Every finding on record at Willowbrooke Court Skilled Care at Evergreens

Repeat Deficiency Based on observations, interviews, and review of facility documents, it was determined that the facility failed to maintain proper kitchen sanitation practices and properly store foods in a safe and sanitary environment to prevent the development of food borne illness.This deficient practice was observed during the tour of two kitchens and was evidenced by the following:On 08/28/2025 9:30 AM, the surveyor toured the Country Kitchen which served the second-floor residents with the Director of Culinary Services (DCS) in the presence of a second surveyor.The surveyor observed a Dietary Aide (DA) coming out of the rear kitchen area without a hair restraint for a lengthy think dark beard. The DCS stated he did not think a beard net was required unless food production or food handling was being performed. The front area of the Country Kitchen had two plate warmer drawers which held clean plates. The top drawer had a sticky brownish debris on the handle as well as on the top trim inside the drawer front. The DCS acknowledged it needed to be cleaned.There was a square opening in the ceiling above the [name redacted] toaster oven like unit. The DCS stated there was a leak and maintenance had not fixed the ceiling yet.There was an open plastic 64-ounce (oz) tub of peanut butter that had a received date of 8/25/25 but had no opened date. The DCS acknowledged this and stated there should have been an opened date, that is their process.In the rear kitchen area, there was a top single door reach in refrigerator which had a one quart opened container of almond milk with a received date of 8/25/25 but had no opened date. The DCS acknowledged this and stated there should have been an opened date.On 8/28/2025 at 10:00 AM, the Nutrition Services Manager (NSM) joined the tour. Prior to joining the tour, the NSM walked through the rear kitchen to the front kitchen area without a hair restraint.On 8/28/2025 at 10:18 AM, the tour continued to the main kitchen. The walk-in freezer had a large build-up of ice on the floor towards the left back corner under the metal shelving and extended towards the center. The DCS stated that maintenance was aware and stated, they were working on it, we chip it off to clean it.There was an opened half gallon of whole milk with no opened date in the produce walk-in refrigerator. The DCS acknowledged this and stated, they should have put an opened date on the milk.The surveyor observed a woman seated in a chair near the pot wash area without a hair restraint. The DCS acknowledged that she should have been wearing a hair restraint.There was as rack which held inverted stacked metal pans. The NSM separated two pans which revealed water in between them (Wet Nesting - poses an increased risk of bacterial growth. When pans are not completely dried, moisture becomes trapped between them, creating an ideal environment for bacteria to thrive. This can lead to foodborne illnesses). The NSM acknowledged that the pans were not properly air dried before stacking.There were double stack convection ovens in use which had a large build-up of debris. The DCS acknowledged this and stated, the ovens should be cleaned once a week and this needs to be looked at.In the storeroom there were two boxes of vinyl gloves, and one box of thickener stored less than 18 inches from the ceiling / sprinkler heads. The DCS acknowledged they were stored too high and should not have been less than 18 inches.The surveyor observed multiple dry storage items that were opened without opened dates as follows:- A one-gallon bottle of maple syrup. - A 61 oz bottle of sesame oil. - A one-gallon bottle of vanilla. - A 10-pound (lb.) bag of dry pasta, which was unsealed and open to the air.- A small bag of powdered sugar loosely wrapped with clear plastic.- Two small one lb. boxes of corn starch, one of which was unsealed and open to the air.- A 20 lb. bag of dry split peas.The DCS acknowledged the above and stated, it was the responsibility of the dietary staff (chef, cooks, servers, etc.) as well as himself to ensure that an opened date was written on any opened product, and it was properly resealed. He added that this was their system.There was a white ceiling tile in the middle of the room over a dry storage rack which was bowed, with a brown reddish discoloration and appeared cracked. The DCS stated there was a leak about a week ago and maintenance has not changed it yet.On 09/02/2025 at 12:49 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), the Executive Director and the Regional Clinical Director to present the concerns during the kitchen tours.A review of the facility provided policy Personal Appearance Standards with a revised date of 2/2025, reflected that staff with facial hair must wear a beard guard while in the production kitchen. It also included, hair restraints should be worn when in the production area where food was prepared or plated from a hot to cold workstation.A review of the facility provided form Receiver Daily Tasks, reflected that the inside of the convection ovens should be cleaned weekly on Sundays.A review of the facility provided policy Guide to Proper Food Storage Techniques dated 8/2010, reflected the following:- Proper food handling and storage techniques must be followed to prevent contamination and pathogen growth.- The best way to control pathogen growth is to control time and temperature.- Milk and dairy products need time and temperature control for safety.- Rotate food to use the oldest first.- Identify items by the date on the label or expiration date.- Once equipment has been cleaned and sanitized, it must be stored in a way to prevent contamination.A review of the facility provided policy Date Marking Ready- To-Eat Foods with revised date of 7/2025, reflected that foods should be labeled to include the date the product was prepared or opened and the date the product should be used by.NJAC 8:39-17.1(a);17.2(g)

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 06/05/24 from 8:56 AM to 9:25 AM, the surveyor, accompanied by the Regional Culinary Director (RCD) observed the following in the kitchen: 1.) The RCD washed her hands at a designated hand washing sink for 12 seconds. 2.) The step can style trash can at the employee hand washing sink had small flying insects (identified by the RCD as fruit flies) flying inside and outside of the trash can when opened. When the surveyor stepped on the pedal to open the trash can, there was a white paper towel with an orange discoloration inside with small insects crawling on it. The RCD stated she would get someone to empty the trash can. 3.) In the refrigerator, identified as the Produce Refrigerator by the RCD, there was a half pan of carrots sealed with plastic wrap. The half pan of carrots was not labeled with a date the carrots were prepared nor a use-by date. The RCD removed the half pan of carrots from the refrigerator. On 06/06/24 from 11:50 AM to 12:10 PM, the surveyor, accompanied by the RCD and Culinary Director (CD), observed the following in the kitchen: 4.) Two (2) Line Cooks and one (1) Prep [NAME] were wearing beard guards that did not cover their mustache facial hair. The RCD instructed the kitchen staff to pull their beard guards over their mustaches. 5.) A multi-tiered shelving unit, identified by the RCD as the storage area for clean and dry dishware, contained a stack of full pans and a stack of third pans that were wet nested. The surveyor lifted the pans to reveal there was liquid between the pans. The RCD instructed kitchen staff to re-wash the pans. During an interview with the surveyor on 06/06/24 at 12:50 PM, the RCD stated the following: 1.) The process for hand washing included washing hands for 15-20 seconds to prevent cross contamination and food-borne illnesses. 2.) The trash cans at the hand washing sink were designated for hand washing purposes only and that the trash cans should be emptied and kept clean for infection control purposes. The RCD further stated that pest issues, such as fruit flies, should be reported to management as fruit flies can lay eggs and continue to spread if not eliminated. 3.) The sealed carrots should have been labeled with the date they were prepped and would be good for three (3) days since it was a prepared product. 4.) [NAME] guards, a type of hair restraint, should cover all facial hair, including mustaches, to prevent hair from entering food or food prep items, since hair is full of bacteria. 5.) Dishware, such as pans, should be air dried before storing nested and if pans are wet nested, they should be re-washed because, wet nesting promotes bacteria growth. Review of the facility's Hand Washing Procedure from the Culinary Services Manual, revised 12/07, included, Apply approximately one tablespoon of hand soap from proper dispenser to your hands. Join hands and work up a good lather for 20 seconds, in addition concentrate under nails, between fingers, and under wedding bands. Review of the facility's Trash policy from the Environmental Services Manual, revised 08/2011, included, All trash containers will be covered with a fitted metal or plastic cover, and In order to maintain sanitary conditions, trash containers should be lined with plastic liners. The policy did not address how to prevent and address pest issues related to trash cans in the kitchen. Review of the facility's Date Marking Ready-To-Eat Foods policy from the Culinary Services Manual, revised 02/17, included, All ready-to-eat foods will be labeled to include the following information: product name and date (month, day and year) the product was prepared or opened and the date the product should be used by. Review of the facility's Food Storage Chart, revised 10/14, included under 3 days for refrigerated storage was, ready-to-cook foods prepared on site. Review of the facility's Personal Appearance Standards from the Culinary Services Manual, revised 01/16, included, Men with facial hair, mustache and or/beard, must wear a beard guard while in the production kitchen, and, Hair restraints, such as hats, hair covering, or nets, and clothing that covers body hair shall be worn when in the production area where food is prepared or plated from a hot or cold work station. Review of the facility's Ware Washing policy from the Culinary Services Manual, undated, included, Allow cleaned items to air dry and cool completely before storing. NJAC 18:39-17.2(g)

Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to a.) identify and investigate a bruise of unknown origin and b.) follow interventions implemented on the Care Plan (CP) for a resident identified as having fragile skin. This deficient practice was identified for 1 (one) of 2 (two) residents (Resident #117) reviewed for accidents and was evidenced by the following: The Admission Record dated 06/06/24, indicated that Resident #117 had diagnoses which included, but were not limited to, dementia and major depressive disorder. The quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care, dated 04/11/24, indicated that the resident had severe cognitive impairment and required maximum assistance with all aspects of activities of daily living (ADLs). On 06/04/24 at 07:06 PM during tour, the surveyor observed Resident #117 lying in bed with the left arm exposed. The surveyor observed that the resident had a large irregular shaped dark purplish colored bruise noted on the left forearm. The resident was not able to be interviewed due to cognitive deficits. The surveyor also observed that the left-side rail was padded, and the right-side rail was not. On 06/05/24 at 12:12 PM, the surveyor observed Resident #117 lying in bed and was non-verbal. The resident was able to make eye contact with the surveyor. The surveyor observed that both the resident's arms were exposed, and the surveyor visualized a large, irregular shaped, dark, purplish colored bruise on the left forearm and a skin tear with steri-strips (to keep the edges of the wound together as it heals) on the right forearm. The surveyor observed that the left side rail was padded and the side rail on the right side was not padded. The surveyor reviewed the residents Care Plan (CP) which revealed the following documentation: -Focus: That the resident was at risk for skin tear/bruise related to my fragile skin. The focus was initiated on 07/12/2021. The CP reflected an intervention that was initiated on 02/07/2024, that the enabler bars were to be padded to protect the resident's skin. -Focus: The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to the resident requiring hospice services. The surveyor reviewed the nursing Progress Notes (PN), dated 06/04/24 at 08:01 PM, which indicated that a nurse performed a weekly skin assessment and that no new skin abnormality was noted. This skin assessment was performed after the surveyor's first observation of the bruise. There was no documentation in the PN that the resident had a large bruise on the left forearm. On 06/05/24 at 12:12 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that the bruise on the resident left forearm was identified a week ago (could not provide a specific date) by the resident's companion from hospice. The CNA stated that the companion from hospice provided care to the resident from 7:00 - 9:00 AM and reported to her that the resident had a bruise on the left forearm. The CNA stated that the companion also told her that she reported the left forearm bruise to the Licensed Practical Nurse (LPN) that was providing care to the resident. On 06/05/24 01:01 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that he was not notified that the resident had a bruise on the left forearm. He stated that the resident did not have a companion but had a hospice CNA that came in for a couple hours each morning to care for the resident. When the surveyor asked LPN #1 about the bruise on the resident's left forearm, the LPN stated that he had not seen the bruise. LPN #1 stated that if a resident had a bruise of unknown origin, then an incident report should have been completed and the bruised area should have been measured and assessed. He continued to add the resident should have been assessed for further injury and an investigation should have been conducted. He explained that during the investigation the nurse would obtain statements from the staff going back three shifts and that the family and primary care physician would have been notified. He then stated that Resident #117 had some behaviors, such as flailing of the arms during care, which could have caused a bruise. On 06/06/24 at 10:06 AM, the surveyor reviewed the resident's medical records and there was still no documentation or assessment documented in the electronic medical record (EMR) regarding the bruise on the residents left forearm. On 06/06/24 at 09:14 AM, the surveyor observed a staff member providing care to Resident #117. The staff member was interviewed and identified herself as the Home Health Aide (HHA) from hospice. The HHA stated that she reported the bruise on the resident's left forearm a week ago to the facility CNA and LPN. She stated that she did not remember what the CNA's name was or what the LPN's name was. The HHA also stated that the siderail on the left had been padded, however she had not seen any padding on the side rail on the right side since she had been caring for the resident. On 06/06/24 at 09:00 AM, the Director of Nursing (DON) provided the surveyor incident and accident reports and investigations for the last 6 months for Resident #117. There were no incident or accident investigation for the bruise of the left forearm, however there was an incident and accident investigation provided for the skin tear of the right arm. On 06/06/24 at 09:25 AM, the surveyor interviewed the CNA who stated that the resident's left siderail had been padded, however the right siderail had not been padded for a couple months. On 06/06/24 at 10:27 AM, the surveyor interviewed LPN #1 who stated that purpose of the CP was to assure that special needs of the resident was provided. He stated that the CP assured that all staff members knew what needs the resident had and to provide those needs. He stated that he usually reviewed the residents CP quarterly when the skilled nursing assessment was completed. LPN #1 explained that nurses were made aware when skilled nursing assessment was due for a resident because it would trigger on the daily EMR when it was scheduled. LPN #1 stated explained that he was aware that Resident #117s siderails should be padded to protect the resident's skin, however had no explanation as to why the residents right siderail was not padded. He stated that the skin assessments were completed when the resident's bath was scheduled. He stated that the skin assessment should include any abnormalities of the skin. On 06/06/24 at 10:37 AM, the surveyor interviewed the DON who stated skin assessments were scheduled during first shower day of the week and the nurse was responsible to assess the skin for any abnormalities such as bruises, pressure ulcers, skin tears etc. She stated that if the nurse identified a bruise or any other skin impairment then the nurse would be responsible to assess the area, document findings, complete an incident report incident of unknown origin, start an investigation, and get a statements from CNAs going back three shift. She stated that the nurse was also responsible to alert the practitioner and the resident's family. She also indicated that the nurses would be responsible to notify the DON. The DON explained the CP process to the surveyor and stated that CPs were developed to assure that resident needs and preferences were identified, to include mitigating risk that could potentially negatively impact the resident and to mitigate those risk by formulating interventions to prevent accidents or incidents. She stated that an example of a resident risk would include a resident that had an issue with flailing arms and had the potential of bruising or developing skin tears from this behavior and the facility would pad the residents side rails or provide skin protectant sleeves to prevent skin tears. On 06/06/24 at 11:41 AM, the surveyor interviewed LPN #2 who performed the skin assessment for Resident #117 on 06/04/24 at 08:01 PM. LPN #2 stated that skin assessments were done once a week with shower. The LPN explained that the nurse usually performed the skin assessment with the CNA present. The LPN stated that she asked the CNA that was assigned to the resident on the evening of 06/04/24 how the residents skin condition was, and the CNA told her that the resident had no skin issues. The LPN admitted that she did not actually assess and visualize the residents' skin and that she relied on the CNA to inform her of any skin abnormalities. She stated that she trusts the CNA and that the CNA was dependable to give an accurate description of the resident's skin condition. She stated that the CNA did not report to her that the resident had a large bruise on the left forearm. On 06/06/24 at 12:08 PM, the surveyor interviewed the DON who stated if the nurse performed a weekly skin assessment, the nurse should be visualizing the resident's skin and documenting the condition of the skin on the resident's progress notes. The DON examined Resident #117's left forearm in the presence of the surveyor and confirmed that the resident had a bruise on the left forearm that was in the healing stage. She stated that she would start the investigation. The DON stated that when the surveyor reported the bruise to the LPN, the LPN should have started the accident and incident investigation, even if the bruise was old or in a healing stage. The DON also indicated that that nurse who performed the resident's skin assessment on 06/04/24 at 08:01 PM, should not have depended on the CNA to give her a description of the resident's skin and should have assessed the resident's skin herself. The DON also accompanied the surveyor to Resident #117's room and confirmed that the both the residents siderails should have been padded as the CP interventions indicated. On 06/07/24 at 09:01 AM, the surveyor team met with the DON and Licensed Nursing Home Administrator (LNHA) who stated that an investigation was started regarding Resident #117's left forearm bruise. She indicated that the siderail pad must have become dislodged and was on an armchair in the Resident #117's room. She indicated that a physician's order was obtained for the siderail pads so that the nurse would check to assure that they were in place in case it contributed to the bruising. She also stated that the facility-initiated training related to skin checks procedure and documentation of previous skin impairments and the incident reporting procedure. The facility policy titled Non-impaired Skin Integrity dated 09/15, indicated that the facility strived to identify all residents at risk for developing impaired skin integrity, the level and nature of the risk and initiate the appropriate plan of care. The policy also indicated that the licensed nurse was responsible for initiating the appropriate interventions according to the resident's level of risk and performing weekly visual skin integrity checks were to be completed by the licensed nurse or designee on the resident's bath/shower day. The facility policy titled, Incident Reporting/Injury Investigation Residents and Visitors dated 03/19, indicated that the facility strived to ensure that incidents involving a resident or visitor were recorded, patterns, or trends of occurrences were investigated, and measures were implemented to alleviate or decrease further occurrences. The policy indicated that the description of the resident's incident/injury, resident status, intervention, and any relevant observation shall be documented in the electronic progress notes. The policy also indicated that resident incidents shall be reported to the nursing supervisor and that an incident report had been completed in its entirety and that upon receipt of a report of incident/injury the charge nurse of supervisor shall immediately evaluate the resident, provide any needed intervention, and complete all areas of the Incident Investigation form. The facility policy titled, Person-Centered, Interdisciplinary Care Planning and Care Conference dated 10/2022 reflected that the facility ensured that the person-centered, interdisciplinary care plan team members follow-through with their responsibilities and identify problems/needs and strengths and follow-up on the approaches. NJAC 8:3.9-4.1(a)5 NJAC 8:3.9-13.4(c)2i, ii

