Every finding on record at White House Healthcare and Rehabilitation Center

Based on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner, putting 147 residents who received meals from the kitchen (12 residents received nutrition via feeding tubes) out of 159 total residents at potential risk for foodborne illness. Specifically, failures included: improper freezer temperatures, a lack of functioning thermometers in the refrigerators/freezers, improper concentration of sanitizer solutions, uncleanable surfaces due to rust, not labeling foods removed from original packaging with the identification of the contents, unclean microwaves in the pantries, improperly maintained equipment such as refrigerators in the nursing pantries, an ice machine was unclean on the inside box where ice was made and stored, and tray line food holding temperatures were outside of safe temperature ranges.Findings include: Review of the facility's undated Food Receiving and Storage revealed, Foods shall be received and stored in a manner that complies with safe food handling practices . Danger zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow rapid growth of pathogenic microorganisms that can cause foodborne illness . Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times. When food is delivered to the facility it is inspected for safe transport and quality before being accepted . Refrigerated/frozen storage . foods are stored at or below 41 F, unless otherwise specified by law . Refrigerated foods are dated and monitored so they are discarded . Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing . Foods and Snacks Kept on Nursing Units - All food items to be kept at or below 41 F are placed in the refrigerator located at the nurse's station and dated . All foods belonging to residents are labeled with the resident's name, the item and the 'use by' date . Refrigerators must have working thermometers and are monitored for temperature according to state- specific guidelines . Review of the undated Utensil Washing Instructions for San-IT sanitizer revealed, sanitize by: immersing utensil for (2) minutes in solution of 1 oz. of San-It sanitizer per 4 gallons of water, to achieve 200 PPM of quat [quaternary ammonia]. No upper limit for concentration in PPM was noted on the instructions. 1. The initial kitchen tour was conducted on 09/02/25 from 11:03 AM through 12:03 PM with the Dietary Manager (DM). The following concerns were noted: a. In the three-sink pot washing area of the dairy kitchen, scrubbies for washing pots and pans were stored directly on top of the grease trap surface which was completely rusted. b. The temperature of the chest freezer in a room off the dairy kitchen had individual serving sized packages of ice cream. The internal temperature of the freezer was 10 degrees F. The ice cream containers were soft to touch, verified by the DM. c. The bottom shelf of the stainless-steel cart in the dairy kitchen was covered in rust. The DM stated the staff primarily used the cart to store racks for the hot food cart, which were in place on the rusted surface. d. The internal temperature of the cook's reach in refrigerator in the dairy kitchen was 43 degrees F. Sandwiches, soda, and fruit salad were stored within. e. In the dish room of the meat kitchen, there was a section of baseboard of approximately two feet long that had pulled away from the wall and was lying on the floor with accumulated dust/dirt on top of it.f. The first sink (used for holding the wash solution) of the three-sink pot washing system in the meat kitchen had two metal bumps sticking up approximately one inch above the surface of the bottom of the sink and the seams of the interior edges of the sink (where the walls and bottom of the sink connected) had been repaired with a bumpy metal material. These surfaces contained rust and black residue. The DM verified the rust and black residue could not be removed when cleaning the sink. g. The top horizontal surface of the grease trap in the dishwashing room in the meat kitchen was rusted. Scrubbies used for washing dishes/pans were stored directly on the rusted surface. h. The reach in refrigerator in the meat kitchen contained multiple bags of frozen meats that had been removed from the original packaging (boxes). The bags of meat were dated with a use by date; however, the identity of the frozen meats was not recorded on the bags. There was a bag with meat patties; however, the type of meat was not documented and could not be determined. The DM stated he thought it was a bag of veal patties. There was a bag of what appeared to be unidentifiable meat nuggets. The DM stated the cook told him it was chicken. i. The shelf under the steam table in the meat kitchen was completely rusted. Nothing was stored on the shelf at the time.j. A bucket of wiping rag sanitizer solution in use in the meat kitchen was tested for concentration of the sanitizer. The DM used a quaternary ammonia test strip and the concentration read 100 parts per million (PPM). The DM stated he wanted it to be at a concentration of at least 150 PPM and preferably 200 PPM to effectively sanitize kitchen surfaces. The DM stated he was not sure what the recommended PPM should be for this specific product. The DM stated the bucket was mixed that morning at around 9:00 AM. The DM showed the surveyor the quaternary ammonia-based product San It in a one-gallon jug. The DM stated the sanitizer came from a local vendor. The DM stated he would get manufacturer information that documented the desired concentration in PPM. k. Most of the boxes of frozen meat (at least 20) stored in the walk-in freezer in the meat kitchen had deteriorated and collapsed, were crushed, and were no longer intact. There were multiple rips, tears, and holes in the cardboard boxes and the boxes were melded together with ice. The DM stated this was a result of the defrost cycle and occurred when the foods thawed during defrosting. The DM stated he had talked to the maintenance staff about this and they told him the freezer was working properly. The thermometer read 5 degrees F. Foods were frozen to touch at this time.l. The thermometer in the walk-in refrigerator in the meat kitchen read 12 degrees F. The DM stated the thermometer was not working and verified refrigerator temperatures should be around 40 degrees F. m. A chest freezer was located in the hallway into the kitchen area. There were two bags of meat removed from the original boxes. One bag contained breaded patties, and the DM stated it was breaded fish. There was no label to identify the contents. The second bag contained nuggets, and the DM stated it was fish nuggets; however, there was no label identifying the contents. 2. A tour of four nursing pantries located on One South, One North, Two South, and Two North was made with the DM on 09/02/25 from 12:08 PM - 12:22 PM. Each pantry contained refrigerators, microwaves, and food storage areas. Concerns were found in three of the four pantries:a. Observation in the One South Pantry refrigerator revealed the internal thermometer read 50 degrees F. Snacks and beverages were contained in the refrigerator. The DM verified the temperature should be 41 degrees or less and that the door could not be completely closed due to the seal that was no longer adhered to the door. The entire length of the rubber seal at the top of the refrigerator door was no longer affixed to the top of the door creating a gap. b. Observation of the Two South Pantry refrigerator revealed the temperature of one of the two refrigerators in the room was 50 degrees F. The DM stated the thermometer might not have been working properly. There was a freezer compartment above the refrigerator that contained popsicles. There was excessive ice built up several inches thick on the interior. The log for recording temperatures did not include recording the freezer temperatures; only refrigerator temperatures were recorded. The microwave oven interior surface contained areas of an unknown black residue. The DM stated it did not look good.c. Observation in the Two North Pantry revealed the microwave contained grey residue on the interior surface and a large brown spill covered the bottom of the microwave floor. The DM verified it was not clean. In the refrigerator there as a package of food that the DM stated was a resident's food container; it had no label with the resident's name/room or expiration date. There was a second container with a resident's food with a name and date of 07/26/25. The DM stated it should have been discarded by nursing staff after three days. 3. A follow up observation of the kitchen and pantries was conducted on 09/04/25 from 9:54 AM through 11:15 AM. a. Dietary Aide (DA)1 was at the entry to the walk-in freezer in the meat kitchen. The freezer door was open, and there was a 55-gallon garbage can near the door that was filled with deteriorated boxes of meat that were now soggy and wet. DA1 stated he was throwing away the boxes that were busted. The temperature of the walk-in freezer was 40 degrees. The DM stated the freezer went up to 20 degrees on defrost, it dripped, and then the boxes got wet. b. The top surface of the booster continued to be rusted. The DM verified that was where scrubbies for washing dishes/pots were often stored. The DM verified that rusted surface was not a cleanable surface. c. A bucket of wiping rag sanitizer solution, mixed and in use, was tested for concentration using a test strip. The concentration was greater than the top threshold of the test strip and was over 400 PPM. The DM stated he was not sure if the concentration of sanitizer was too high as he did not have the manufacturer's information. d. In the kitchen dish, the section of baseboard of approximately two feet long that had pulled away from the wall and was lying on the floor with accumulated dust/dirt on top of it, remained in place. The DM stated he had not noticed this previously but would report it to the maintenance department.e. The first sink of the three-sink pot washing system in the meat kitchen continued to have two metal bumps sticking up above the surface of the bottom of the sink and the seams of the interior edges of the sink continued to have a bumpy metal material. These surfaces contained rust and black residue. The DM stated this pot washing sink was used for washing pots/pans the dinner meal each day and agreed the surface was not cleanable due to the rust and black substance. f. The ice machine located in the basement in the employee lounge, used by the dietary staff had gray/brown residue on the wall of the interior surface that was directly above the ice in the bin. The DM took a paper towel and wiped the substance off, verifying the surface was not clean and the ice could be contaminated. The Brown/grey residue was observed on the paper towel. The DM stated the Maintenance department was responsible for cleaning the ice machine. g. An observation of tray line holding temperature for lunch was conducted (at 10:36 AM). Concerns were noted with three foods: The mashed potatoes were 127 degrees F; the coleslaw was 52 degrees F, and the three-bean salad was 52 degrees F. DA2 measured the temperatures and verified what they were stating the cold foods should be cold enough. DA2 stated the cold foods should be at 30 degrees F and the hot foods should be at 160 degrees F. The pan of mashed potatoes were in a steam table pan on top of another steam table pan that was in a bath of water on the stove. There was no direct means to keep the potatoes hot. h. Inspection of the microwaves and refrigerators in Two South Pantry and Two North Pantry revealed new microwaves had been purchased. A new refrigerator had also been purchased for the One South Pantry. i. On 09/04/25 at 11:08 AM, upon return from the nursing pantries to the kitchen, the tray line meal service was being conducted with residents' plates being served up and loaded into the carts. The DM stated the hot food temperatures should be 165 degrees on the tray line and verified cold food temperatures should be 41 degrees or less. The DM measured the temperature of the mashed potatoes at 11:15 AM and they were 132 degrees F. The DM verified they were not hot enough. The DM measured the temperature of the coleslaw and three bean salad and they were both 50 degrees F, which he stated was not cold enough. 4. During an interview on 09/04/25 at 8:43 AM, Administrator 1 stated they had fixed everything identified during the initial kitchen tour and had purchased a new refrigerator and microwaves. Administrator 1 stated he was not aware of the issue with the deteriorating boxes in the meat freezer. During an interview on 09/04/25 at 4:37 PM, Administrator 1 stated they did not have records for work orders and repairs in the kitchen which had been requested. He stated the department heads went over everything in morning meetings and some things got fixed and did not get documented. The Administrator stated there were maintenance books that staff could document issues needing repair. During an interview on 09/05/25 at 11:03 AM, the Maintenance Director stated there was a maintenance communication book used to alert him of needed repairs. He stated staff also called him and paged him if repairs were needed. The Maintenance Director stated there was no formal system for documenting issues and repairs. The Maintenance Director stated maintenance staff also did rounds and fixed things as they saw them. The Maintenance Directors stated he was aware of the base board that had pulled away from the wall in the dish room. The Maintenance Directors stated a freezer had been replaced. The Maintenance Director stated the walk-in freezer was working perfectly. He stated the defrost cycle created condensation and that was why water dripped. The Maintenance Director stated he was aware of the booster surfaces being rusted. The Maintenance Director stated the ice machines were cleaned every month, which involved dumping the ice, shutting off the ice machine, and cleaning it. The Maintenance Director stated the ice machine had just been cleaned on Monday and stated he had not noticed any residue on the interior walls. The Maintenance Director stated the maintenance staff serviced the dietary stainless-steel carts; however, was not aware of the rusted bottom shelf. During an interview on 09/05/25 at 11:42 AM, the Registered Dietitian (RD) stated she did not have oversight responsibility in the kitchen and did not routinely do kitchen sanitation inspections. The RD stated she was not aware of the rusted surfaces in the kitchen. The RD stated sanitizer solutions should be mixed according to the appropriate concentration. The RD stated staff should monitor refrigerator and freezer temperatures. The RD verified there were no labels on the bags on meat in the reach in refrigerator on 09/02/24 specifying what was in the bag. The RD stated hot food holding temperatures should be 165 degrees F and cold food should be under 40 degrees F. