Every finding on record at Winchester Gardens Health Care Center

COMPLAINT #2706331, 2717796 Based on interviews, review of medical records and other pertinent facility documentation on 2/19/26 and 2/20/26, it was determined that the facility failed to maintain a complete medical record when no evidence was provided that : 1) a private aide assigned to Resident #1 was educated on the resident's care needs, and 2) Resident #3's vital signs and pain level were assessed when their foley catheter became dislodged. This deficient practice was identified for 2 residents reviewed (Resident #1 & Resident #3) and was evidenced by the following:1). Resident #1 was not at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: mid-cervical fracture of the left femur, fracture of the right humerus, lack of coordination, and cognitive impairment. Review of Resident #1's comprehensive Assessment Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 1/1/26, indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating that the resident's cognition was moderately impaired. Further review of the MDS revealed that the resident required, Substantial/Maximal assistance with all transfers. The MDS also indicated that the resident had one fall that occurred prior to admission to the facility and another fall that occurred prior to the current fall. A review of Resident #1's baseline care plan (BCP) indicated that Resident #1 required a one-person assist for all activities of daily living (ADLs). A review of Resident #1's comprehensive care plan (CCP) revealed a focus related to the resident was a fall risk and an actual fall with a right shoulder fracture that was initiated on 12/16/25. A review of the Facility Reportable Event (FRE) which the facility sent to the New Jersey Department of Health (NJDOH), indicated that on 1/1/26 at 5:50 AM, Resident #1's Private Aide (PA #1) informed the Registered Nurse (RN #1) that at approximately 4:15 AM, Resident #1 fell and that PA #1 helped the resident back to bed. The FRE further indicated that staff informed the medical doctor (MD) of the incident, an x-ray was obtained that revealed that the resident had an, .acute right femoral neck fracture [right leg fracture]. A review of the statement provided by RN #1 revealed that she rounded at 11 PM and re-educated PA #1 on Resident #1's high fall risk and that the PA was to call for assistance if she needed a break. RN #1 further indicated that at 2:30 AM she returned to the room and observed the resident sleeping and she then offered PA #1 a break, which was declined. RN #1 next returned to the room at 5:50 AM to administer medication when PA #1 informed her that at 4:15 AM PA #1 used the bathroom in the resident's room and when she opened the door to re-enter the room PA #1 observed the resident standing at the foot of the bed and before reaching the resident PA #1 observed Resident #1 slide down onto the floor mat. PA #1 then picked the resident up and placed them back in bed without calling for assistance. A review of the statement provided by the assigned Certified Nursing Assistant (CNA #1), revealed that she rounded at 11 PM and that at that time she explained to PA #1 not to attempt to provide care and to use the call bell if anything was needed. On 2/19/26 at 1:16 PM, the surveyor attempted to contact CNA #1 for an interview without success. During an interview on 2/19/26 at 1:29 PM, NS #1 stated that the role of a PA was to provide companionship to residents, and that all care was to be provided by facility staff only. NS #1 further stated that upon a PAs arrival to the unit, they were to report to the nurse who would verbally remind them of what level of care their resident required and that they were not to provide any hands-on care but to call for assistance when needed. When asked if any of this information was documented anywhere, NS #1 stated that it was provided verbally to the PA. During a telephone interview on 2/19/26 at 2:02 PM, RN #1 stated that rounds were conducted at the start of each shift and they verbally remind all PAs that they were not to provide any hands-on care and that they were to inform staff if a resident requires any type of assistance. RN #1 stated that at the start of the shift on 12/31/26 she reminded PA #1 of Resident #1's required care level. RN #1 further stated that prior to the incident they rounded and entered Resident #1's room at 2:30 AM on 1/1/26, and offered PA #1 an opportunity for a break, which she declined. RN #1 stated that due to a new admission and a fall on the other side of the unit that night, they did not return to resident #1's room until 5:50 AM. RN #1 stated that the call bell did not ring, nor were any staff informed of what happened until RN #1 entered Resident #1's room. During a joint interview with the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), and the Assistant Nurse, on 2/19/26 at 