused with behaviors of being combative with staff. The nurse stated she was unsure if Resident #3 was combative or had inappropriate behaviors with other residents. The nurse also stated Resident #3 wandered on the nursing unit and into other residents' rooms. The surveyor observed the resident ambulating in the hallway at that time with a Wanderguard on his/her ankle. On 6/12/ 14 at 9:45 a.m., the surveyor reviewed the medical record of Resident #3 which revealed that the resident had [DIAGNOSES REDACTED]. The surveyor reviewed the progress notes of Resident #3 at that time, which revealed multiple/various incidents of inappropriate behaviors including wandering in personal space and face to face altercations between this resident and other residents over a period of several months. On 6/13/14 at 2:00 p.m. the Director of Nursing was asked by the surveyor, in the presence of the survey team, if these incidents of abusive/inappropriate behavior between residents was reported to the state agency, and she responded that they had not been reported. 2. On 6/11/14 at 12:30 p.m., the surveyor reviewed the medical record of Resident #8 which revealed that the resident had [DIAGNOSES REDACTED]. During the initial tour of the facility, Resident #8 was identified by the nurse as being confused and having combative behaviors with staff and other residents. The resident was observed sitting in a wheelchair at a table in the dining room with a Wanderguard attached to the wheelchair. Review of the nurses notes revealed that on 3/23/14 at 2:30 p.m. Resident #8 was self propelling in a wheelchair in the hallway. Another resident reached out and grabbed Resident #8's arm at which time Resident #8 hit that other resident multiple times with a closed fist in the left arm. On 6/13/14 at 2:00 p.m. the DON stated that the incident had not been reported to the state agency. 3. On 6/11/14 at 1:30 p.m., during the initial tour of the facility, the nurse told the surveyor that Resident #9 was verbally and physically aggressive towards staff. The nurse also stated that Resident #9 had attempted to hit and kick other residents. On 6/12/14 at 11:10 a.m., the surveyor reviewed the medical record of Resident #9, which revealed that this resident had [DIAGNOSES REDACTED]. Review of the progress notes from 5/4/14 to 6/13/14 revealed that Resident #9 displayed behaviors including face to face altercations and inappropriate behaviors toward other residents. On 6/13/14 at 1:30 p.m. the Administrator stated that the incidents had not been reported to the State Department of Health. 4. On 6/12/14 at 11:00 a.m., the surveyor reviewed the medical record of Resident #1, which revealed that the resident had [DIAGNOSES REDACTED]. Further review of the Progress Notes by Patient, revealed that from 1/1/14 to 6/9/14, indicated there were incidents of resident to resident physical including behaviors including face to face altercations and inappropriate behaviors toward other residents by Resident #1. On 6/16/14 at 10:30 a.m., the Administrator told the surveyor that none of the incidents had been reported to the state agency. NJAC 8:39-9.4 (f)

Based on observation, interview and record review, it was determined that the facility failed to consistently utilize ordered devices intended to prevent falls. Resident #11 sustained a fall with a head injury that required sutures. This deficient practice was identified in Residents #2 and #11, 2 of 4 residents reviewed for falls. In addition, the facility failed to maintain a safe environment for all residents. These deficient practices were identified by the following: 1. The surveyor was told during a tour of the nursing unit on 3/13/12 that Resident #11 was confused and unable to effectively communicate verbally and had fallen recently when she flipped over the wheelchair she was seated in and had to have sutures. The UM told the surveyor that Resident #11 was now in a geri-recliner with a tray table in place. According to an "Incident Details" report dated 10/3/11, Resident #11 was found at 10 p.m. on hands and knees on the floormat next to the bed. The "Fall Investigation" form indicated that the resident's bed alarm, which had been ordered by the physician on 4/11/11, was not in use at the time of the fall. The resident did not sustain an injury. According to an electronic nurses note dated 1/30/12 at 3 p.m. Resident #11 was found face-down on the floor next to the bed and wheelchair with a large amount of blood coming from the head. When rolled over the resident was found with a large "V" shaped laceration to the center forehead. Resident #11 was sent to the hospital and received 4 sutures to this area. The surveyor reviewed the Incident Details report concerning the 1/30/12 fall. According to the investigation, Resident #11 fell from the wheelchair in her room and was found on the floor by the social worker who alerted the nurse. This nurse's documentation noted the laceration was approximately 4 to 5 cm in length and that the resident was alert following the fall. A follow-up note from the UM on 2/1/12 stated the resident returned the same day from the hospital with 4 sutures to the forehead. The "Fall Investigation Form" stated the resident's wheelchair fall deterrent alarm had not been on the resident's wheelchair at the time of the fall. This alarm had been ordered on [DATE]. On 3/14/12 at 12:55 p.m. the surveyor observed Resident #11 in the dining room being fed lunch by a nursing assistant. The scar from the 1/30/12 fall was observed on the resident's