Based on observation and interview, the facility failed to ensure foods stored in dry storage were resealed closed when opened. This failure had the potential to affect the 12 residents who ate food prepared by the kitchen. Findings include: The following observations in the kitchen were made with and verified by the Director of Culinary and Nutrition Services (DCN). On 10/24/22 at 10:30 AM, observation of the dry storage room revealed one box of thickener, one bag of dried cranberries, one bag of cake mix, one container of fried onion sticks, one bag of raisins, and one container of chopped nuts, that were open to air. During an interview on 10/24/22 at 10:43 AM, DCN stated, The food items should be sealed closed after opened. I understand that bugs can get into anything that is open. During an interview on 10/27/22 at 10:49 AM, the Interim Administrator stated, My expectation for the kitchen is that any food item that is opened should be sealed shut. The facility did not provide a policy that addressed ensuring open food items in storage were sealed. NJAC 8:39-17.2(g)

Based on record review, staff interview, and review of facility policy, the facility failed to ensure the right to formulate advance directives by failing to ensure a current copy of each resident's advance directive was in the resident's medical record for two of three residents (Resident (R) 6 and R7) reviewed for advance directives. Findings include: 1. Review of R7's profile located on the ''Profile'' tab of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE]. Review of the ''Misc'' (miscellaneous) tab in EMR revealed a notarized durable power of attorney dated 09/10/01 and signed by R7. Review of the document revealed no reference to health care decision making. Review of the physician's orders under the Orders'' tab of the EMR revealed physician's ''DNR [do not resuscitate]'' order dated 10/10/2022. Review of the ''Misc'' tab in EMR revealed a document titled ''E.P._Admission Paperwork.'' Review of the admission paperwork document revealed R7 had received written information about New Jersey Advance Health Care Directives. The document indicated R7 had a living will and had given a copy to the facility. During an interview with the Social Services Director (SSD) on 10/26/22 at 3:56 PM, SSD was told there was no living will in R7's record. SSD stated she was responsible for the admission paperwork but did not know why R7's living will was not in the record or where it was located. SSD stated she would check R7's paper record. On 10/26/22 at 4:49 PM, SSD was unable to locate a living will for R7 and stated R7's family will bring physical copy of his living will but was not sure it would match MD's DNR order. SSD stated she will discuss with MD about MD'S DNR order. SSD also stated that when R7 moved from assisted living to skilled nursing care, the system failed to carry over the living will from assisted living. On 10/27/22, at about 12:00 noon, SSD produced a ''Durable Power of Attorney for Health Care for the Appointment of a Heath Care Representative (Proxy Directive)'' dated 08/08/2001 for R7. SSD acknowledged that the record for R7 had been incomplete until the living will was located. The advanced directives included a DNR. 2. Review of the ''Misc.'' tab in the EMR for R6 revealed a durable power of attorney (DPOA) dated 08/03/18. The DPOA failed to reveal any references to R6's health care management, advance directives, or code status. Review of the physician's orders under the Orders'' tab of the EMR revealed physician's ''DNR'' (do not resuscitate) order dated 06/12/22. During an interview on 10/26/22 at 3:56 PM, SSD was asked if R6 had an advance directive, and if SSD had enquired from the resident or family about advance directives. SSD stated there was an MD order in the medical record indicating R6 was a DNR. SSD stated she would find out if there was any document that reflected R6's wishes for her care, and that the document may have failed to transfer from assisted living to the skilled nursing. On 10/26/22 at 4:30 PM, SSD produced a ''Living Will and Health Care Directive'' for R6, dated 8/3/18. SSD stated the document had failed to cross over with the resident from her assisted living facility. SSD admitted that the medical record for R6 was incomplete without R6's living will. Review of policy #H11 titled ''Health Care Records'' dated 12/2017 revealed the policy of the facility was ''to strive to maintain a health care record for each resident that is complete, accurately documented, readily accessible, systematically organized and per the policies and procedures of the Privacy Protection Manual.'' Review of the facility's policy #A-07 dated 12/2018 and titled ''Advance Health Care Directives for Residents in Skilled Care Center and Residential Community'' revealed its purpose was: ''To strive to establish procedures to support effective administration of residents' advance health care directives in Acts skilled care centers and residential communities and to strive to ensure compliance with the Federal Patient Self-Determination Act and the State Advance Directives Statutes. 1. The skilled care center and residential community will honor properly executed and clearly stated Advance Health Care Directives so that residents and their families will be assured that medically indicated treatment decisions correspond with their wishes. 2. Periodic discussion on the subject of Advance Health Care Directives will be held at the skilled care center and/or residential community. 3. Information concerning Advance Health Care Directives will be made available to all residents upon move-in and as requested. Note: This information is found in the Resident Information Book. 4. While the director of nursing (DON), . nurse practitioner (NP), social services coordinator or his/her designee may review the contents of the information provided to the resident in the Resident Information Book, he/she shall make dear to the resident that he/she is not providing legal advice and direct the resident to contact his/her attorney with any questions pertaining to his/her circumstances.'' The policy further provided that upon admission, residents will be provided information of the following. -Proxy Directive (Durable Power of Attorney for Health Care) -Living Will. A copy of any Advance Health Care Directives shall be kept as part of the resident's health record. NJAC 8:39-9.6(a)(b)