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and policy review, the facility failed to allow one out of 33 sampled residents (Resident (R)15) to exercise her right to go to the day room to attend activities. R15 was not allowed to co-mingle with other residents in the activity room after she sustained an infection. R15 was currently on enhanced barrier precautions which did not dictate that the resident could not leave her room and attend activities in the day room or socialize there. This created the potential for R15 to experience isolation and the inability to enjoy previous activities in which she had participated.Findings include: Review of the facility's Resident Rights Policy policy, dated 06/2025, revealed, . All residents in this facility have rights guaranteed to them under Federal and State law, and by this facility's personnel . The residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . To meet with members of and take part in activities of social, commercial, religious and community groups . Review of the facility's Enhanced Barrier Precautions policy, dated 08/2022, revealed, . Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents . The use of EBPs does not impose limitations on group activities or room restrictions for residents . Review of R15's undated admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R15 was admitted to the facility on [DATE]. Diagnoses included dementia. Review of R15's most current Activity Assessment, dated 05/27/23 and located in the EMR under the Assessment tab, revealed R15 participated in self-directed activities and group activities. R15's favorite activities included, [R15] enjoys going to church, listening to gospel & oldies music, and looking at magazines. Review of R15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/08/24 and located in the IQIES portal, revealed R15 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three out of 15. Review of R15's Infection Note, dated 02/04/25 and located in the EMR under the Progress Notes tab, revealed R15 tested positive for candida auris on this date and contact isolation precautions were initiated. Review of R15's Orders tab in the EMR, located under the Resident tab, revealed on 05/29/25 R15 was placed on EBP and contact precautions were discontinued. Review of R15's Care Plan, dated 03/06/25 and located in the EMR under the Care Plan tab, revealed a focus area of [R15] needs individualized activity visits to provide physical, social, mental, and sensory stimulation. [R15] needs to be kept within specific areas during specific times due to diagnosis of C. Auris. The goal was, [R15] will respond to 1:1 [one to one] activity visits evidenced by conversing, smiling, and participating with staff Xs [for] 90 days. Interventions were, Provide 1:1 room visits consisting of auditory, olfactory, and tactile stimulation for peer interaction and socialization. Label resident's name on zip lock bag containing magazines and tactile materials. Keep zip lock bag in specific area away from other residents. Wear gloves during 1:1 visits when providing tactile stimulation due to resident's dx. [diagnosis] of C. Auris. Review of quarterly Recreation Progress Notes prior to R15 becoming infected with candida auris in February 2025, revealed she enjoyed socializing with other residents and staff as well as participating in group activities as follows: Review of a Recreation Progress Note, dated 09/05/24 and located in the EMR under the Progress Notes tab, revealed, [R15] . continues to enjoy strolling down two north hallway conversing with staff and peers, and participating in light exercise, sing-along, music events and reminiscing activities. Rec [recreation] staff will continue to encourage and invite to small group activities for socialization . Review of a Recreation Progress Note, dated 12/05/24 and located in the EMR under the Progress Notes tab, revealed, . She continues to enjoy strolling down two north hallway conversing with staff and peers and participating in light exercise, sing-along, music events and reminiscing activities. Rec. [recreation] staff will continue to encourage and invite to small group activities for socialization . Review of R15's activity participation 1:1 Room Visits record, from 08/01/25 through 09/04/25, revealed R15 received 1:1 visits only and did not participate in any group activities. Observations during the survey revealed R15 was lying in bed in her room each time she was checked: On 09/02/25 at 4:22 PM, R15 was lying in bed on her back, under the covers, awake with her eyes open. The signage attached to the doorway of her room indicated she was on enhanced barrier precautions. On 09/03/25 at 10:11 AM, R15 was lying in bed under the covers, with her eyes closed. On 09/03/25 at 3:14 PM, R15 was lying in bed under the covers, with her eyes closed. On 09/04/25 at 9:25 AM, R15 was lying in bed under the covers, and was awake. She motioned the surveyor over and made hand gestures and spoke but her words could not be understood. She was not able to communicate her needs. On 09/04/25 at 4:50 PM, R15 was lying in bed under the covers and was awake. On 09/05/25 at 9:48 AM, R15 was lying in bed under the covers and was awake. On 09/05/25 at 11:03 AM, R15 was lying in bed under the covers and was awake. During an interview on 09/04/25 at 9:40 AM, Certified Nursing Assistant (CNA) 2 stated R15 was dependent on staff for care and could at times communicate basic needs such as that she was wet or she pointed to the television to have staff turn it on. CNA2 stated R15 got out of bed at times and into a wheelchair and was placed in the hallway near the entrance to the room. CNA2 stated activity staff came to the room to do activities with the resident but she did not go to the activity/day room on the unit to participate in group activities due to her infection. CNA2 verified R15 had attended group activities prior to being placed on infection control precautions. During an interview on 09/04/25 at 2:08 PM, Licensed Practical Nurse (LPN) 2 stated R15 had gone to the hospital for a gastrostomy tube replacement and tested positive candida auris in the hospital. LPN2 stated R15 was currently on enhanced barrier precautions. LPN2 stated R15 could sit in the hallway outside her room but she could not go to the dayroom for activities because she would touch everything and she carried the candida auris on her skin. During an interview on 09/05/25 at 8:56 AM, the Activity Director (AD) and Activity Aide (AA) were interviewed. The AD stated the residents who had candida auris had special activity programs due to not being able to go to group activities. This included provision of an activity bag with R15's name that remained in her room which contained magazines and musical props. The AA stated R15 was severely cognitively impaired and she provided 1:1s in the resident's room. The AA stated R15 was not allowed to leave the room. The AA and AD stated R15 participated in and enjoyed group activities prior to contracting candida auris. The AA and AD stated R15 had been on 1:1 visits in her room since she became infected with candida auris (February 2025). During an interview on 09/05/25 at 9:14 AM, the Infection Preventionist (IP) stated the hospital had contacted the facility with the positive candida auris result for R15 in early February 2025. The IP stated at first R15 was on contact precautions and then it was changed to enhanced barrier precautions after being provided with information from the state and the Center for Disease Control recommended contact or enhanced barrier precautions. The IP stated R15 was allowed to come out of her room once on enhanced barrier precautions and she was not prohibited from attending group activities. The IP stated he had trained staff in this. The IP stated once a person had the candida auris infection, it could not be eliminated but could be managed with hand washing and disinfecting surfaces. The IP stated if R15 was not allowed to come out of her room, there would be a physician's order which indicated this but there was no order. During an interview on 09/05/25 at 5:35 PM, the Director of Nursing (DON) stated R15 was allowed to go out of her room. She stated enhanced barrier precautions did not prohibit R15 from going to common areas such as the day room for activities. The DON stated she had occasionally seen R15 in her wheelchair out in the hallway near the nursing station and stated the resident enjoyed talking with staff when out of the room. NJAC 8:39-4.1(a)NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure one resident and family member out of 32 sampled residents (Resident (R)103) were invited to the quarterly care plan meeting. The facility's practice did not include inviting residents or families to quarterly care plan meetings. This created the potential for residents/families to lack information regarding care and services provided and lack the opportunity to provide input into care provided.Findings include: Review of the facility's Care Planning - Interdisciplinary Team policy, dated 03/2022, revealed, . Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT) . The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . Review of R103's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R103 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (ischemic stroke) and vascular dementia. Family Member (F)1 was documented as being R103's Responsible Party and Emergency Contact #1. Review of R103's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/25 and located in the EMR under the MDS tab, revealed R103 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of the MDS tab in the EMR, located under the Resident tab, revealed R103 had three MDS assessments completed following her admission to the facility (admission MDS with an ARD of 02/09/25, a Significant Change MDS with an ARD of 05/12/25 and a Quarterly MDS with an ARD of 08/12/25). Review of the IDCP (Interdisciplinary Care Plan) Meeting/Care Plan Conference Record, dated 02/03/25 and located under the Assessment tab, revealed a care plan meeting was held in conjunction with the Initial MDS review and indicated F1 was invited to and attended the meeting in person. Review of the IDCP Meeting/Care Plan Conference Record, dated 05/05/25 and under the Assessment tab, revealed the care plan meeting was held in conjunction with the Significant Change MDS review and indicated F1 had been invited to the meeting and attended the meeting via phone call. Review of the IDCP /Care Plan Conference Record, dated 08/04/25 and under the Assessment tab, revealed the care plan meeting was held in conjunction with the Quarterly MDS review. The question that asked whether the resident/designated representative was invited to participate in the care plan meeting was marked No. The question that read, Resident/designated representative attended the meeting was marked No. During an interview on 09/02/25 at 2:38 PM, F1 stated he had attended one care plan meeting since R103 was admitted to the facility. F1 stated he was R103's emergency contact and decision maker. F1 stated he did not feel he was well informed regarding R103's current medical condition, care, or of her current psychological state. R103 was present during the interview; however, the resident was confused and did not respond to or participate in the conversation. During an interview on 09/04/25 at 1:09 PM, the Social Service Director (SSD) stated she and the Minimum Data Set Coordinator (MDSC) were responsible for setting up care plan meetings and inviting residents and families to the meetings. The SSD stated they invited residents and families/responsible parties to care planning meetings that corresponded with the Initial, Annual, and Significant Change MDS assessments; however, residents, families, and responsible parties were not invited to care plan meetings that corresponded with quarterly MDS reviews. During an interview on 09/05/25 at 10:42 AM, the MDSC stated residents and families were notified of care plan meetings prior to the scheduled meetings. The MDSC stated families were called. The MDSC stated residents and families/responsible parties were invited to the initial, significant change, and annual care plan meetings; however, they were not invited to the quarterly care plan meetings. During an interview on 09/05/25 at 5:36 PM, the Director of Nursing (DON) verified that residents/families/responsible parties were not invited to care plan meetings that corresponded with quarterly MDS reviews. The DON stated residents and families were invited to care plan meetings that corresponded with initial, significant change, and annual MDSs. The DON stated she was not aware of the requirement to invite residents/families to all care plan meetings, which included quarterly MDS reviews. NJAC 8:39-4.1(a)NJAC 8:39-11.2(e)