3:06 PM, the DON stated receiving a phone call about the incident on the morning of 1/1/26 and that the NS #1 was told to initiate the protocol and to immediately collect statements prior to anyone leaving. The DON further stated that there were no existing contracts with PA agencies and that families were able to select any agency to provide companionship for their loved one. The DON further stated that PAs were instructed to report to either the NS or the assigned nurse on the floor where they would receive verbal instructions regarding any updates related to their resident's care status and that they were not to provide any hands-on care but to use the call bell and/or seek staff for any assistance the resident required. When asked how the facility ensured that PAs understood those instructions, the DON stated that the PAs would verbally repeat the instructions back to the staff member. There was no documentation that PA #1 was educated and understood what level of care Resident #1 required. 2). Resident #3 was not at the facility at the time of the survey. A closed medical review was conducted. A review of the admission Record revealed that Resident #3 was admitted to the facility with diagnoses that included but were not limited to: encephalopathy, dementia, urine retention, diarrhea, Non-[NAME] Lymphoma. The comprehensive Minimum Data Set (MDS), an assessment tool, dated 10/24/25, revealed a Brief Interview of Mental Status (BIMS) of 4 out of 15, which indicated that the resident was severely cognitively impaired. Further review of the MDS indicated that Resident #3 had an indwelling catheter. A review of Resident #3's care plan (CP), revealed a focus related to the resident being on enhanced barrier precautions due to the presence of an indwelling urinary catheter. The interventions included the monitoring of the resident's vital signs, labs and diagnostics as ordered by the physician that was initiated on 10/21/25. A review of Resident #3's progress notes (PN), included a change in condition (CIC) note created by Registered Nurse (RN #2) dated 11/10/25 at 8 PM, that indicated that the resident's foley had dislodged and they were to report to the physician as necessary. Further review of the PN did not indicate that vital signs were taken and/or that pain was assessed. On 2/20/26 at 10:12 AM, surveyor attempted to reach RN #2 via telephone, without success. On 2/20/26 at 2:19 PM, the surveyor conducted a joint interview with the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), and the Assistant Nurse (AN), the DON stated that if a foley becomes dislodged the nurse should assess the site, obtain vital signs and assess for pain. The DON further stated that all this information should be documented in a PN and that the importance of the documentation was so that everyone was aware of the resident's status. During a follow-up interview with the DON, the LNHA, and the AN on 2/20/26 at 4:20 PM the DON stated that at the moment that the foley was dislodged, Resident #3's pain level and vital signs should have been assessed and documented. The DON further stated that the dislodging of a foley could be a traumatic experience which was why it was important that the assessment and documentation occur. On 2/21/26 at 11:15 AM, the DON provided an electronic communication that included a timeline of the events that occurred on 11/10/25. The timeline indicated that on 11/10/25 at 6:30 PM RN #2, contacted Resident #3's medical provider to inform them that the resident's catheter had dislodged and that, at that time no signs of bleeding or trauma were observed, and vital signs were at baseline. There was no documentation provided that this information was entered into the resident's medical record. A review of the facility's Private Duty Services policy, revised 1/15/26, revealed that, The facility maintains oversight to ensure private aide services support resident safety, and community standards. A review of the facility's Charting and Documentation policy revised 1/10/25, revealed that all services provided to residents should be documented and that documentation would be complete and accurate. The policy listed what information was to be documented and included, .c. Treatment or services performed, d. Changes in a resident's condition. The policy further indicated that the documentation would be complete and accurate. A review of the facility's, Resident Monitoring: Vital Signs policy, revised 1/25/25, revealed that vital signs should be taken, at clinically appropriate intervals and when there were any changes in a resident's condition. N.J.A.C. 8:39-27.1(a)

REPEAT DEFICIENCY Based on observation, interview, record review and policy review, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following:On 9/2/2025 at 10:00 AM, in the presence of the Food Services Director, the surveyor observed the following: In the food preparation area, the surveyor observed a thick black grease-like substance on 3 of the 12 burner stoves. The residue was easily dislodged using the tip of a pen. NJAC 8:39-17.2(g)