Based on review of facility policy, observations, and staff interviews, the facility failed to follow appropriate infection control practices for hand hygiene and glove wearing for two out of five residents (Resident (R6 and R115) observed during medication administration, and one out of one resident (R115) observed during wound care. Findings include: Observation on 10/25/22 at 9:37 AM revealed Registered Nurse (RN) 1 applying an Aspercreme Lidocaine 4% patch (a pain-relieving patch) to R6. RN1 approached R6 in the dining area and RN1 wheeled R6 to R6's room. RN1 did not perform hand hygiene. RN1 stood R6 up and pulled down R6's pants in order to access R6's right knee. RN1 opened the Lidocaine patch, pulled off the protective film and applied the patch to R6's right knee. RN1 pulled R6's pants back up, did not don gloves and did not perform hand hygiene. RN1 wheeled R6 back to the dining area at 9:41 AM. RN1 proceeded to pull medications for R4 from the medication cart, administered the medications to R4, and still did not perform hand hygiene. RN1 pulled and administered medications to R9, assisted R9 in taking the medications with a spoon, and still performed no hand hygiene. RN1 performed hand hygiene at 10:01 AM. Further observation of RN1 on 10/26/22 at 9:31 AM revealed RN1 administering medications to R12 in R12's room. RN1 performed no hand hygiene before entering R12's room. On 10/26/22 at 9:47 AM, RN1 assisted R115 with taking his pills. RN1 held R115's straw and cup while R115 took his pills one at a time and sipped from the cup held by RN1. R115 requested more ice. RN1 lifted a Styrofoam cup with a lid that had been lying on R115's bedside table and took the cup out of the room and into the hallway. RN1 made a brief stop in the Director of Nursing's (DON) office, placed R115's used cup briefly on a table in the DON's office; RN1 retrieved the cup, took it to the kitchen, filled it with ice and took it back to R115's room. On 10/26/22 at 10:25 AM, observation of RN1 placing another lidocaine patch on R6. RN1 did not perform hand hygiene or don gloves. RN1 removed the patch from the package, placed the packet on the floor, peeled off the protective film and applied the patch with bare hands on R6, right knee. RN1 picked the packet off the floor, proceeded to the medication cart to retrieve R6's phone, took the phone down the hall to R6's room, returned to the medication cart, and finally performed hand hygiene with hand sanitizer. Observation of wound care with RN1 and Assistant Director of Nursing (ADON) on 10/26/22 at 10:11 AM revealed RN1 donned a pair of gloves without first performing hand hygiene. RN1 removed the old dressing in R115's back and changed gloves. No hand hygiene was performed before changing gloves. ADON, who was assisting RN1, removed her gloves and donned another pair without performing hand hygiene. At the conclusion of the wound care, RN1 took off the gloves with which she had performed wound care. RN1 touched the resident, the resident's wheelchair, and the resident's glasses before performing hand hygiene. During an interview on 10/26/22 at 12:24 PM, the DON was asked what her expectations were for nurses to perform hand hygiene and don gloves. DON stated staff should don gloves during eye drop administration, PEG (feeding tube) care, urinary catheter care, handling briefs, or taking someone to the toilet. Also, when giving certain medications if the staff is pregnant and the medication would be harmful to staff. DON stated staff did not need to wear gloves if touching a resident who is clothed. The foregoing observations were discussed with the DON, and she agreed that they were breaches in infection control and prevention standards and RN1 should have performed hand hygiene in the scenarios observed. DON added that gloves should be worn when rubbing cremes and applying a medication patch and hand hygiene ''after each thing you do.'' During an interview with RN1 at 12:45 PM on 10/26/22 the forgoing observations were discussed. RN1 agreed that they were breaches in infection control and prevention standards. RN1 further stated that it was difficult to apply a Lidocaine path with gloved hands because the patch became twist and difficult to control. RN1 stated she was careful not to touch the medication when she applied it. During an interview with the facility's Infection Preventionist, (ICP) the foregoing observations were discussed with the ICP, and she confirmed that they were all breaches of infection control standards contrary to what she had been teaching. ICP stated more training would be done with staff. Review of facility's policy# B-03.81C titled ''HAND WASHING AND HAND HYGIENE'' revealed the policy was ''to strive to prevent infections through adequate hand washing and hand hygiene techniques.'' Policy further provided: '' C. Always decontaminate hands: When coming on and going off duty Before and after direct resident contact. Before and after inserting urinary catheter, intravenous catheter, or other invasive devices. Before and after entering isolation precaution settings Before and after changing a dressing After contact with a resident's intact skin (i.e., when taking a pulse or blood pressure and lifting a resident). After blowing and wiping nose After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings. If moving from a contaminated body site to a clean body site during resident care. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. After handling soiled or used linens, dressings, bedpans, catheters and urinals After removing gloves' Review of facility's policy #B-03.6IC, revised 03/2020 titled ''Gloves'' revealed ''gloves are worn . for all procedures or tasks involved with touching blood and body fluids, mucous membranes, or non-intact skin.'' NJAC8:39-19.4(a)1

Based on observation, interview and record review, it was determined that the facility failed to ensure a.) a compartment for the storage of controlled drugs was affixed and properly secured; b.) an affixed locked storage unit used to store controlled medication prescriptions and controlled medications for return to pharmacy was properly secured; and c.) an accurate account of controlled substances was maintained for 1 of 1 medication storage rooms reviewed for proper storage of medications. This deficient practice was evidenced by the following: 1. On 2/22/19 at 09:20 AM, the surveyor observed the locked medication storage room in the presence of the Director of Nursing (DON) and noted a metal storage box lying on the counter. The DON opened the box with a key and stated that controlled drugs were stored in the box. The DON and the surveyor counted the quantity of the medications contained in the box and compared the count to the Controlled Medication Utilization Record for accuracy. The surveyor observed the following medications were stored in the box: 1. [MEDICATION NAME] Immediate ([MEDICATION NAME]) five milligram (mg), quantity 20 tablets. 2. [MEDICATION NAME] 10 mg, quantity 10 tablets. 3. [MEDICATION NAME] with [MEDICATION NAME] ([MEDICATION NAME]) 5 mg/325 mg, quantity 24 tablets. 4. [MEDICATION NAME] 100 mg/5 mL (milliliter) solution, quantity 29.55 mL. 5. [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg, quantity 10 tablets. 6. [MEDICATION NAME] ([MEDICATION NAME]) 10 mg Gel Pens, quantity 2 gel pens. The DON stated that only a couple of the nurses's had a key to access the medication storage room. The DON could not explain why the box was not affixed to a surface. 2. On 02/22/19 at 09:32 AM, the surveyor and the DON returned to the medication storage room. The surveyor noted a metal storage box affixed to the wall with a key stored in the lock on the outside of the box. The DON stated that the box was used to store controlled medication prescriptions and controlled medications that were to be returned to the pharmacy. The surveyor observed the DON open the box exposing a prescription for [MEDICATION NAME] 5/325 mg (sixty tablets). The DON stated that she did not know why the key was stored in the lock of the box. 3. The surveyor reviewed the Record of Narcotic Count for the month of (MONTH) 2019 which revealed the signatures of an incoming nurse and an outgoing nurse to count controlled medications for accuracy each shift. The surveyor noted the (MONTH) 2019 Record of Narcotic Count revealed the following: On 02/01/19, the incoming nurse did not sign the form at 7 AM. On 02/01/19, the incoming nurse and outgoing nurse did not sign the form at 3 PM. On 02/04/19, the incoming nurse did not sign the form at 7 AM. On 02/04/19, the outgoing nurse did not sign the form at 3 PM. On 02/10/19, incoming nurse did not sign the form at 7 AM. On 02/11/19, incoming nurse did not sign the form at 3 PM. On 02/11/19, the outgoing nurse did not sign the form at 11 PM. On 02/15/19, the incoming nurse did not sign the form at 7 AM. On 02/15/19, the incoming nurse and outgoing nurse did not sign the form at 3 PM. On 02/15/19, the outgoing nurse did not sign the form at 11 PM. On 02/18/19, the incoming nurse did not sign the form at 7 AM. On 02/18/19, the incoming nurse and outgoing nurse did not sign the form at 3 PM. On 02/18/19, the outgoing nurse did not sign the form at 11 PM. At that time, the DON stated that nursing was responsible to ensure that the narcotic inventory was completed and signed each shift. The DON further stated that she was ultimately responsible to ensure that it was done. The surveyor reviewed the facility's policy, Medication, Controlled Substances (M-04.4) (Revised: 10/18). The policy revealed, Controlled substances are counted from the narcotic sheets each shift. The nurse going off duty and the nurse coming on duty must count all controlled substance medication together. Upon request, the DON could not provide a policy regarding the measures in place to secure the narcotic key. NJAC 8:39-29.4(h); 29.7(c)