Based on interview, record review, and policy review, the facility failed to ensure written notice of the facility's bed hold policy and/or transfer notices that contained all necessary information were provided to three of four residents and/or representatives (Resident (R) 1, R22, and R7) reviewed for transfer notices out of a total sample of 32. This failure had the potential for the resident and/or representative not to have knowledge of where and why a resident was transferred, how to appeal the transfer, or to be knowledgeable of the facility's bed hold policy. Findings include: Review of the facility's undated policy titled, Bed-Holds and Returns revealed, . Written information will be given to the residents and the resident representatives that explains in detail:b. The reserve bed payment policy as indicated by the state plan (Medicaid residents),The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond thestate bed-hold period (Medicaid residents); andd. The details of the transfer (per the Notice of Transfer).4. Medicaid residents who exceed the state's bed hold limit and/or non-Medicaid residents who request abed-hold are responsible for the facility's basic per diem rate while his or her bed is held . 1. Review of R1's admission Record, located under the Profile Tab of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension. On 09/01/25 at 9:30 AM, R1 was observed being transferred to the hospital due to hypertension. The resident was not provided a written copy of the facility's bed hold policy. Review of R1's Progress Note, dated 09/01/25 at 1:21 PM and located in the EMR under the Progress Notes tab, revealed R1 was transferred to the hospital due to hypertension on the day shift. Review of R1's EMR revealed no documented evidence R1 or the resident representative was provided with a written transfer or bed hold notice. During an interview on 09/01/2025 at 10:20 AM, Licensed Practical Nurse (LPN) stated that she was not aware of any paperwork for a bed hold notice. LPN2 stated she was only aware of the papers to be sent to the hospital with a resident, which included the diagnoses, medication list, and why the resident was being sent to the hospital. During an interview on 09/03/2025 at 3:24 PM, the Administrator stated that R1 was sent out to hospital emergently, and they could not give R1 the bed hold papers. During an interview on 09/04/2025 at 11:25AM, LPN1 and LPN2 both stated that there was no written bed hold notice to give to residents on transfer. They stated they were to notify the Administer when residents were sent out. 2. Review of R22's admission Record, located under the Profile Tab of the EMR, revealed R22 was admitted to the facility on [DATE] with diagnoses that included hypertension, abnormalities of gait and mobility, and depression. Review of R22's Progress Note, dated 05/28/25 at 1:25 PM and located under the Progress Notes tab of the EMR, revealed R22 was transferred to the hospital due to hypertension. Review of R22's EMR revealed no documented evidence R22 or any resident representative was provided with a bed hold notice at the time of transfer. During an interview on 09/04/2025 at 11:25AM, LPN1 and LPN2 both stated that there was no written bed hold notice to give to residents on transfer. They stated they were to notify the Administer when residents were sent out. Both stated there was no paperwork that they had ever given residents as they were transferred from the facility. 3. Review of R7's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R7 was originally admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, type 2 diabetes mellitus, asthma, adjustment disorder with depressed mood, and dialysis-dependent end-stage renal disease. Review of R7's Progress Notes tab of the EMR revealed on 07/16/2025, at approximately 3:20 AM, R7 was observed to be breathing with accessory muscles. The resident was assessed, and as needed (PRN) oxygen was administered via nasal cannula at 2 liters per minute (LPM), as oxygen saturation was reported at 88%. Monitoring continued, and the resident's physician was notified. Due to no improvement in the resident's condition, the physician issued orders to transfer R7 to the emergency department (ED). According to facility documentation, the family was notified, and written documentation was provided to the resident at the time of transfer and mailed to the resident's representative. A review of the transfer notice provided by the Administrator revealed that it did not include the reason for the transfer, the location of the transfer, the resident's appeal rights, or the contact information for the ombudsman. During an interview on 09/05/2025 at 1:34 PM, the Administrator confirmed that the document is given to the resident at the time of transfer and mailed to the representative. When asked about the missing elements in the transfer notice, he stated that the facility provides its contact information for residents or their representatives to reach out with any questions or concerns. NJAC 8:39-4.1(a)31,31NJAC 8:39-5.1(a)

Based on observation, interview, record review, and policy review, the facility failed to ensure one out of one sample residents reviewed for range of motion (ROM) (Resident (R) 58) out of a total sample of 32 residents, had an elbow splint/hand roll applied in accordance with physician's orders. This created the potential for R 58 to experience a worsening of her contracted left arm/hand.Findings include: Review of the facility's Resident Mobility and Range of Motion (ROM) policy, dated 07/2017, revealed, . Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM . Review of the R58's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R58 was admitted to the facility on [DATE]. Diagnoses included hemiplegia (partial or total paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke) affecting left non-dominant side. Review of R58's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/25 and located in the EMR under the MDS tab, revealed R58 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of eight out of 15. R58 was not coded as exhibiting any rejection of care during the assessment period. R58 was impaired in ROM to the upper extremity and lower extremity on one side. R58 required substantial assistance with toileting hygiene, tub/shower transfer, partial moderate assistance with dressing, rolling left and right, sitting to lying, lying to sitting on bedside, and sitting to standing. Review of the physician Order Summary Report, active through 09/05/25 and located in the EMR under the Orders tab, revealed an order for, Splint device: apply to left hand and elbow AM when out of bed and remove when in bed PM, initiated on 07/18/25. Review of the Rehab Department Discharge Request & RNP [Restorative Nursing Program] Referral Form, dated 07/16/25 and provided by the facility, revealed the recommendation for, Splinting/bracing: Resident will tolerate hand splint & elbow splint on left UE [upper extremity] to be applied in the morning when the resident got out of bed and in the evening when she went to bed. Review of the Care Plan, dated 07/17/25 and located in the EMR under the Care Plan tab, revealed a focus area of Resident is on Nursing Restorative Program: AM: Assistance with Splint or brace - resident will tolerate hand splint and elbow splint on left upper extremity initiated on 07/17/25. The goal was, Resident will maintain her/his current level of function through the review period. Interventions were:- Allow/provide rest periods between exercises, ambulation.- Encourage/assess resident in performing nursing restorative program:Assistance with Splint or brace - resident will tolerate hand splint and elbow splint onleft upper extremity.- Monitor for any deterioration in goals, inform and refer to rehab as needed forevaluation and treatment as needed.- Promptly notify the nurse if any changes are observed.- Staff to examine body parts carefully each time post ROM for changes such asswelling, redness, break in skin and promptly inform the nurse.Review of the POC [Plan of Care] Response History report for Nursing Restorative Program: Assistance with splint or brace - resident will tolerate hand splint and elbow splint on left upper extremity, from 08/06/25 through 09/05/25 and located in the EMR under the Tasks tab, revealed no documented evidence R58's splint was not applied on:08/06/25 - 08/14/2508/16/25 - 08/17/2508/19/25 - 08/24/2508/29/25 - 09/01/25. The form included a column for refusals. No refusals were documented on the form. Observations during the survey revealed R58 was not wearing the left hand/elbow splint when she was up and out of bed during the day as follows: On 09/02/25 at 4:39 PM, R58 was up sitting in her wheelchair in the day room. Her left hand was observed to be contracted into a fist. R58 stated she had a splint but was not wearing it. On 09/03/25 at 10:00 AM R58 was sitting in her wheelchair in the day room without the splint/hand roll in place. On 09/03/25 at 3:08 PM, R58 was sitting in her room in her wheelchair without the splint in place. On 09/04/25 at 9:17 AM, R58 was sitting in the day room without the splint/hand roll in place. On 09/04/25 at 2:06 PM, R58 was sitting in the day room without the splint/hand roll in place. On 09/04/25 at 4:47 PM, R58 was sitting in the day room without the splint/hand roll in place. During an interview on 09/04/25 at 1:56 PM, Certified Nursing Assistant (CNA)1 stated R58 was paralyzed on one side and required a lot of assistance with ADL care. CNA1 stated R58 had a splint and roll for her palm she was supposed to wear; however, she did not always want to wear it. CNA1 stated she offered to apply the splint for R58 in the mornings. CNA1 stated she asked R58 this morning; however, R58 did not want to wear it. CNA1verified that R58 had not worn the hand splint at all today during day shift. CNA1 stated she would let the nurses know if R58 did not want to wear it. During an interview on 09/04/25 at 2:19 PM, Licensed Practical Nurse (LPN)2 stated R58 was alert with confusion and forgetfulness and was dependent on staff for activities of daily living (ADLS). LPN2 stated staff had to apply R58's elbow splint and hand roll. LPN2 stated R58 was supposed to wear the splint and hand roll during the day. LPN2 stated, For the most part, she will wear it. LPN2 stated she had not been informed that R58 had not been wearing the splint. LPN2 stated therapy staff applied the splint and they worked with R58 daily. During an interview on 09/05/25 at 8:45 AM, the Director of Rehab (DOR), an Occupational Therapist (OT), stated R58 had been recently receiving physical therapy (PT) and occupational therapy but had been discharged to the restorative nursing program. The DOR stated R58 should be wearing the left elbow splint and hand roll when she was up and out of bed during the day. The DOR stated the Restorative Aide (RA) was the main person who applied the splint and hand roll; however, the RA was not working today. The DOR stated application of the splint was important to keep R58's contractures from worsening. During a follow up interview on 09/05/25 at 10:08 AM, the DOR stated R58's elbow splint had been washed yesterday and left to air dry. The DOR stated it was still wet. Registered Nurse (RN)3 joined the conversation and stated R58 was known to remove her splint after it was applied. RN3 stated there was documentation on one day (08/25/25) that R58 had removed her splint. RN3 stated the documentation over the past three days showing R58's splint had been applied was documentation for that point in time and R58 may have had the splint on when the record reflected it had been applied. RN3 verified the splint had not been applied on 09/04/25 because it was being washed and had not been applied today yet because it was still wet. During a follow up interview on 09/05/25 at 12:11 PM, the DOR stated he had just applied R58's elbow splint and hand roll. The DOR stated R58 smiled and presented no problem when he applied the splint and hand roll. During an interview on 09/05/25 at 5:10 PM, the Director of Nursing (DON) stated the Restorative Aide was responsible for applying R58's splint. The DON stated it was supposed to be applied in the morning and taken off at night and should be documented under Tasks. The DON stated it should be applied daily and if the resident refused, the refusal should be documented under Tasks. NJAC 8:39-27.1(a)