forehead. At this time the resident's tray table had been removed and was lying against the wall in the dining room. The nursing assistant moved Resident #11 away from the lunch table after finishing the meal. The nursing assistant retrieved the tray table and attempted to place it onto the resident's geri-recliner. The nursing assistant tried for a short while to place the tray, was unsuccessful, and pushed the resident out of the dining room with the tray in place but not secured. The nursing assistant transported Resident #11 to her bedroom, stayed in the room for approximately 20 seconds and then left the room. The nursing assistant returned to the dining room and transported another resident out of the room then the nursing assistant went down the hall, past the nurses station and was out of sight. The surveyor entered the room of Resident #11 and observed the resident in the geri-recliner. The resident was alone in the room and restlessly moving around in the recliner. At 1 p.m. the surveyor placed 1 hand around the end of the tray table and was able to completely remove it from the geri-recliner. At this time the surveyor, who did not leave the resident's room, called the nurse into the room and explained what had occurred. 2. During a tour of the nursing unit on 3/13/12 the Unit Manager (UM) said Resident #2 had dementia, a history of multiple falls and utilized a self-releasing seatbelt, a scoop mattress and fall deterrent alarms to the bed and wheelchair. On 3/13/12 at 1:05 p.m. Resident #2 was observed in the wheelchair at the nurses station with the seatbelt in place. According to an Incident Details report on 10/3/11 at 2:30 p.m. Resident #2 was found on hands and knees on the floormat next to the bed. The fall investigation form indicated that the resident's bed alarm, which had been ordered by the physician on 9/29/11, was not in use at the time of the fall. The resident did not sustain an injury. 3. On 3/13/12 at 2:20 p.m. the surveyor entered a resident room to speak to the resident in bed A who was alert and oriented. While speaking with the resident the surveyor observed a 1 gallon bottle of Biofreeze pain gel on the floor next to the resident. The bottle had a pump top and was located between the 2 resident beds in the room. The bed A resident told the surveyor that a therapy staff member had applied this rub to her knees and shoulders recently. The resident said she had not noticed that the bottle was left on the floor. Although the resident in bed A was alert and oriented, the resident's roommate in bed B was confused and self-propelled her wheelchair throughout the nursing unit. In addition, the bottle was visible from the hallway and any confused resident who was able to ambulate or self-propel a wheelchair would have had access to it. According to the Material Safety Data Sheet (MSDS) information for Biofreeze gel, it is highly flammable, may cause eye irritation and may be harmful if swallowed 4. On 3/13/12 at 1:45 p.m. the surveyor observed the following on the 2nd floor: There was a 1 gallon container of "Lemon-Kleen" Germicidal Cleaner with a cautionary on the label that stated "hazardous to humans - keep out of reach of children" sitting on the floor next to the tub in the whirlpool room. This container was half full. Next to this container was another container of the same product lying on its side. This container was almost empty with only a little amount of liquid remaining. The door to this room was open. On 3/14/12 at 11:05 a.m. the surveyor observed the following in unlocked cabinets in the 3rd floor dining room: There was a spray bottle of "Oasis" Sanitizer with a cautionary on the label that stated "do not drink", a spray bottle of "Oasis" Cleaner Degreaser "Orange Force" and a 1 quart spray bottle of Disinfectant with Bleach. On 3/14/12 at 12:05 p.m. the surveyor observed the following in unlocked cabinets in the 2nd floor dining room: There were 2 spray bottles labeled "Oasis" Sanitizer and "Orange Force" (as above). 6. During the life safety tour on 3/14/12 at 1:15 p.m., the surveyor observed the following items in the second floor tub room which was open and accessible to the residents: 3 -7.5 fluid ounce bottles of DermaVantage moisturizing cream labeled "keep out of the reach of children" 2 -7.5 fluid ounce bottles of 3N1 rinse free foaming shampoo, labeled "keep out of the reach of children" 1 -4 ounce container of Ultra Sure antiperspirant and deodorant labeled "avoid contact with eyes" 1 -3.5 ounce tube of Periguard ointment labeled "keep out of the reach of children" 1 -11 ounce can of Dawn Mist Shaving Cream labeled "keep out of the reach of children" 1 -8 fluid ounce bottle of Proven perineal wash labeled "keep out of the reach of children" 1 -4 ounce container of Dawn Talc (powder) labeled "keep out of child's face" 1 razor At 1:35 p.m. the surveyor observed the following in the third floor tub room; also open and accessible to the residents: The emergency cord was tied around the grab bar which would prevent the alarm from sounding if the cord was pulled. 1 -4 ounce container of Sure antiperspirant and deodorant labeled "avoid contact with eyes" 1 -7.5 fluid ounce container of DermaVantage moisturizing cream labeled "keep out of the reach of children" 1 -12 ounce aerosol can of hair spray labeled "keep out of the reach of children" 1 -4 ounce container of Dawn Talc (powder) labeled "keep out of child's face" 1 -3.5 ounce tube of Periguard labeled "keep out of the reach of children" 5 razors NJAC 8:39 - 27.1 (a) 31.4 (a)