Based on interview and record review, it was determined that the facility failed to provide 12 hours of yearly in-service education for 3 of 5 Certified Nursing Assistants (CNA) reviewed for in-service education (CNA #1, #2, and #3). This deficient practice was evidenced by the following: On 02/21/19, the facility produced a list of 27 CNAs employed by the facility. The surveyor randomly selected five CNAs to review for 12-hours of in-service education provided by the facility from (MONTH) 1, through (MONTH) 31, (YEAR). On 02/25/19, the surveyor reviewed the in-service education which revealed the following: 1. CNA #1 received 2.0 hours of in-service education from 01/01/18 to 12/31/18. 2. CNA #2 received 7.5 hours of in-service education from 01/01/18 to 12/31/18. 3. CNA #3 received 10.5 hours of in-service education from 01/01/18 to 12/31/18. On 02/25/19 at 08:25 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that each employee will complete the required in-services quarterly. The DON further stated that the facility in-service computer program will notify the employee directly if they need to complete in-services. On 02/25/19 at 09:19 AM, the surveyor interviewed the DON. The DON stated that she relied on the CNAs to be accountable to complete the required 12-hours of in-services. The DON further stated that she sent out an email in (MONTH) and (MONTH) of (YEAR) informing staff to complete the in-services. On 02/25/19 at 09:21 AM, the DON provided the emails dated 09/29/18 and 12/28/18. The surveyor reviewed the 09/29/18 and 12/28/18 emails generated by the DON. The 09/29/18 email revealed, Please complete this quarter (computer program name) training and the email dated 12/28/18 revealed, (computer program name) is due by 12/31/18. Thank you. At that time, the surveyor interviewed the DON. The DON stated she does not follow up to ensure the CNAs complete their training but relies on each CNA to be accountable for themselves. NJAC 8:39-43.17(b)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 11/13/17 from 6:40 p.m. to 7:04 p.m., the surveyor, who was accompanied by the Food Service Assistant Director (FSAD), observed the following in the kitchen: 1. In walk-in refrigerator #4, 7 flat pans containing raw cookie dough were stored on a multi-tiered cart. The cookie dough was uncovered and unlabeled. 2. In the same walk-in refrigerator #4, 3 flat pans containing slices of cake was stored on a multi-tiered cart. The cakes were uncovered and unlabeled. When interviewed, at that time, the Sous Chef (CS) stated the cookie dough was for tomorrow's dessert. The SC stated the cookie dough and the cakes were supposed to be covered and labeled. 3. In the Dairy Refrigerator, walk-in refrigerator #3, a prosciutto, salami, mortadella, pork roll, and chocolate icing were stored in a flat pan, on the bottom shelf of a multi-tiered cart. The prosciutto was labeled with Today's date (TD) of 11/2/17 and Good Thru (GT) 11/12/17. The salami was labeled with the TD of 11/5/17 and GT of 11/12/17. The mortadella was labeled with the TD of 11/9/17 and a GT of 11/12/17. The pork roll was labeled with the TD of 10/29/17 and a GT of 11/1/17. The chocolate icing was labeled with the TD of 10/19/17 and a GT of 10/29/17. When interviewed, at that time, the FSAD stated the prosciutto, salami, mortadella, pork roll, and chocolate icing should not have been stored in the refrigerator because they were expired. The surveyor also interviewed the CS about the labels. The SC stated the GT date is when the item would be considered as expired. 4. In the Thaw Refrigerator, walk-in refrigerator #1, a flat pan containing raw breaded chicken was stored on a multi-tiered cart. The raw breaded chicken pan was loosely covered with clear plastic wrap and stored on the second shelf over other thawing raw meats. When interviewed, at that time, the FSAD stated that the flat pan containing the raw breaded chicken should have been stored on the bottom shelf. 5. In the dry storage room, a bin containing flour was opened and exposed. 6. The dish machine was in operation for the dinner cleanup. The surveyor observed multiple wet stacked flat pans and wet stacked loaf pans on a drying rack located at the clean end of the dish machine. The surveyor observed a Food Service Worker (FSW) remove 3 clean and sanitized loaf pans from the dish machine. The FSW stacked the 3 loaf pans on top of each other and placed them on the dry rack. When interviewed, at that time, the FSAD said the pans were not supposed to be stacked while wet. The FSAD further stated the pans were supposed to be stored separately when wet. The FSAD said the pans are stacked once they are completely dried. 7. A FSW with a long ponytail walked to the handwashing sink located near the prep area. The FSW did not have a hairnet on her head. 8. A FSW with a hair bun walked to the dish machine area. The FSW did not have a hairnet on his head. 9. A FSW with a long beard had his beard restraint net around his neck and not covering his beard. On 11/15/17 at 10:50 a.m., the surveyor observed the following in the kitchen, in the presence of the Food Service Director (FSD). 10. A FSW with a long ponytail walked through the kitchen. The FSW did not have a hairnet on her head. 11. In walk-in refrigerator #1 a flat pan containing lobster tails was stored on a multi-tiered cart. The lobster tails were uncovered and exposed. When interviewed, at that time, the FSD said the lobster tails were supposed to be covered. The surveyor reviewed the facility's Food and Supply Storage policy, Policy #B003, with the revision date of 1/17. The policy revealed that open packages and unused portions should be covered, labeled, and dated. The policy further revealed that products are good through the close of business on the date noted on the label. The policy reflected that if raw animal food is stored on the same multi-tiered rack, poultry is to be stored on the bottom of the rack. The policy also revealed that foods stored on ladder/speed, (multi-tiered) racks must be fully covered to prevent contamination from airborne contaminants as well as from dripping condensation. The policy further revealed that the bag should either cover the entire cart or each tray should be covered individually. The surveyor also reviewed the facility's Uniform Dress Code policy, Policy #E006, with the revision date of 1/17. The policy revealed that staff were to wear approved hair restraint when on duty. The policy further revealed that the only exception is to remove hair restraints when delivering trays to patients/residents. The policy also reflected that facial hair must be effectively restrained per local and state regulations. The policy also reflected that hair restraints are worn by all when in the kitchen. NJAC 8:39-17.2(g)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to ensure that indwelling urinary catheter drainage bags were stored in a way to prevent the spread of infection. This deficient practice was identified for two of two resident's reviewed for the use of indwelling urinary catheters, (Residents #4 and #5) and was evidenced by the following: 1. On 11/13/17 at 6:45 p.m., during the initial tour with the Director of Nursing (DON) the surveyor observed Resident #4 resting in bed. The DON stated the resident was alert and oriented to self and family and was involved with care. The DON further stated the resident had an indwelling urinary catheter for post-surgical wound healing. On 11/14/17 at 9:15 a.m., the surveyor entered the resident's bathroom and observed a black plastic bag tied to a handrail in the shower. The indwelling urinary leg bag connecting tube was directly touching the black plastic bag and uncapped. On 11/14/17 at 10:45 a.m., the surveyor reviewed the resident's medical records. The Admission Record reflected that Resident #4 was admitted to the facility with medical [DIAGNOSES REDACTED]. A review of the November 2017 Physician order [REDACTED]. A review of the ongoing Residents Plan of Care (P(NAME)) dated 11/2017 indicated a history of Urinary Tract Infections (UTI's) related to a Fistula (an abnormal connection between two organs). On 11/15/17 at 10:05 a.m., the surveyor interviewed the resident's Certified Nursing Assistant (CNA). The CNA stated that the urinary catheter drainage bag was to be rinsed out with water after use and then stored in a plastic bag in the resident's bathroom. The CNA further stated that the blue cap was to be attached to the end of the catheter tubing when not in use and the tip was cleaned with alcohol prior to capping and prior to insertion. The surveyor entered Resident #4's bathroom with the CNA and observed the uncapped catheter bag in the black storage bag. The CNA stated if the cap pops off of the catheter bag, she Puts it back on because she replaces the black plastic bag every morning and the inside of the bag is clean. On 11/15/17 at 10:15 a.m., the surveyor interviewed the resident's Registered Nurse (RN). The RN stated, if a cap was not on the end of the catheter bag, it should, Be tossed so not to risk infection. 2. On 11/13/17 at 6:45 p.m., during the initial tour with the Director of Nursing (DON) the surveyor observed Resident #5 walking in the hallway with his/her rolling walker. The DON stated the resident was alert and oriented to self with confusion. The DON further stated the resident had an indwelling urinary catheter for the [DIAGNOSES REDACTED]. On 11/14/17 at 9:21 a.m., the surveyor entered the resident's private bathroom and observed a black plastic bag tied to a handrail in the shower. The indwelling urinary catheter bag was wet. The indwelling urinary bag connecting tube was directly touching the black plastic bag and uncapped. On 11/14/17 at 1:02 p.m., the surveyor entered the resident's private bathroom and observed a black plastic bag tied to the handrail in the shower. The indwelling urinary catheter bag connecting tubing was observed uncapped and directly touching the inside of the black plastic bag. On 11/15/17 at 9:17 a.m., the surveyor reviewed the resident's medical records. The Admission Record reflected that Resident #5 was admitted to the facility with medical [DIAGNOSES REDACTED]. A review of the November 2017 Physician order [REDACTED]. A review of Virtua Department of Pathology & Laboratory Medicine Microbiology lab report dated 4/10/17 indicated a positive urine culture. Further review of the medical record indicated a PO dated 4/11/17 for the antibiotic, [MEDICATION NAME] 500 mg capsule by mouth three times a day for the [DIAGNOSES REDACTED]. A review of the resident's Interdisciplinary Care Plan (ICP) revised on 11/19/17 revealed a focus area of bladder management. The focus area indicated, I have an indwelling urinary catheter due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. I have failed a couple of voiding trials, and will no longer attempt any. I require extensive assist with my catheter. Please provide catheter care per the physician's orders [REDACTED]. The goal of the ICP indicated, I will not experience any complications with my catheter and my risk factors for UTIs will be reduced. On 11/15/17 at 9:55 a.m., the surveyor interviewed the resident's Certified Nursing Assistant (CNA). The CNA stated that the urinary catheter drainage bag was to be rinsed out with water after use and then stored in a plastic bag in the resident's bathroom. The CNA further stated that the blue cap was to be attached to the end of the catheter tubing when not in use. On 11/15/17 at 9:59 a.m., the surveyor interviewed the resident's Registered Nurse (RN). The RN stated that the cap would need to be placed on the end of the catheter tubing to prevent germs from going up into the tubing and causing an infection. On 11/15/17 at 11:30 a.m., the DON stated that the indwelling urinary catheter bags should be discarded and replaced if the cap is not connected to the end of the catheter tubing. On 11/15/17 at 10:56 a.m., the surveyor reviewed the facility Policy and Procedure for the Storage and Cleaning of Large Urinary and Leg Bags revised 4/2016. The purpose of this Policy and Procedure indicated, To ensure all urinary collection bags are cleaned, stored, and concealed per policy. The procedure indicated, Both the large collection bags and leg bags will be rinsed after use. The large collection bags will be capped and stored in a black trash bag in the resident's bathroom. NJAC 8:39-19.4(a)5