Based on interview, record review and policy review, the facility failed to ensure laboratory results were followed up on in a timely manner for one of three sampled residents (Resident (R) 58) reviewed for a urinary tract infection (UTI) out of a total sample of 32. R58's Urinalysis and Culture and Sensitivity (C & S) results revealed she may have had a urinary tract infection. There was no documentation of follow up indicating the Physician was notified of the results and no documentation of whether the physician wanted to treat the infection until the surveyor asked about it nine days later. This created the potential for R58 to experience a UTI without treatment. Findings include: Review of the facility's Lab and Diagnostic Test Results - Clinical Protocol, dated 11/2018, revealed, . 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility . Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors) . Options for Physician Notification - 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager or a telephone message to another person acting as the physician's agent (for example, office staff). A. Facility staff should document information about when, how and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record . Physician Responses 1. Time frames - A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. A. A physician should respond within one hour regarding a lab test result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non immediate lab test notification with a request for response . b. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance . Review of R58's undated admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R58 was admitted to the facility on [DATE]. Diagnoses included hemiplegia (partial or total paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (ischemic stroke) affecting left non-dominant side. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/25 and located in the EMR under the MDS tab, revealed R58 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of eight out of 15. Review of a Nursing Progress Note, dated 08/24/25 and located in the EMR under the Progress Notes tab, revealed, . Resident alert with confusion and forgetfulness all ADL's [activities of daily living] care rendered, resident c/o [complain] that she has a towel in her diaper, resident daughter's visited and noted care given to their mom and saw that their (sic) were no towel place in her diaper. [Attending Physician] was called ordered for resident to have U/A [urinalysis] and C/S [culture and sensitivity] done. All orders was (sic) carried out . Review of a Nursing Progress Note, dated 08/25/25 at 7:41 AM and located in the EMR under the Progress Notes tab, revealed, . Urine specimen obtained, contaminated. All shift to follow/up. Resident slept at long interval throughout the night, easily aroused. No acute distress noted. No c/o urinary pain or discomfort. PO [by mouth] fluids encouraged, Afebrile [no fever] T [temperature] 98.0. Left in bed resting, call bell placed within reached (sic). fall/safety precaution maintained . Review of a Nursing Note, dated 08/25/25 at 11:53 PM and located in the EMR under the Progress Notes tab, revealed, . Urine specimen collected and is on 1south fridge . Review of the Urine Culture Result, with a specimen date of 08/25/25 at 6:00 AM, a result date of 08/28/25 at 10:02 AM, and located in the EMR under the Results tab, revealed the clean catch urine was positive for Escherichi A Coli (E Coli) and Aerococcu S Urinae and these were abnormal results. Under Details, the following was documented, 10,000 - 50,000 CFU/mL Escherichia coli (Abnormal) *** Probable ESBL (Extended Spectrum Beta-Lactamase) producing organism . 50,000 - 100,000 CFU/mL Aerococcus urinae (Abnormal) *** Susceptibility testing not routinely performed on this isolate . Review of the Urinalysis Lab Results Report, with a collection date of 08/26/25 at 7:34 AM, a reported date of 08/26/25 at 11:06 AM, and located in the EMR under the Results tab, revealed abnormal results including turbid urine, trace ketones, trace protein, positive nitrite, large leukocyte Esterase, white blood cells in the urine/uL 297.5, casts Urine/uL 2.16, and bacteria urine/uL 7058.4. There was one Urinalysis found in the R58's EMR; there was no documentation on the report of the urine sample being contaminated. Review of the Progress Notes section (which included Physician Notes) from 08/25/25 after 11:53 PM through 09/04/25 at 3:25 PM showed no further documentation related to whether the second urine specimen was sent to the lab, what the results were, whether the physician was contacted about the results, or what the physician's decision was regarding treating the abnormal results of the Urinalysis and C & S, etc. Review of the Order Summary Report, current as of 09/06/25 and located in the EMR under the Orders tab, revealed no antibiotic had been prescribed following the abnormal lab results. During an interview on 09/04/25 at 2:19 PM, Licensed Practical Nurse (LPN) 2 stated R58 was dependent on staff for activities of daily living and was alert but forgetful. LPN2 stated the C & S was collected 08/25/25 and reported to the facility on [DATE]. LPN2 stated the C & S results were abnormal, indicating a potential UTI. LPN2 stated once the lab results were received, the next step was to for nursing staff to contact the doctor and them him/her know what the results were. LPN2 reviewed R58's EMR and verified there was no documented follow up after the urine sample was collected on 08/26/25. LPN2 verified there was no documentation to show the physician had been notified and what his/her decision was regarding treatment and no documentation on the UA or C & S that the urine specimen was contaminated. LPN2 stated she would have to follow up to find out what happened. During an interview on 09/05/25 at 9:44 AM, Registered Nurse (RN) 3 stated R58 stated on 08/24/25 she had a towel in her private parts and her family took her to the bathroom, but there was nothing there. The resident's physician was contacted, and he ordered a urinalysis and culture and sensitivity to rule out a urinary tract infection. RN3 stated it was difficult to get a urine sample from R58 on the day shift so the next shift was asked to obtain it. RN3 stated the C & S results came back on 08/25/25. RN3 stated the results were reported to the Infection Control Physician and he declined prescribing an antibiotic because R58 was asymptomatic. RN3 stated the resident's Attending Physician who had ordered the UA and C & S had been called this morning (09/05/25) to notify of the results. RN3 indicated this information was now documented (on 09/04/25 and 09/05/25 following the surveyor's inquiries) in progress notes. During an interview on 09/05/25 at 5:19 PM, the Director of Nursing (DON) stated the typical process for labs included collecting the urine, placing the sample in the 1 south refrigerator, the sample being collected the next day. The DON stated the results were auto populated in the computer system the next day. The DON stated that typically the Nurse Practitioner (NP) would review the results for labs on a daily basis from Monday through Friday and would make a recommendation regarding treatment. The DON stated both the nurse and NP should write a progress note and she verified that this had not been done. The DON verified there was one urinalysis report and it did not indicate the urine specimen was contaminated. The DON stated it was a possibility that the laboratory notified the facility by phone indicating the result was contaminated and did not upload the contaminated result. The DON stated the Urinalysis dated 08/26/25 was probably the second result. The DON stated R58 did not exhibit symptoms of a UTI currently and did not require treatment. The DON stated it was difficult to get nurses to document adequately in the EMR. NJAC 8:39-35.2(d)11

Based on observation, interview, record review, and policy review, the facility failed to ensure one of one sampled resident (Resident (R)103) reviewed for dental services out of a total sample of 32 was scheduled for dental services within three days and in accordance with facility policy after her dentures were lost on 05/25/25.Findings include: Review of the facility's undated Dental Services policy revealed, . Routine and 24-hour emergency dental services are available to meet the resident's oral health service in accordance with the resident's assessment and plan of care . Dentures will be protected from loss or damage, to the extent practicable, while being stored . If dentures are damaged or lost, residents will be referred for dental services within 3 days . Review of R103's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R103 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (ischemic stroke) and vascular dementia. Family Member (F)1 was documented as being R103's Responsible Party and Emergency Contact #1. Review of the undated Census tab in the EMR under the Resident tab revealed R103's primary payer source was Medicaid. Review of R103's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/25 and located in the EMR under the MDS tab, revealed R103 was not edentulous. Review of R103's quarterly Minimum Data Set (MDS), with an ARD of 08/12/25 in the EMR under the MDS tab revealed R103 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of a Quarterly Nutrition Review dated 05/12/25, in the EMR under the 'Progress Notes tab revealed R103 was prescribed a regular, mechanical soft texture diet. Review of a Nursing Progress Note, dated 05/07/25 and located in the EMR under the Progress Notes tab, revealed, . Resident denture found. Resident noted removing denture from mouth and keeping it in her hand/sometimes she has it wrapped in a tissue on the bedside table. RP [Family Member (F)1] made aware of found denture, as per RP [Responsible Party] he will talk to resident about her behavior of removing dentures . Review of a Nursing Progress Note, dated 05/26/25 and located in the EMR under the Progress Notes tab, revealed, . Resident missing her denture as of 05/25/25. Son is aware . Review of a Nursing Progress Note, dated 05/29/25 and located in the EMR under the Progress Notes tab, revealed, . Resident denture still missing. Resident noted with good PO [by mouth] intake during meals with no difficult [sic]. On dental consult for next visit . Review of a Nursing Progress Note, dated 08/08/25 and located in the EMR under the Progress Notes tab, revealed, . Resident's son expressed concern of mother's upper denture and claimed that his mother is on the list to be seen by dentist . Review of social service Progress Notes, from 02/04/25 through 09/05/25, revealed no mention of R103's denture being lost or the status of her dental appointment. Review of the email from the Dentist to the facility, dated 09/04/25 and provided by the facility, revealed R103 was on the dental list to be seen on 09/09/25 for Initial impressions for dentures. The email indicated the visit had been originally scheduled for 09/03/25; however, the visit had been cancelled. During an interview on 09/02/25 at 2:59 PM, F1 stated R103 lost her dentures after coming to the facility. F1 stated R103 removed her dentures and placed them on her meal tray resulting in the dentures being lost a couple of times, then being found, and then being lost permanently. F1 stated the facility had not found the dentures after the last time they were lost. F1 stated he had been told the facility would follow up but had not heard anything about R103 being scheduled to see the dentist. During a follow up interview on 09/05/25 at 3:14 PM, F1 stated he thought R103 lost her dentures permanently around the end of May 2025, stating, They have been missing quite a while. F1 stated he felt like it had been too long for R103 to wait to see the dentist. F1 stated he had not been updated regarding when she was scheduled for a dental appointment. During observations on 09/02/25 at 3:01 PM and 09/04/25 at 9:12 AM, R103 did not have upper dentures/teeth. During an interview on 09/04/25 at 12:54 PM, the Registered Dietitian (RD) stated R103 was on a mechanical soft diet due to her denture being lost. The RD reviewed the Progress Notes in the EMR and stated the dentures had been missing since 05/25/25. The RD stated the Assistant Administrator was responsible for scheduling dental visits. During an interview on 09/04/25 at 2:29 PM, Licensed Practical Nurse (LPN) 2 stated R103 was on the list to see the dentist and she should have been seen yesterday (on 09/03/25) but the dentist did not come to the facility. LPN2 showed the surveyor the list posted at the nursing station and it documented R103's name and that she was scheduled as a new patient exam. During an interview on 09/04/25 at 1:09 PM, the Social Service Director (SSD) stated missing dentures were discussed in the morning department head meetings. The SSD stated if a resident who was on Medicaid lost their dentures, she recommended replacement of the dentures. The SSD stated replacing the dentures was important because loss of dentures could affect the resident's nutritional status. The SSD stated the Registered Dietitian would be immediately notified to address necessary diet texture changes while the dentures were lost. The SSD stated the resident would be put on the list to see the dentist so new dentures could be made. The SSD stated the facility put interventions in place once dentures were received to ensure they were not lost again. The SSD stated the status of obtaining dentures should be documented in the medical record under progress notes. The SSD reviewed R103's Progress Notes and stated R103 was on consultation for the next week to be seen by the dentist in a noted dated 05/29/25; however, she did not see anything else in the record showing what occurred since that time. The SSD stated there was a dental list maintained by the Assistant Administrator. The SSD stated the dentist came to the facility once or twice a month. The SSD stated there was a consultation record in the hard chart that documented dental visits. The SSD reviewed R103's hard chart and stated there was no consultation record showing she had been scheduled for or seen by the dentist since admission. During an interview on 09/05/25 at 3:07 PM, Assistant Administrator (AA)2 stated R103 had a history of wrapping her dentures up and they had been lost more than once. AA2 stated he thought R103's dentures had been found after they were lost on 05/25/25 and it was a later date when they were permanently lost. AA2 stated there was no documentation after 05/25/25 showing R103's had been found and then lost for good at a later date (other than 05/25/25), but he thought the date when the dentures were lost for good occurred after 05/25/25. AA2 stated R103 would have been scheduled earlier to see the dentist if she had lost her dentures on 05/25/25 as the dentist came to the facility on a monthly basis. AA2 stated R103 was scheduled to be seen by the dentist on 09/03/25; however, the dentist did not come on that date and it would be rescheduled. NJAC 8:39-15.1

Based on observation, interview and record review, it was determined that the facility failed to a.) ensure the physician signed and dated monthly medication orders and b.) ensure the physician or the non-physician practitioner (NPP) performed face-to-face monthly visits. The deficient practice was identified for 19 of 32 residents reviewed (#29, 129, 22, 51, 65, 121, 97, 116, 53, 10, 101, 11, 2, 69, 33, 80, 138, 75, 118) and occurred over a 6 month period. The deficient practice was evidenced by the following. 1. A review of the hybrid medical record for Resident #29 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January, February, March, April, or May 2024. 2. A review of the hybrid medical record for Resident #129 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January, February, March, April, or May 2024. One physician progress note (5/4/24) was electronically entered into the medical record, however, no other physician or NPP progress notes were documented for January, February, March, or April 2024. 3. A review of the hybrid medical record for Resident #22 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January, February, March, April, or May 2024. 34033 4. On 5/30/24 at 10:48 AM, the surveyor observed Resident #51 in bed in their room and the resident was unable to be interviewed. The surveyor reviewed the hybrid medical records (paper and electronic) for Resident #51. A review of the resident's Admission Record, (one page summary of important information about a resident) revealed diagnoses that included Alzheimer's Disease, hypertension (high blood pressure), and cerebral infarction (stroke). A review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/5/24, revealed that the resident had had a Brief Interview for Mental Status (BIMS) score of three (3) out of 15, indicating a severely impaired cognition. A review of the monthly physician's orders revealed that the resident's primary care physician had not signed the resident's monthly orders for the months of December 2023 through May 2024. 5. On 5/30/24 at 10:52 AM, the surveyor observed Resident #65 in a bed in their room. The resident stated that he/she went for dialysis every Monday, Wednesday and Friday. The surveyor reviewed the hybrid medical records (paper and electronic) for Resident #65. A review of the resident's Admission Record revealed diagnoses that included Diabetes (high blood sugar levels in the blood), heart failure and chronic kidney disease. A review of the quarterly MDS (QMDS), dated [DATE], revealed that the resident had a BIMS score of 13 out of 15, indicating an intact cognition. A review of the monthly physician's orders revealed that the resident's primary care physician had not signed the resident's monthly orders for the months of December 2023 through May 2024. 6. On 5/30/24 at 10:36 AM, the surveyor observed Resident #121 in a wheelchair in their room. The resident stated that he/she was waiting for his/her aide who then walked into the room. The surveyor reviewed the hybrid medical records (paper and electronic) for Resident #121. A review of the resident's Admission Record revealed diagnoses that included Diabetes, dysphagia (a swallowing disorder) following cerebral infarction and hypertension. A review of the QMDS dated [DATE], revealed that the resident had a BIMS score of 12 out of 15, indicating an intact cognition. A review of the monthly physician's orders revealed that the resident's primary care physician had not signed the resident's monthly orders for the months of December 2023 through May 2024. 34421 7. A review of the hybrid medical record for Resident #97 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023, January 2024, or February 2024. There were no physician or NPP progress notes entered into the record for January 2024, or February 2024. 8. A review of the hybrid medical record for Resident #116 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023, January 2024, February 2024, March 2024, April 2024, or May 2024. There were no physician or NPP progress notes entered into the record for January 2024, February 2024, or May 2024. 46889 9. Resident #53's hybrid medical record review revealed no monthly physician-signed or electronically signed monthly orders for December 2023, January 2024, February 2024, March 2024, April 2024, and May 2024. 10. Resident #10's hybrid medical record review revealed that the physician electronically signed the monthly physician orders for December 2023, March 2024, and May 2024. There were no other signed monthly physician orders for January 2024, February 2024, and April 2024. Additionally, no monthly physician progress notes were written by the physician in January 2024, March 2024, and May 2024. 11. Resident #101's hybrid medical record review revealed that the physician electronically signed the April 2024 monthly physician orders. No other signed monthly physician orders for December 2023, January 2024, February 2024, March 2024, and May 2024. 12. Resident #11's hybrid medical record review revealed no monthly physician-signed or electronically signed monthly orders for December 2023, January 2024, February 2024, March 2024, April 2024, and May 2024. 13. Resident #2's hybrid medical record review revealed no monthly physician-signed or electronically signed monthly orders for December 2023, January 2024, February 2024, March 2024, April 2024, and May 2024. 14. Resident #69's hybrid medical record review revealed no monthly physician-signed or electronically signed orders for December 2023, January 2024, February 2024, March 2024, April 2024, and May 2024. 49078 15. Resident #33's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023, January 2024, February 2024, March 2024, April 2024, and May 2024. 16. Resident #80's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for December 2023, January 2024, February 2024, March 2024, April 2024, and May 2024. 17. Resident #138's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for February 2024, March 2024, April 2024, and May 2024. 48781 18. Resident #75's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for the months of December 2023 through March 2024 and May 2024. 19. Resident #118's hybrid medical records revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for the months of December 2023 through May 2024. On 6/4/24 at 11:02 AM, the surveyor interviewed the Unit Manager (UM), License Practical Nurse (LPN), on the 1st floor North Wing, who has been working in the facility for four years. She stated, The doctors mostly document in the Electronic Health Records (EHR) and the monthly orders are signed electronically. On 6/5/24 at 10:37 AM, interviewed the UM, Registered Nurse (RN), on the second floor North Wing, who has been working in the facility for [AGE] years. The RN stated, The physicians document in the EHR and some have a hard copy in the chart. Doctor [Name Redacted] still documents in the chart. The physicians sign their monthly orders electronically. On 6/5/24 at 12:14 PM, the survey team met with the administration: License Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant DON, two Assistant LNHAs and the Administrator in Training (AIT), regarding concerns with the completion of physician visits and monthly signage of physician orders. On 6/6/24 at 9:37 AM, the survey team met with the DON who acknowledged no improvements on the current concerns regarding physician visits, progress notes completion and monthly signage of physician orders. A review of the most current facility policies and procedures titled, Physician's Orders, and Physician Services stated, The attending physician must certify physician's orders monthly and Physician visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations and facility policy. NJAC 8:39-23.2 (b), (d)

Based on interview and record review, it was determined that the Consultant Pharmacist (CP) failed to report irregularities found in the medical records to the facility. This deficient practice was observed for the following resident. On [DATE] at 12:21 PM, the surveyor reviewed the hybrid medical record (paper and electronic) for Resident #83. The resident's Admission Record (AR) reflected that the resident was admitted with diagnoses including but not limited to Hypertension (elevated blood pressure) and Gastrostomy (G-tube) (an opening into the stomach from the abdomen, for the introduction of food or medications). A review of the resident's Medicare 5 Day Minimum Data Set (MDS) (a standardized assessment tool that measures health status in nursing home residents) dated [DATE], which reflected that the resident had a Brief Interview for Mental Status (BIMS) (a tool used to screen and identify the cognitive condition) Score of three (3) which reflects severe cognitive impairment. The surveyor reviewed the May and [DATE] electronic medication administration record (eMAR) and the current Physician's Order sheet which reflected orders for Sucralfate (a medication used to treat stomach ulcers) 1gm tablet by G-tube four (4) times a day, Nexium (a medication used to reduce stomach acid production) 40mg packet, 1 packet by G-Tube in the morning, Levothyroxine (a medication used to treat an underactive thyroid) 175mcg by G-tube once a day, and an order for enteral feeding (food given by G-tube) Jevity 1.5 (a liquid food product) bolus feed (given a one time) five (5) times per day. The eMAR reflected the administration times of the Sucralfate as 6 AM, 1 PM, 3 PM and 8 PM, the Nexium as 6 AM, the Levothyroxine at 6 AM, and the feeding as 12 midnight, 6 AM, 12 PM, and 9 PM. The Surveyor reviewed the manufacturer package information sheet for Sucralfate which reflected that the medication should be given on an empty stomach and that there was a potential for a drug interaction between the Sucralfate and the Levothyroxine which could be avoided by giving the Levothyroxine two (2) hours before the Sucralfate. The Surveyor reviewed the manufacturer package information sheet for Nexium which reflected that the medication should be given at least 1 hour before meals. The surveyor reviewed the Consultant Pharmacist Review sheet (CPR) for the resident. The CP's responsibility was to review all resident's medication monthly for discrepancies, continued monitoring and correct dose of medications. The CPE sheet did not reflect any comment related to timing of medications and the tube feeding. The Surveyor reviewed the Consultant Pharmacist's Monthly Report (CPMR) for [DATE] and [DATE]. The CPMR reflected that the CP had made recommendations on other unrelated irregularities for the resident during those months but did not make a recommendation on the potential drug interaction or the timing of Nexium or Carafate. On [DATE] at 11:58 AM, The surveyor interviewed the CP by telephone. The surveyor asked the CP if he was aware of the manufacturer dosing recommendations for Sucralfate and Nexium with food and interactions with Sucralfate and Levothyroxine. The CP stated that Sucralfate and Nexium should be given sixty (60) minutes before a meal and Levothyroxine should be separated by two (2) hours from Sucralfate. On [DATE] at 1:56 PM, the surveyor interviewed the Unit Manager LPN (UM) and the medication nurse on duty on the unit where Resident #83 resides. The medication nurse stated that she gives medications to residents as they are ordered in the eMAR. The UM stated that the CP had just called him to have medication times changed for Resident #83. On [DATE] at 2:15 PM, the surveyor in the presence of the survey team informed the facility administrative team of the concern with Resident #83's medication timing and the failure of the CP to report the irregularity. NJAC 8:,d+[DATE].3(a)(1)