Based on interview, record review and review of other facility documentation, it was determined that the facility failed to ensure that each resident was offered a snack at bedtime. This was identified for 4 of 4 alert and oriented resident's who participated in a group meeting and during an individual interview with Resident #1. This deficient practice was evidenced by the following: On 11/14/17 at 10:30 a.m. to 11:30 a.m., the surveyor conducted the group meeting with four alert and oriented resident's. When asked if they were offered a snack in the evening before going to bed, 4 of the 4 residents responded that they are not offered a snack by staff before bedtime and this would be something that they would like to be offered. One of the resident's stated that the facility used to come around with cookies, snacks, and juices in the evening, but this hadn't happened for some time. The exact time frame could not be recalled by the resident. The same alert and oriented resident further stated that snacks are located in the dining room kitchen area all of the time, but you have to go get it yourself if you want one or ask the staff members to bring you one. On 11/15/17 at 8:45 a.m., the surveyor interviewed Resident #1 who was alert and oriented according to the 6/6/17 Quarterly Minimum Data Set (an assessment tool). When the surveyor asked the resident if he/she if offered a bedtime snack, the resident stated, No, I would like to be offered one. On 11/14/17 at 1:57 p.m., the Director of Nursing (DON) provided the surveyor with the Suggested Evening Snacks list updated 3/4/13. The form listed the snacks which were available throughout the week. A review of this form indicated, Nursing staff is responsible to make, distribute and clean up the HC snack/drink for that evening. On 11/14/17 at 2:08 p.m., the surveyor interviewed the DON and Administrator. The DON stated the facility did not have a record of accountability to show that the resident's were offered snacks in the evening. The Administrator stated to the surveyor in the presence of the survey team that the kitchen staff does random audits to see if the resident's are offered an evening snack. At that time the surveyor requested documentation to prove that this practice occurred. Throughout the length of the survey the Administrator was unable to provide the surveyors with documentation showing the resident's were offered a bedtime snack. On 11/15/17 at 11:16 a.m., the surveyor interviewed the Registered Dietitian in the presence of the survey team. The RD stated that she is at the facility on Monday evenings and makes mini muffins which are placed in the common areas on the unit and are available to resident's and family members when they walk by. The RD stated that she does not go room to room to offer the mini muffins to the residents. The RD could not speak of what occurred on the unit Tuesday through Sunday because she was not at the facility during those times. On 11/15/17 at 10:56 a.m., the surveyor reviewed the Policy & Procedure for Bedtime Snacks revised 1/2015. The purpose of this Policy & Procedure indicated, To ensure all residents, if medically indicated, are offered a bedtime snack. The Procedure of this Policy & Procedure indicated, On Monday nights, Dietician prepares snacks and assist CNAs (Certified Nursing Assistants) with the distributing. On other nights, the CNAs or nurses will assist with the offering of snacks. NJAC 8:39 - 27.1 (a)

Based on observation and interview, it was determined that the facility failed to ensure that foods were prepared, stored and served in a sanitary manner. This deficient was evidenced by the following: During the tour of the facility's kitchen on 11/23/15 from 9:55 am until 10:20 am in the presence of the Food Service Director (FSD) and the Executive Chef the following was observed: 1. There were no hair restraints available upon entering the kitchen. The FSD stated that the hair restraints were kept on a rack near her office. At this time, the surveyor observed that staff needed to walk through the entire kitchen in order to obtain a hair restraint. 2. The surveyor observed that there were three male food service workers who were not wearing any beard restraints for their beards. When interviewed at this time, the FSD stated that she did know that hair restraints were needed for beards. 3. The entire kitchen's wall, floor wall junctures and cove bases was heavily stained with black, red and brown colored substances and had a heavy build - up of dirt and debris. 4. The stove and oven was heavily coated with grease and burnt substances. The convection oven was heavily coated with grease and burnt substances. At this time, the FSD stated that the stove and convection oven were cleaned weekly. The FSD stated that the convection oven, stove and oven should not look like this. 5. Inside the dish machine room, there was a four tiered pot drying rack. The surveyor observed that there were three 4- inch pans and three full pans nesting on the rack that was visible with water. There were also two gray clean utensil trays on the bottom rack. Inside the clean utensil tray there was a chicken bone, dirt and debris. At this time, the FSD stated that the pans should have been laid sideways in order for them to dry properly. The FSD and chef both stated that the pans and utensils would have to be cleaned again. 6. There were three 4 -tiered racks on the outside of the dish room. The FSD stated that these rack were used for drying clean pots and pans. The surveyor observed on rack #1: Ten 4 inch pans nesting on the rack and visible with water. The surveyor observed that there were also dried red, yellow and brown substances on this rack and, also rack #2 and #3 were coated with dirt and debris, and dried red, yellow and brown substances. 7. Refrigerator #1 labeled Dining Room had an unlabeled pitcher of red colored liquid. The FSD stated that she was not sure what the liquid was and discarded the pitcher of liquid. 8. Refrigerator #2 contained 13 containers of apple sauce; and ten containers of coleslaw with a use by date of 11/17/15. 9. Refrigerator #3 contained 33 containers of seasonal fruit, 13 small dishes of coleslaw and nine small dishes of apple sauce. All were unlabeled and did not contain a use by date. 10. The meat slicer contained dried particles of meat. 11. The mixer was found to have dried colored food particles, and the five mixer paddles were stored inside a gray colored tray that contained dirt and debris. 12. Inside the dry storage room there was a box of open and unsealed chocolate chip morsels. 13. The walk-in produce refrigerator, the walk-in diary refrigerator; raw refrigerator and walk-in freezer were heavily stained with food particles. When interview at this time, the FSD stated that she had only been the FSD for ten months. The FSD stated that the food service workers were responsible for cleaning the kitchen and the appliances. The FSD stated that she did know what happened. NJAC 8:39 17.2(g)