Based on observation, interview, record review, and facility policy review, the facility failed to maintain the cleanliness of the oxygen concentrator filter, change nasal cannula tubing, and transfer orders from the hospital to the residents Electronic Medical Record (EMR), for one of two residents (Resident (R) 120), sampled for respiratory care. This deficient practice increased the risk for infection in a resident that had respiratory distress. Findings include: 1. Review of R120's Profile located in the EMR revealed that R120 was initially admitted to the facility on [DATE] and readmitted on [DATE], from a hospital admission. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/08/22 at 1:37 PM and 08/09/22 at 9:14 AM, revealed that R120's oxygen tubing was dated 07/27/22. The oxygen concentrator that was black in color, was completely covered in a thick white dust. Observation on 08/10/22 at 8:51 AM, revealed that R120's oxygen tubing had been changed and was dated 08/10/22. The oxygen concentrator had not been cleaned. Review of R120's Orders located in the EMR revealed that R120 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 08/10/22 at 10:36 AM, with the Assistant Director of Nursing (ADON), revealed that upon observation of R120's oxygen tubing, which was now dated correctly, the oxygen concentrator filter was covered in dust. The ADON stated, the concentrator is dirty, and that maintenance cleans the filters. I have no idea why the tubing was not changed. Observation on 08/10/22 at 10:48 AM, revealed the Assistant Administrator in R120's room putting on gloves and washing the oxygen filter with soap and water. Upon interviewing the Assistant Administrator at 10:50 AM, he stated the filter had some dust on it. He then agreed that the entire filter was covered in a layer of white dust. I then asked for the maintenance logs for oxygen concentrator filter cleaning. Interview on 08/10/22 at 10:53 AM, with the Registered Nurse/Unit Manager (RN), revealed that the oxygen tubing is changed for all residents on Wednesday's during the night shift. A piece of tape with the date is placed on the tubing. When the RN was asked if the person changing the tubing has to sign-off for completing the procedure, she stated no, and that maintenance has to clean the concentrator filter. Interview on 08/10/22 at 1:45 PM, the Assistant Administrator stated that maintenance was not keeping logs of when oxygen filters were cleaned. Administration identified the lack of completion of monthly logs by the maintenance department and stated that this would be addressed in the next Quality Assurance (QA) meeting that will be held this month. Interview on 08/10/22 at 4:04 PM, with the Director of Nursing (DON), revealed that her expectations for the nursing staff is to change the oxygen tubing weekly and follow protocol. The oxygen concentrator should not have been dirty, and the tubing should have been changed. During an interview on 08/11/22 at 9:36 AM, with the DON, revealed that R120 had been in the hospital and returned to the facility on [DATE]. Upon his return, the nurse did not enter the orders for his oxygen. The resident did not have oxygen before he went to the hospital. The order was on the hospital discharge papers and just did not get transferred to the EMR. Orders are now in the system. Review of the facility's policy titled, Respiratory Therapy Equipment, undated, revealed, The purpose of this procedure is to provide guidelines to help prevent nosocomial infections associated with respiratory therapy equipment, and to prevent transmission of infections to residents and staff .Change oxygen cannula and tubing weekly during the (11-7) shift .Wash filters from oxygen concentrators monthly. NJAC 8:39-19.4(k)

Based on interview, record review, review of the Centers for Disease and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure that one Resident(R)111, of five residents sampled for immunization reviews, were offered and given the option to receive or decline an additional pneumonia vaccine. Findings include: Review of the CDC guidelines located at: https://cdc.gov/vaccines/vpd/pneumo/hcp/recommendations, revealed adults with a previous Pneumococcal Vaccine [MEDICATION(S)] (PPSV23) only, the CDC recommends for those over [AGE] years of age a Pneumococcal valent Conjugate Vaccine (PCV), either PCV20 or PCV15 should be given greater than one year after their last PPSV23 dose. 1. Review of R111's undated Face Sheet located in R111's electronic medical record (EMR) located under the Profile tab, indicated R111 was initially admitted to the facility on [DATE] with a readmission on 07/12/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the EMR revealed the resident was [AGE] years of age. Review of R111's undated Clinical Immunizations, located in R111's EMR under the Immunization tab, revealed R111 received [MEDICATION(S)] on 01/16/19. Further review of R111's EMR and physical medical record revealed that R111 had not been offered, administered, or declined the PCV20 or PCV15 vaccine as recommended by the CDC. During an interview conducted with the Infection Control Preventionist (ICP) on 08/11/22 at 11:13 AM, after research of resident's documents and vaccinations, the ICP stated, no, the resident had not received the PCV20 or PCV15 vaccine. We will offer it to her now. The ICP confirmed the resident had not received the vaccination and should have been offered it. Review of the facility's undated policy titled, Vaccination Policy, revealed All residents have the option to receive the pneumonia vaccine to prevent the spread of infection .Vaccine will be offered to residents [AGE] years and older, or if ordered by a physician .the resident's medical record includes documentation that indicates, at a minimum, the following : Intent (A) that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunizations due to medical contraindication or refusal. The policy did not address giving those residents over [AGE] years of age an additional pneumonia vaccine per CDC guidelines. NJAC 8:39-19.4(i)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain appropriate infection control practices for 1 resident who tested positive for [MEDICAL CONDITIONS]. This deficient practice was identified for Resident #145, 1 of 3 residents reviewed for infections and was evidenced by: On 02/12/20 at 10:50 AM, the surveyor observed Resident #145 seated in a wheelchair in the resident's shared room. Resident #145 told the surveyor he/she had gotten diarrhea after being on antibiotics. On 02/13/20 at 12:26 PM, Resident #145 told the surveyor he/she had [MEDICAL CONDITION]. but remained in a shared room and continued to use the shared bathroom with the adjoining room. Clostridum Difficile ([MEDICAL CONDITION]) is a contagious bacterial infection of the large intestine which causes diarrhea. The resident said he/she has resided in a room and shared a bathroom with another resident since admission. This was confirmed by surveyor review of the facility Census List that revealed Resident #145 has resided in the shared room since admission. A review of Resident #145's records revealed Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #145's Admission Minimum Data Set (MDS), an assessment tool, dated 1/29/20 revealed Resident #145 had a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated the resident's cognition was moderately impaired, required extensive assistance of a staff member for toileting and hygiene, and was always continent of bowel and bladder. A review of Resident #145's Order Summary Report revealed an order dated 02/04/20, for the antibiotic [MEDICATION NAME] Suspension 250 milligrams (mg) per 5 milliliters (ml). Give 2.5 ml by mouth four times a day for 10 days for treatment of [REDACTED]. A review of Resident #145's Order Summary Report revealed an order dated 02/05/20, for [MEDICATION NAME] Suspension 250 milligrams (mg) per 5 milliliters (ml). Give 2.5 ml by mouth four times a day for [MEDICAL CONDITION] for 10 days. This order contained the clarification that 2.5 ml equals 125 mg. A review of Resident #145's Medication Administration Record [REDACTED]. The surveyor reviewed a final laboratory report with an approval date of 02/04/20 indicating the resident tested positive for [MEDICAL CONDITION] toxin B. The surveyor reviewed a final laboratory report with an approval date of 02/07/20 indicating the resident tested positive for [MEDICAL CONDITION] toxin B. The report further indicated that contact precautions were recommended. The surveyor reviewed the Laboratory Report for Resident #145 which revealed on 01/29/2020 the resident's WBC result was noted to be an elevated 14.7 (normal range on the report was 4-10.5) and an elevated 13.3 on 02/03/20. On 02/13/20 at 12:39 PM, The surveyor asked the Certified Nursing Assistant (CNA) to identify any resident on isolation on the unit. The CNA was not able to identify Resident #145 as being on isolation. On 02/13/20 at 12:41, the unit Registered Nurse (RN) revealed if a resident had [MEDICAL CONDITION], they should be on isolation. The RN identified another room with a resident that was on contact precautions and indicated a resident with [MEDICAL CONDITION] would go on contact precautions and either be moved to a single room, or be cohorted with someone with the same infection. On 02/13/20 at 12:45, the RN Unit Manager (UM) revealed that residents with [MEDICAL CONDITION] are assigned a private room. The RN UM further revealed that although Resident #145 tested positive for [MEDICAL CONDITION] and was initially going to be moved to a single room, based on the Infectious Disease (ID) physician's recommendation the facility allowed the resident to remain in a room with a resident who did not have a [MEDICAL CONDITION] infection because Resident #145 did not have additional symptoms which would include fever, leukocytosis and abdominal cramping. The surveyor was provided an Email from the ID physician which indicated the facility informed him Resident #145 did not have diarrhea when he made the recommendation to stop contact isolation. The facility provided the surveyor with a copy of Clinical Infectious Disease Guidelines from the Infectious Disease Society of America which the ID physician referenced in his Email for residents with [MEDICAL CONDITION]. Under section XVI Infection Prevention and Control the guideline indicated a resident should remain on contact isolation for at least 48 hours after diarrhea has resolved. On 02/20/20 at 10:19 AM, in the presence of the surveyor team and the assistant administrator, the surveyor had a telephone interview with the ID physician who confirmed if a resident tested positive for [MEDICAL CONDITION] and had loose stools, they should be isolated. The ID physician further indicated if the resident had other symptoms such as an elevated white blood cell count (WBC's) in addition to a positive [MEDICAL CONDITION] test, the [MEDICAL CONDITION] test would prove more positive. The ID physician indicated that he believed Resident #145 was colonized with [MEDICAL CONDITION] and loose stools were secondary to medication for constipation. On 02/20/20 at 12:17 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed if a resident tested positive for [MEDICAL CONDITION], they should be put on contact precautions and placed in a private room. The DON further revealed the facility follows McGeer Criteria for Infection Surveillance Checklist and provided the surveyor a copy of the checklist. The surveyor observed the criteria for [MEDICAL CONDITION] infection included a positive test for [MEDICAL CONDITION] and 3 or more liquid or watery stool (diarrhea). The surveyor reviewed a written statement from the Nurse Practitioner (APN) and was provided by the facility on 02/21/20. The statement revealed Resident #145 started on [MEDICATION NAME] after the resident tested positive for [MEDICAL CONDITION] and lab work confirmed the resident had leukocytosis (elevated WBC's) in addition to multiple loose bowel movements. The surveyor reviewed the statement provided by the Infection Control Preventionist (ICP) RN, dated 2/14/20, which indicated although Resident #145 tested positive for [MEDICAL CONDITION], and experienced loose bowel movements, the resident did not exhibit other symptoms of [MEDICAL CONDITION] including foul smelling stool. The progress notes for Resident #145 revealed the following: 1. physician progress notes [REDACTED]. 2. Nursing Progress note indicated the resident had 2 loose bowel movements, with foul odor reported, on 02/01/20. 3. Nursing Progress note indicated the resident requested an antidiarrhea medication because the resident was having loose bowel movements every 4 hours. 4, Infection note dated 02/02/20, indicated Resident #145 tested positive for [MEDICAL CONDITION] and was being transferred to another room and contact (isolation) precautions were maintained 5. physician progress notes [REDACTED]. The note further indicated an intervention to place the resident on contact precautions. 6. The surveyor further read nurse Progress notes dated 02/06/20, 02/07/20 (from 2 different nurses), 02/12/20 02/13/20 (from 2 different nurses) and 02/14/20 (from 2 different nurses), and Infection notes dated 02/06/20, 02/10/20 all documenting contact precautions were being maintained for Resident #145 related to [MEDICAL CONDITION]. The surveyor reviewed the Medication Administration Record [REDACTED]. According to the Medication Administration Record [REDACTED]. The surveyor reviewed the policy titled, Antibiotic Stewardship Program, with a revision date of 12/12/19, provided by the Assistant Administrator. This policy revealed if isolation was indicated, the facility would follow the policy for isolation as directed by the Infectious Disease Consultant. The surveyor reviewed the undated policy titled, Isolation, Initiating which revealed Isolation precautions should remain in effect until discontinued by the attending physician or criteria are met. The surveyor reviewed the undated, Infection Prevention and Control, Contact Precautions, provided by the facility administrator. The policy's purpose was to reduce the risk of epidemiologically important microorganisms by direct or indirect contact. The policy indicated residents on contact Precautions should be in a private room or cohorted with residents with the same organism. At the surveyor's request, the facility was unable to provide documentation indicating the residents sharing Resident #145's room and bathroom had [MEDICAL CONDITION]. NJAC 8:39-19.4(a)

Based on surveyor observation in the presence of the facility's Assistant Administrator on 12/18/17, it was determined that the facility failed to ensure the resident's physical environment remains free of accident hazards as evidenced by the following: At 1:10 p.m., the surveyor observed an unlocked door to a laundry chute room located on the building's 1-North Unit. The doorframe to this room had a wad of paper lodged in the latch plate that prevent the door's positive latch from working. The door was equipped with a keypad lock the was engaged. However, the wad of paper rendered it useless and the door readily opened without even turning the doorknob. Although, the door was in the closed position, residents could still enter this room and access the laundry chute. Residents were observed in the area during time of observation. NJAC 8:39-31.2(e)

Based on interview and record review it was determined that the facility failed to provide appropriate pharmaceutical services with respect to dispensing medications which resulted in a delay of treatment for [REDACTED].#19. The evidence was as follows: On 10/7/14 at 12 Noon the surveyor reviewed Resident #19's Nurse's Progress Notes which indicated a 10/4/14 note timed at 9:56 a.m. that a new physician order [REDACTED]. The surveyor then reviewed physician orders [REDACTED]. The surveyor reviewed the Nurse's Progress Notes that indicated a 10/4/14, 10:55 p.m. note, which indicated that Resident #19 was still complaining of nausea and, according to the Supervisor, [MEDICATION NAME] was not available in the facility. The note stated a phone call was placed to the pharmacy about the order and the pharmacy would be sending it that night. Additional review indicated a 10/5/14, 2:32 p.m. note which documented that Resident #19 was still complaining of nausea. The pharmacy was again notified about the [MEDICATION NAME] order and they stated that they would send it that afternoon. Further review indicated a 10/5/14, 9:01 p.m. note which documented that at 4 p.m. Resident #19 was still complaining of nausea and [MEDICATION NAME] 5 mg was administered with relief. The surveyor then reviewed the Medication Administration Record [REDACTED]. On 10/7/14 at 12:30 p.m. the surveyor interviewed the Unit Manager (UM) who stated that the pharmacy did delay sending the [MEDICATION NAME] to the facility while Resident #19 was complaining of nausea. He then stated that the facility Nurses did follow up with the pharmacy during that period of delay. On 10/8/14 at 9:36 a.m. the surveyor interviewed a Nurse representative of the dispensing pharmacy who stated that she was aware of the above delay. N.J.A.C. 8:39-29.6(a), 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to ensure that medications were stored under proper temperature controls. The facility also failed to ensure that the pharmacy labeled medications with manufacturer specified storage requirements. This deficient practice was observed on 1 of 4 units of the facility, 2 North. The evidence was as follows: 1. On 10/3/14 at 10:36 a.m. the surveyor, in the presence of Nurse #1, inspected the 2 North medication refrigerator and observed 4 insulin pens stored there. There were 2 Novolog FlexPens, 1 Levemir FlexPen and 1 Lantus Solostar Insulin pen which were labeled for 4 different residents. Nurse #1 stated at that time that all 4 Insulin pens were punctured, in use and all 4 residents had active orders for these Insulin pens. On 10/3/14 the surveyor reviewed the manufacturer specifications for the 4 Insulin pens which indicated the following: Novolog FlexPen- "Once punctured and in use Novolog FlexPen must not be stored in a refrigerator;" Levemir FlexPen- "After initial use, Levemir FlexPen must not be stored in a refrigerator;" and Lantus Solostar Insulin pen- "Opened and in use Lantus Solostar should not be refrigerated but should be kept at room temperature." On 10/3/14 at 10:36 a.m. the surveyor interviewed Nurse #1 who stated that she thought that once the above Insulin pens were opened and in use, they could be stored in the refrigerator. 2. On 10/6/14 at 10:36 a.m. the surveyor, in the presence of Nurse #1, reviewed the pharmacy labels on the 4 Insulin pens in Example #1. According to the label, the Novolog FlexPen should be refrigerated until opened. Once opened they may keep at room temperature for 28 days. Both the Levemir FlexPen and the Lantus Solostar labels indicated to refrigerate. On 10/6/14 at 11:51 a.m. the surveyor interviewed a Pharmacist representative of the dispensing pharmacy by telephone. She confirmed that the pharmacy labels were documented as stated above and she agreed that the above Insulin pens once punctured and in use were not supposed to be stored under refrigeration. She also agreed that documenting the correct storage requirements on the labels would help direct the Nurses to store the medications under proper storage requirements. N.J.A.C. 8:39-29.4(a)10,(h)

Based on observations and interviews it was determined that the facility failed to maintain dignity for residents while dining by using plastic glasses and Styrofoam/paper dishware. This deficient practice was identified for residents who were observed at the lunch meal service on all 4 of 4 units of the facility and was evidenced by the following: During surveyor initial tour of the kitchen on 10/2/14 at 10 a.m., in the presence of the kitchen supervisor, the surveyor observed that cake, cut fruit and sandwiches were placed on white paper dessert plates and stored inside the walk-in refrigerator. On 10/2/14, 10/3/14 and 10/6/14 between 12 noon and 1 p.m. the surveyor observed residents dining during the lunch meal on the 1 North, 1 South, 2 North, and 2 South units. Some drinks were served in soft clear plastic glasses and the dessert was served in small clear plastic cups with lids. Sandwiches, pie, cake and bread pudding were served on white paper dessert plates. Additionally, some soups and salads were served in Styrofoam bowls. Similar observations were made during the lunch meals for the residents who chose to eat in their own rooms. On 10/7/14 at 9:45 a.m. the surveyor interviewed the Food Service Director (FSD) who stated that she had always served desserts and some soups, salads and drinks on paper plates or in Styrofoam cups or clear plastic small glasses for all meals. The FSD further stated that she was not aware that food should not be served on disposable dishes on a routine basis. N.J.A.C. 8:39-17.2 (e)