Based on observation, interview, and record reviewed, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner. This deficient practice was evidenced by the following: The surveyor observed the following in the pantry kitchen in the presence of the Nutrition Care Manager (NCM) on 2/2/15 from 6:30 p.m. to 7:05 p.m.: 1. A low temperature chemical sanitizing dish machine mounted under the counter was in operation for clean-up of the supper meal. When interviewed, a Food Service Worker (FSW) working at the dish machine stated the dish machine temperatures were supposed to be in the 120 to 125 degree range. The FSW said she did not know anything about the use of test strips or how to use the them. (Test strips are used to check the amount of sanitizer dispensed in the rinse cycle to ensure adequate sanitization). The NCM stated that they test the concentration of sanitizer dispensed once a day in the morning. The NCM stated the dish machine was used after breakfast, lunch and supper. When reviewed, the dish machine log indicated the sanitizer concentration should range between 50 to 75 parts per million (ppm). Documentation on the dish machine log indicated the concentration of sanitizer was 70 ppm and 60 ppm on 2/1/15 and 2/2/15, respectively. The manufacturer's specifications of the chemical sanitizer indicated the concentration of sanitizer should be 100 ppm, no lower than 50 ppm and no higher than 200 ppm. for adequate sanitization. When observed by the surveyor, the test strip container has a color grid which indicated that 25 ppm, 50 ppm, 100 ppm, 200 ppm, and 300 ppm. There was no color on the grid to indicate 60 ppm or 70 ppm. No objective information was provided to the surveyor to indicate what color 60 ppm or 70 ppm concentrations appear on a test strip. The color for 50 ppm was turquoise and 100 ppm was olive green. The NCM tested the concentration of the sanitizer dispensing during the rinse cycle. She collected the rinse solution in a container, dipped a test strip into the rinse solution, and then compared the color on the test strip to the color grid on the test strip container. Three test strips were used and none of the test strips turned a color which matched the color grid to indicated adequate sanitizer was dispensing. The NCM said the test strips did not match any color on the test strip container. The NCM stated they would shut the dish machine down and have it checked the next day. The surveyor observed the following in the main kitchen in the presence of the Director of Dining Services (DDS) and the Executive Chef (EC) on 2/3/15 from 8:15 a.m. to 9:30 a.m.: 1. In the walk-in refrigerator, packages of raw tuna were stored on a multi-tiered cart directly above packages of cooked meat balls. 2. In the walk-in refrigerator, a 20 lbs case of raw catfish fillets was observed on a shelf. The facility label indicated "today's date" was 2/1/15 and the "expiration date" was 2/3/15. When interviewed, the EC stated "today's date" indicated the receiving date in the facility and the catfish was fresh not frozen on delivery. The EC stated the cat fish fillets had been received on the previous Saturday, not 2/1/15. The DDS provided the surveyor with the invoice dated 1/30/15 which indicated the raw catfish fillets had been delivered to the facility on [DATE]. The EC stated the facility label was wrong. When interviewed, the DDS and EC stated the raw catfish had a 3 day shelf life and had expired one day earlier on 2/2/15. 3. In the walk-in refrigerator, multiple sealed hams labeled by the facility "today's date" 2/3/15, the receiving date, were observed on a shelf. When examined, no dates or codes were found on the sealed hams. The EC and the DDS were unable to identify the manufacturer's date of expiration. A FSW was interviewed and he stated he did not recall ever seeing a date on the hams. The FSW found the manufacturer's date of expiration for the hams on the box which had been broken down for trash. No system was in place to ensure the manufacturer's dates of expirations were labeled on individual packages of hams if received without a date of expiration labeled on the food. 4. In the walk-in refrigerator, a sealed package of smoked salmon was observed on a shelf. The facility label indicated the smoked salmon was received on 1/28/15 and had a date of expiration, 2/28/15. When interviewed, the DDS and EC were unable to identify the manufacturer's date of expiration. 5. In the walk-in refrigerator, multiple containers of a nutritional supplement which have a fourteen day shelf life once thawed were observed on a shelf. The containers were labeled with a date that indicated the day the containers were pulled from the freezer to thaw. When interviewed, the DDS and EC stated they only label the nutritional supplement with a pull date. No system was in place to label the containers with a "use by date." On 2/3/15 at 11 a.m., the DDS asked the surveyor to come to the pantry to speak with the Chemical Company Representative (CCR) who serviced the dish machine in the pantry. The CCR stated there was nothing wrong with the dish machine or the concentration of sanitizer that it dispensed. The CCR stated that the 60 ppm or 70 ppm documentation on the dish machine log was right because the concentration of sanitizer should be in that range. The CCR was unable to provide objective information which would indicated the color a test strip would be at 60 ppm or 70 ppm. On 2/4/15 at 10:15 a.m., the surveyor, the DDS and the Licensed Nursing Home Administrator (LNHA) went to the pantry to check the dish machine which was still not in use. Three dish machine cycles were run. Test strips were used to check the concentration of the sanitizer during the second and third time the dish machine was run. The test strip turned yellow color which indicated the chemical sanitizer was dispensing at a concentration greater than 200 ppm. The LNHA said that the dish machine was shut down until it would be fixed. When interviewed, the DDS stated she had not tried using any other test strips to check the concentration of the sanitizer. NJAC 8:39-17.2g

Based on interview, observation and record review it was determined that the facility failed to adequately monitor and provide new/different interventions for a resident with multiple falls from a wheelchair in the same location. This deficient practice was noted for 1 out of 4 residents, Resident #6, reviewed for falls and evidenced by the following: During the initial tour on 1/27/14 at 10 a.m. the nurse stated that Resident #6 had dementia, a cerebral vascular accident (CVA), restlessness and multiple falls out of bed and the wheelchair. The surveyor observed Resident #6, at 12:25 p.m., in the lounge area near the resident's room sitting in front of a table in a tilt-in-space wheelchair with a tabs alarm (a device which will sound when disconnected). Resident #6 did not respond to the surveyor and had his/her eyes closed and tapping the table. Throughout the survey, 1/27/14 to 1/30/14, Resident #6 was observed either lying in bed or sitting in the lounge area near his/her room alone in a tilt-in-space wheelchair in front of a table occasionally touching objects on the table. The resident was calm and quiet. The surveyor sat in the lounge area and could not see any staff member that would be able to visualize the resident unless directly facing the lounge area. The surveyor reviewed Resident #6's Care Plan on 1/29/14 at 10:40 a.m. According to the Care Plan, Resident #6 was unable to communicate effectively and had behavioral issues such as "motor restlessness, agitation, anger, shouting, anxiety, and impulsivity." The Care Plan documented to try multiple interventions to alleviate the behaviors that included 1:1 observation when available and decrease sensory stimulation. The Care Plan noted that Resident #6 had poor safety awareness and to place the resident next to the table in the lounge area by his/her room to "increase visibility." The Care Plan also documented to bring the resident to a more visible area during meal times if the resident continued to be agitated. The surveyor reviewed the Interdisciplinary Progress Notes (IDCP) on 1/29/14 at 11:20 a.m. Resident #6 had 8 falls from April to November 2013 from his/her wheelchair in the lounge area. The surveyor reviewed the Incident/Accident Reports for the 8 falls that occurred in the lounge area on 1/30/14 at 10 a.m.: 4/26/13: A CNA heard the resident's tab alarm and found the resident on the floor. The facility recommended monitoring the resident closely. This was the resident's first fall from the wheelchair. 6/10/13: A CNA was with the resident when s/he stood up quickly and fell . The facility adjusted the resident's wheelchair to tilt back and provided an anti-thrust cushion. The physician also increased the resident's psychotropic medications to help relieve the resident's restlessness. 7/26/13: The resident was agitated and while the CNA was in another resident's room the tab alarm sounded. The CNA found the resident on the floor. The facility recommended providing close monitoring and 1:1 as much as possible. The physician increased another psychotropic medication to help relieve the agitation. 9/6/13: A CNA was in another resident' s room and heard the tabs alarm and found the resident's lower body on the floor. The facility made no new recommendations. 9/29/13: A nurse heard the tabs alarm and found the resident on the floor. Occupational Therapy (OT) evaluated the resident's wheelchair and sitting position and made no recommendations. At this point the facility documented to move the resident to the dining room area to increase visibility. 10/28/13 (1st fall): A CNA was in another resident's room and heard the tabs alarm and found the resident sliding half-way out of the wheelchair. The facility documented no new recommendations. Resident #6 was placed on 1:1 observation for the remainder of the shift. 10/28/13 (2nd fall): A CNA "was keeping an eye on him" due to the resident being agitated. The CNA heard the tabs alarm and found the resident on the floor. It was unclear where the CNA was when s/he heard the alarm. OT documented no new recommendations and to continue 1:1 as needed when possible. Physical Therapy (PT) documented to change the cushion on the wheelchair to improve the resident's sitting position and adjusted the leg rests. 11/7/13: Resident #6 was restless and staff found the resident on the floor. PT evaluated the resident on 11/11/13 and recommended a tilt-in-space wheelchair. PT did a Seating/Mobility Evaluation on 11/14/13 and documented that Resident #6 was sliding out of the wheelchair due to agitation from poor sitting position. The surveyor noted on 1/30/14 at 10 a.m. that Resident #6 had no further falls since 11/7/13 from his/her wheelchair in the lounge area. The surveyor spoke to the Administrator and Director of Nursing (DON) on 1/30/14 at 12 noon regarding Resident #6's multiple falls. The DON stated that multiple interventions have been used including medication adjustments, a new wheelchair and increased monitoring. The facility faxed additional information on 1/31/14, a day after the completed survey. The surveyor reviewed the information on 2/4/14 at 10 a.m. The information included a list of all Resident #6's falls. The following additional information noted: 7/26/13: The CNA was providing "close supervision as much as possible." (Resident #6 fell when the CNA was in another resident's room. No other staff member was documented as supervising the resident) 9/6/13: Resident #6 slid out of the wheelchair. Resident #6 was not restlessness and the CNA remained with the resident afterwards. (No information was noted as to why the resident continued to slide out of the tilt-back wheelchair). 10/28/13 (2nd fall): OT would consider ordering a new wheelchair. (The surveyor could not find any documentation in the medical record during the survey) 11/7/13: PT in progress of evaluating the use of a new wheelchair. The surveyor noted that PT did not evaluate Resident #6 for a new wheelchair until 11/11/13 N.J.A.C. 8:39-27.1(a)