Based on observations, interviews, and documentation review on 9/3/13 in the presence of facility management, it was determined that the facility failed to handle potentially hazardous foods in a sanitary manner in accordance with safe food handling practices and facility policy to thaw frozen foods as evidenced by the following: At 11:50 a.m., the surveyor observed chicken thawing in the cook's prep sink in the meat kitchen. The chicken consisted of a large semi-frozen block of unpackaged chicken leg/thigh portions sitting directly in the sink. The cold water was running but the chicken was not submerged in a pan with the water overflowing to a drain. The cook then turned the running water off and left the sink with no water flowing on the chicken. At 12:35 p.m., the surveyor observed that the chicken was still in the sink and the water was now flowing but the chicken was still not submerged in a pan. In an interview, at the time, the Food Service Director (FSD) stated that the cook was removing pieces of chicken as they thawed to prepare for cooking. When the surveyor asked the FSD what the proper method was to thaw meats, the FSD responded that the proper method was under running water. The surveyor then asked if the proper method also included the meat to be submerged in a pan overflowing to a drain with water less than 70 degrees F. The FSD confirmed the regulation and stated that the block of frozen chicken was too big for their pans. In an interview, at the time, the facility's Dietician also confirmed the proper thawing method. A review of the food thawing policy titled "Thawing Food SOP" revealed under Procedure 1) b. "Submerge the food under running potable water at 70 degrees F or lower; clean and sanitize the sink and work area before and after thawing foods this way." There is no evidence this policy was consistently followed. NJAC 8:39-17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to provide professional standards of quality with respect to administration, ordering of medications, and following physician orders. This deficient practice was observed for 2 of 6 residents observed on the morning medication pass of 8/28/13, Resident #'s 17 and 18. The evidence was as follows: 1. On 8/28/13 at 8:08 a.m. during the medication pass, the surveyor observed Nurse #1 administer medications to Resident #17 including Folic Acid 1 milligram (mg) and Vitamin D3 800 International Units (IU) by mouth (po). At that time the surveyor reviewed the 8/2013 Medication Administration Record (MAR) which indicated that between 8/1/13 and 8/8/13 it was documented that both the Folic Acid and the Vitamin D3 were administered daily (qd) at 5:00 p.m. and the Time Of Administration (TOA) was set at 5:00 p.m. but between 8/9/13 and 8/28/13 the TOA was changed to 9:00 a.m. and each medication was documented as administered qd at 9:00 a.m. during that time. On 8/28/13 the surveyor reviewed the 7/2013 MAR which indicated that the Folic Acid and Vitamin D3 were documented as administered qd at 5:00 p.m. each day of 7/2013 with the TOA set at 5:00 p.m. On 8/28/13 at 10:50 a.m. the surveyor also reviewed the Physician Order Sheet (POS) dated 7/24/13 which indicated a current order for Folic Acid 1 mg po qd at 5:00 p.m. and Vitamin D3 800 IU po qd at 5:00 p.m. On 8/28/13 at 10:55 a.m. the surveyor and Nurse #2, the Charge Nurse, reviewed Resident #17's Physician orders and Nurse #2 stated that the current order for the Folic Acid and Vitamin D3 were for each to be administered at 5:00 p.m. She further stated that there was no physician order to change the TOA from 5:00 p.m. to 9:00 a.m. She also stated that she could not explain why the TOAs were changed. She further agreed that the issue of changing physician ordered TOA without a physician's order was against accepted Standards of Practice of the ordering and administration of medications. On 9/3/13 at 9:41 a.m. the surveyor interviewed the Consultant Pharmacist (CRPh) who stated that the physician ordered TOA for medications can not be changed without a physician order. He also agreed that this issue was against accepted Standards of Practice of the ordering and administration of medications. On 9/3/13 the surveyor reviewed the Facility policy titled "Medication Ordering And Prescribing Authority" which included that medications will be administered only upon the written and/or verbal order of a practitioner granted clinical privilege at the facility who is legally authorized and licensed to prescribe medications (Physician)... 2. On 8/28/13 at 8:08 a.m. during the medication pass the surveyor reviewed the MAR and directly following, the surveyor reviewed physician orders which indicated a current order for Vitamin C 500 mg CR (controlled release) capsule po qd. Nurse #1 did not find this medication in the medication cart but did find Vitamin C 500 mg immediate release tablets. The physician was telephoned and approved the change of order to the immediate release tablet which Nurse #1 administered at that time. On 8/29/13 the surveyor again reviewed physician orders which indicated that there was no documented order to change the above Vitamin C CR capsule to the Vitamin C immediate release tablet. On 8/29/13 at 1:12 p.m. the surveyor interviewed Nurse #2 who stated that there was no order documented that changed the Vitamin C CR capsule to the immediate release tablet up to that point in time. She then stated that she will document this order and she agreed that the telephone order should have been documented as a new order immediately when the order was received the day before (8/28/13). On 9/3/13 at 9:41 a.m. the surveyor interviewed the CRPh who agreed that the telephone order to change the Vitamin C CR capsule to the immediate release tablet had to be documented as a new physician order as accepted Standard of Practice of ordering of medications. On 9/3/13 the surveyor reviewed the Facility policy titled "Medication Ordering And Prescribing Authority" which included that verbal orders must be recorded immediately in the resident's chart by the person receiving the order and this order must be signed by the prescriber within 30 days. There is no evidence this policy is consistently followed. 3. On 8/28/13 at 9:10 a.m. during the medication pass, the surveyor observed Nurse #3 administer the supplement Pro-Stat Sugar Free AWC, 30 milliliters (ml) po to Resident #18. At that time the surveyor inspected the medication cart and found that that was the only Pro-Stat product present in the cart. On 8/28/13 the surveyor inspected the medication rooms and found a bottle of Pro-Stat Sugar Free (not AWC). On 8/28/13 the surveyor reviewed physician orders which indicated a current order for Pro-Stat Sugar Free twice daily (bid) (not AWC) which was the same product found in a medication room as stated above but was not in the medication cart. On 8/28/13 the surveyor reviewed the formulas of each Pro-Stat product which indicated that there was a difference. The Pro-Stat AWC product contained 17 grams (g) of total protein, 7 g of total carbohydrates and Vitamin C 175 mg. The Pro-Stat (not AWC) contained 15 g of total protein, 10 g of total carbohydrates and no Vitamin C. On 8/29/13 at 11:30 a.m. the surveyor interviewed Nurse #4, a Charge Nurse who agreed that Nurse #3 should have administered the supplement ordered by the physician during the above observation as accepted Standard Of Practice of supplement administration. On 9/3/13 at 9:41 a.m. the surveyor interviewed the CRPh who agreed that the Pro-Stat product ordered by the physician was different from the Pro-Stat product administered by Nurse #3 which was against accepted standard of practice of supplement administration. NJAC 8:39-27.1(a) NJAC 8:39-11.2(b)

Based on observation, interview and record review, it was determined that the facility failed to provide medication security with respect to medications stored in an unlocked medication room out of Nurses's eyesight. This deficient practice was observed for 1 of 4 Nursing unit's of the facility and was evidenced by the following: On 8/29/13 at 12:43 p.m. the surveyor observed that the door to the 1-North medication room was closed to the point where the latch on the door leaned against the door frame. The surveyor observed that there was no nurse within eyesight of the medication room at that time. The medication room was located at the 1-North Nurse's Station which had direct access to the common corridor. The surveyor then knocked on the door to the medication room. There was no answer and the surveyor opened the door, walked into the room where there was nobody present. In a timeframe of approximately 30 seconds, Nurse #5 came to the medication room and asked the surveyor who let him into the room. The surveyor responded that he let himself into the medication room as the door was not latched to the frame. Nurse #5 then stated that she had left the medication room just before. In a continuation of the interview on 9/3/13 at 11:25 a.m. Nurse #5 stated that she usually ensured that the medication room was locked before she left the area but could not explain why the surveyor found the door unlocked during the above observation. She then stated that going forward she will make sure that the door to the medication room was locked when she leaves the area. At the time when the surveyor let himself into the unlocked medication room as observed above, he inspected the room and found medications stored on an open shelf about Torso level. These medications included "Bingo Cards" of Metoprolol Tartrate 25 milligrams (mg), Namenda 10 mg, Clonidine 0.2 mg, Meclizine 25 mg, Metformin 500 mg, Furosemide 20 mg, Enalapril 20 mg, Phenytoin 100 mg, Donepezil 10 mg, Hydralazine 10 mg, Amlodipine 5 mg, Hydrochlorothiazide 25 mg, Omeprazole 40 mg, Diovan 160 mg, Simvastatin 80 mg. Also found were Lidoderm Patches, and Lactulose Syrup. Also found on an open shelf at eye level were Rubbing Alcohol, Docusate Sodium Liquid, Mylanta Liquid, Milk Of Magnesia Liquid, Fleets Enema, Aspirin Tablets, Acetaminophen Tablets, Oscal Tablets and Vitamin C tablets. On 9/3/13 at 9:31 a.m. the surveyor interviewed the 1-North Charge Nurse who stated that there were two residents who were cognitively impaired and also who could walk without assistance who lived on the 1-North unit. She further stated that one of these two residents was able to self propel in a wheel chair. There was also no residents near the medication room at the time of the observation. On 9/3/13 at 9:41 a.m. the surveyor interviewed the Consultant Pharmacist (CRPh) who stated that all medications must be secured at all times. On 9/3/13 the surveyor reviewed the facility policy titled "Medication Storage" which included that "...medications will be stored in a manner that ensures the safety of the residents and is in accordance with Department Of Health Guidelines." Further review indicated that "..all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel." There is no evidence this policy was consistently followed. NJAC 8:39-29.4(h)

Based on observation, interview and record review, it was determined that the facility failed to; (a) ensure that acceptable standards of practice of documentation and order clarification were met and (b) provide timely notification to a Physician of an abnormal X-ray report, both according to professional clinical nursing standards. This deficient practice was observed for 5 of 28 residents reviewed, Resident #'s 3,11,18, 27 and 28. The evidence was as follows: 1. On 6/1/12 at 7:49 a.m. during the medication pass the surveyor observed Medication Nurse #1 administer a [MEDICATION NAME] 20/37.5 tablet by mouth (po) to Resident #18. The nurse did not document on the Medication Administration Record (MAR) with her initials that she administered the medication. At 8:02 a.m. the nurse prepared and administered 5 medications by mouth (po) to Resident #11. The nurse did not document the MAR with her initials that she administered the 5 medications. The nurse then attended to the next resident on the medication pass. On 6/1/12 at 8:22 a.m. the surveyor and Medication Nurse #1 reviewed the MARs for Resident #'s 18 and #11 which indicated that the nurse had not initialed either of the MARs. The nurse then acknowledged that she forgot to initial the MARs at the time of the medication administration and agreed that she should have done so when the medications were administered. On 6/1/12 at 12:29 p.m. the surveyor interviewed the Director Of Nurses (DON) who stated that the nurse was supposed to initial the MAR immediately after she administered medications to the resident. On 6/5/12 the surveyor reviewed the facility policy titled "General Dose Preparation and Medication Administration" which indicated that the nurse was supposed to document necessary medication administration when medications were given. 2. On 6/1/12 at 9:27 a.m. during the medication pass the surveyor reviewed the MAR of Resident #27 which indicated an order for [REDACTED]. Further review indicated that there was no nurse's initial that the patch was applied that morning. At that time the surveyor interviewed Medication Nurse #2, Resident #27's 7:00 a.m. to 3:00 p.m. medication nurse who acknowledged that the MAR was not documented that the [MEDICATION NAME] Patch was administered that morning. Refer to Example 1. 3. On 6/1/12 at 10:31 a.m. the surveyor reviewed physician orders, and the 4/2012, 5/2012 and 6/2012 MARs of Resident #28 which indicated a current order dated 4/28/12 for [MEDICATION NAME] Gel, apply to affected area twice daily (bid) to lower back as needed (prn), no dose was documented. [MEDICATION NAME] was indicated for pain. The 4/2012 and the 5/2012 MARs were each hand written and documented as above. The 6/2012 MAR was computer generated by the pharmacy and was documented to apply 4 grams (g) to lower back back bid prn. The surveyor observed the tube of [MEDICATION NAME] gel that was dispensed by the pharmacy with a measuring device to measure 2 g and 4 g doses. The surveyor reviewed the medication reference book, which was located at the nurse's station, which indicated that the medication was supposed to be applied in measured doses i.e. 2 g or 4 g... depending on the area it was intended to be applied. On 6/1/12 at 10:48 a.m. the surveyor interviewed the Physician and Head Nurse #1. The surveyor told the Physician per the medication reference that the [MEDICATION NAME] was supposed to be ordered by dose and asked the Physician which dose he wanted to be applied to Resident #28. The Physician then stated 2 g. Head Nurse #1 then stated the 4 g dose documented on the 6/2012 MAR was a pharmacy decision and was not as a result of a clarification with the Physician. She then agreed that the original order should have been clarified with the Physician. She also stated that the pharmacy should not have documented the 6/2012 MAR with a 4 g dose without first clarifying the order with the Physician. On 6/5/12 the surveyor reviewed the facility policy titled "Physician/Prescriber Authorization and Communication of Orders to Pharmacy" which indicated that Pharmacy may contact facility staff before dispensing medication when the Pharmacist believes that there is a need to clarify the medication order because the medication order is unclear, incomplete or vague. 4. On 5/31/12 the surveyor reviewed Resident #3's "Nurses Notes" dated 2/17/12 and timed 5:00 p.m. which indicated an X-ray result for Resident #3 was received and indicated a nondisplaced [MEDICAL CONDITION] fibula (leg). Continued surveyor review of the "Nurses Notes" dated 2/22/12 and timed 1:30 p.m. indicated that Resident #3's Physician was notified of the X-ray results of 2/17/12 on 2/22/12, five days later, causing a delay in treatment. Refer to F309 N.J.A.C. 8:39-27.1(a)