Based on interview, observation and record review it was determined that the facility failed to notify a resident's physician in a timely manner regarding a new complaint of pain. This deficient practice was noted for 1 out of 10 residents, Resident #3, reviewed for physician notification and evidenced by the following: During the initial tour on 1/27/14 at 10:50 a.m. the nurse told the surveyor that Resident #3 was alert and oriented and sustained a fractured elbow after a fall. The surveyor interviewed Resident #3 on 1/27/14 at 12:50 p.m. The resident told the surveyor that s/he broke his/her elbow after falling. Resident #3 moved his/her elbow with no range of motion limitations. The surveyor reviewed Resident #3's Interdisciplinary Progress Notes (IDCP) on 1/28/14 at 12 noon. A nurse's note dated 7/30/13 documented that Resident #3 had a fall resulting in pain to his/her back and buttocks, and a skin tear to the left elbow. The resident's physician was notified about the fall. A nurse's note dated 7/31/13, timed 11 p.m.-7 a.m., documented that Resident #3 complained of left elbow pain upon movement and received Tylenol with some pain relief. This was the first time the resident complained of elbow pain. Resident #3 continued to complain of pain to the left elbow from 7/31/13-8/6/13. A nurse's note dated 8/1/13 and timed for the 7 a.m.-3 p.m. shift, documented that Resident #3 complained of low back pain and left arm pain and was given Tylenol at 7:30 a.m. No documentation was noted that the physician was notified that the Tylenol, according to the August 2013 electronic Medication Administration Record, [REDACTED] A nurse's note dated 8/1/13, timed for the 3 p.m.-11 p.m. shift, documented that Resident #3 complained of severe back pain in which Tylenol had no effect at 4:30 p.m., and that the physician was aware and ordered a stronger pain medication that was given at 6:30 p.m. This note made no mention of elbow pain. A nurse's note dated 8/6/13 documented that Physical Therapy (PT) reported that Resident #3 had pain to the left elbow and that it was the "same pain s/he was experiencing last week." The nurse contacted the physician and an x-ray was ordered. The next nurse's note documented that Resident #3 had an x-ray which revealed a left elbow fracture. The surveyor told the Administrator and the Director of Nursing (DON) about the concern on 1/30/14 at 12 noon. The DON stated that Resident #3's physician was aware of the left elbow pain. The surveyor stated that there was no documentation that the physician was notified until 8/6/13. The facility faxed additional information to the surveyor on 1/31/14, a day after the completed survey. A physician's note dated 8/1/13, but not timed, documented about Resident #3's elbow pain and ordered a stronger pain medication. This physician's note was not in Resident #3's medical record during the survey and made no mention about Resident #6's unresolved back pain. N.J.A.C. 8:39-13.1(d)

Based on observation, interview and record review it was determined that the facility failed to administer all medications without an error rate of less than 5%. This was observed during the morning medication pass on 1/27/14 for 2 nurses, 5 residents and 25 medications with 2 errors. This deficient practice was observed on 1 of 2 nursing units and resulted in a medication administration error rate of 8% as evidenced by the following: On 1/27/14 at 10:35 a.m. the surveyor observed the medication nurse administer Potassium Chloride 20 milliequivalents by mouth and [MEDICATION NAME] 25 milligrams by mouth. Review of the Electronic Medication Administration Record [REDACTED]"to be given with a meal." The surveyor reviewed manufacturer's specifications and the Nursing Drug Handbook (a reference guide) and both indicated to administer these medications with or immediately following a meal. On 1/27/14 at 10:45 a.m. the surveyor asked the medication nurse what time breakfast was served to the resident. The nurse responded that usually it was between 8:00 and 8:30 a.m. In an interview on 1/28/14 at 1:45 p.m. the Director of Nursing (DON) told the surveyor that breakfast comes between 8:00 and 8:00 a.m. NJAC 8:39-27.1(a)

Based on observation and record review it was determined that the facility failed to ensure that the Consultant Pharmacist reported medication issues to nursing and the physician and that the physician reviewed and responded to the Consultant Pharmacist's recommendations. This deficient practice was observed for 2 of 9 residents, Resident #2 and #3, reviewed for monthly medication review as evidenced by the following: 1. On 1/27/14 at 10:35 a.m. the surveyor observed the medication nurse administer Potassium Chloride 20 milliequivalents (meq) by mouth (po) and Metoprolol Tartrate 25 milligrams (mg) po. Review of the Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"to be given with a meal." The surveyor reviewed manufacturer's specifications and the Nursing Drug Handbook (a reference guide) and both indicated to administer these medications with or immediately following a meal. On 1/28/14 at 1:00 p.m. the surveyor reviewed the Consultant Pharmacist recommendation to the physician for Resident #2 dated 6/17/13. The Consultant Pharmacist advised that the Metoprolol dosing time should be adjusted as the medication was usually suggested with meals. There was no mention of the dosing time for the Potassium Chloride and no further recommendations noted after 6/17/13. During an interview on 1/28/14 at 1:45 p.m. the Director of Nursing (DON) stated that the nurses enter medications into the computer and confirmed breakfast usually comes between 8:00 and 8:30 a.m. The DON stated the time for administration of the Metoprolol and Potassium had been changed to 9:00 a.m. 2. The surveyor reviewed Resident #3's January 2014 Monthly physician's orders [REDACTED]. The surveyor reviewed Resident #3's eMAR in which Metoprolol TOA was 10 a.m. and 6 p.m. According to manufacturer's specifications, Metoprolol was to be given with or immediately following a meal. The surveyor spoke to the Administrator and the DON on 1/28/14 at 1:30 p.m. The DON stated that breakfast was served between 8-8:30 a.m. The surveyor then reviewed the Consultant Pharmacist's monthly Drug Regimen Review. The surveyor noted there was only one documented reference to give Metoprolol with meals dated 8/20/12. No further documentation was noted regarding the TOA of Metoprolol. The surveyor spoke with the Administrator and DON on 1/29/14 at 2:45 p.m. The DON stated that the timing of Metoprolol for Resident #3 was changed to 9 a.m. when the surveyor questioned the timing of Metoprolol on the eMAR. The surveyor noted on the physician's orders [REDACTED]. N.J.A.C. 8:39-29.3(a)1

Based on observation and interview it was determined that the facility failed to maintain a sanitary environment for residents and staff. This deficient practice was evidenced by the following: During a tour of the kitchen and related storage areas on 1/27/14 with the Director of Dining (DOD) from 9:55 a.m. until 11:05 a.m., the following was observed: 1. The metal floor plates in the walk-in dairy refrigerator were coming up off the sub-flooring creating a tripping hazard. 2. There were dried pieces of white residue in the mixing bowl stored on the large floor mixer. The mixer and bowl were covered with plastic and the DOD confirmed that the equipment was considered clean. 3. There were 2 partially uncovered containers of ice cream in the reach-in freezer. Cardboard covers used to protect the ice cream were damaged. 4. One white cutting board was heavily stained and scored. The surface on one red cutting board was peeling. 5. Two racks that were used to store clean pots were soiled. 6. Two fire suppression pipes that were located over the tilting braising pan were soiled with grease and dust. 7. There was grease build-up on the interior of the cover of the tilting braising pan. Staff confirmed that the tilting braising pan was considered clean. 8. There was spilled ice cream in the bottom of the ice cream dipping station freezer. 9. Ceiling tiles over the 3 compartment sink were soiled. 10. The tubing for the soap dispensing system was submerged in the wash water in the 3 compartment sink. N.J.A.C. 8:39-31.4(a)