Based on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 1 (one) of 12 residents (Resident #23) during the review of resident assessment. This deficient practice was evidenced by the following: The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. On 9/3/25 at 11:38 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse (MDSC/RN), who stated that in April, she thought that she had submitted the Resident #23 admission MDS (A/MDS) assessment. The MDSC/RN revealed that she did not submit the assessment on time. On 9/4/25 at 10:38 AM, the MDSC/RN provided the surveyor with a final validation report (generated after every MDS transmission) from the Centers for Medicare and Medicaid Services (CMS) of Resident #23's submitted A/MDS assessment that was not submitted within fourteen days of completion. Resident #23 A/MDS assessment has an assessment reference date (ARD, the last day of the observation period) of 4/20/25. It was signed as completed on 4/22/25 and not transmitted until 9/3/25. On 9/4/25 12:02 PM, the surveyor met with the Licensed Nursing Home Administration (LNHA) and the Director of Nursing (DON) regarding the above concern; there is no information provided. The DON stated that they follow the RAI (Resident Assessment Instrument, a tool that helps gather information about a resident's strengths and needs, which is used to create an individualized care plan) manual. NJAC 8:39-11.1

Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to follow up on the psychiatry (psych) consult recommended by the physician to address the dementia care of a resident who is receiving antipsychotic medications. This deficient practice was identified for 1 (one) of 1 resident (Resident #2) reviewed for dementia care. This deficient practice was evidenced by the following: On 9/3/25 at 12:20 AM, the surveyor observed Resident #2 sitting in a wheelchair inside the dining room having lunch. On 9/4/25 at 11:51 AM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #2, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #2 was admitted with diagnoses that included but were not limited to unspecified dementia (loss of memory), unspecified severity, with other behavioral disturbance. A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) dated 7/17/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident had severe cognitive impairment. Further review of A/MDS reflected in Section N - High Risk Drug Classes: Use and Indication that Resident #2 was receiving antipsychotic and antidepressant medications while in the facility. A review of the Physician Order Sheet (OSR) revealed the following:1. quetiapine (an antipsychotic medication) 25 mg (milligram)1 tablet orally once daily for behavior disturbance with the start date of 7/12/25.2. venlafaxine (a generic medication for brand name medication called Effexor, an antidepressant medication) 75 mg 1 tablet orally once daily for depression with a start date of 7/12/25.3. donepezil (a generic medication for brand name medication called Aricept, a medication to treat Alzheimer's disease) 10 mg 1 tablet orally once daily for dementia with a start date of 7/11/25. A review of the [Name withheld] Physician Orders form with a handwritten order on 7/10/25 at 10:00 PM, a telephone order of psych consult - resident on quetiapine, divalproex, Aricept, and Effexor. A review of the physician's progress notes dated 7/11/25 and 7/17/25 revealed that the physician's plan of care includes dementia care. A review of Resident #2's Care Plan (CP) report revealed that Resident #2 was receiving antipsychotic and antidepressant drugs regularly and was at risk for falls related to dementia. On 9/4/25 at 9:54 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that there was a psych consult order dated 7/10/25. The LPN stated that the psych consult was recommended and noted that there was no psych consult done for this resident. On 9/5/25 at 9:43 AM, the surveyor interviewed the Director of Nursing (DON), who stated that there was an order for a psych consult on 7/10/25, but the psychiatrist was on vacation, which was why it was not done. A review of the facility policy titled Behavioral Management, with a revised date on 1/10/25, given by the DON, did not address dementia care for a resident who is on a psychotropic medication. On 9/5/25 at 12:29 PM, the surveyor interviewed the DON regarding a policy for dementia care or psychotropic use. Still, the DON stated that they only have a behavioral management policy, which is their general policy and no other information was provided. NJAC 8:39-45.1(a)

Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a COVID-19 Immunization and provide education regarding the vaccine. This deficient practice was identified for 1 of 5 residents reviewed for immunization (Resident #12).On 09/3/25 09:59 AM, the surveyor reviewed Resident #12's medical record which revealed the following information: A review of the Resident's Face Sheet (an admission summary) revealed Resident # 12 had been admitted to the facility with diagnoses which included hemiplegia following cerebral infarction affecting the right dominant side and chronic kidney disease. A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 8/25/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of Resident #12's active Care Plan (CP) printed on 9/5/25 did not reveal any focus, goals, or interventions for vaccinations. A review of Resident #11's electronic Medical Record (eMR) under Immunization did not reveal a Covid-19 Immunization administration record.On 9/3/25 at 10:43 AM, the surveyor discussed the concern with the Director of Nursing (DON) that the historical record of the resident's COVID-19 immunization was not on the eMR. A review of the progress notes (PN) reflected an entry made by the Registered Nurse/Unit Manager (RN/UM) reflected the resident received vaccination back in 2022, after surveyor inquiry. A review of the paper based medical record (hard chart) did not reflect an offer, refusal and education provided to the resident upon and after admission. On 9/4/25 at 9:45 AM, during an interview with the Registered Nurse/Unit Manager (RN/UM) explained the process for immunization for admitted residents. The RN/UM stated the nurse on duty admitting the resident, recorded the historical information of the resident's vaccination record either via resident interview when capable, family interview or previous medical record. At 10:04 AM, the surveyor and the RN/UM reviewed the resident's medical record together. At that time, the RN confirmed that there was no documentation in the medical record of that the COVID-19 immunization was offered, administered or refused and the evidence that education provided. At 10:29 the DON confirmed that the medical record did not reflect the COVID-19 immunization was offered, administered/refused and an education was provided. On 9/4/25 at 9:15 AM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) and the DON, the surveyor discussed the concern regarding the COVID-19 immunization. On 9/5/24 at 12:34 PM, in the presence of the survey team, and the LNHA, the DON stated that they had updated the immunization form of Immunization Information and Permission form which was updated to include the COVID-19 vaccine, acceptance or refusal and the education for the influenza, the pneumonia, the respiratory syncytial virus (RSV) and the COVID-19 vaccines. A review of the facility provided policy for Immunization, dated/revised on 9/4/25 reflected that all residents would receive education regarding immunization benefits prior to being offered the vaccine. A right of refusal would also be included in the education for the resident/ resident representative and documented in the resident's medical record. N.J.A.C. 8:39-19.4(a)

REPEAT DEFICIENCY Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store potentially hazardous foods in a manner to prevent food borne illness. This repeat deficient practice was observed and evidenced by the following: On 5/28/24 at 06:01 PM, while on 4th floor, in the area labeled Den, the surveyor observed a staff refrigerator with signage that stated, all items must be labeled with name and date. The surveyor observed a 2 liter bottle of Coke Cola, a container of salad and brown bag with a container of food. All items were missing labels including names and dates. On 5/28/24 at 6:24 PM, the surveyor in the presence of the Executive Chef (EC) observed the following during the kitchen tour: 1. Upon entering the kitchen the surveyor observed two servers (dietary aides) server #1 and #2 with hair not fully restrained, servers #3 and #4 without hairnets, and server #5 with beard guard improperly placed. The EC could not explain why those servers were not wearing hair and beard restraints properly. 2. In the standing drink refrigerator, the surveyor observed an opened 60 ounce (oz) bottle of cranberry juice without a label and an opened 60 oz bottle of grape juice with an open date of 4/25/24. The EC stated all items that have been opened need to be labeled with the open date and use by date. The EC acknowledged the grape juice should have been discarded after three days. 3. Surveyor observed servers #6 and #7 scooping ice cream into a bowl, both observed not wearing disposable gloves and both servers' hands were touching the inside of bowl. The EC stated gloves should be worn whenever preparing any food items. 4. Surveyor observed in the standing refrigerator, a 1/2 gallon fat free milk, a 24 ounce (oz) bottle of chocolate syrup, a 1 gallon Caesar dressing, a 5 lb. tub sour cream, all opened and missing open/use by labels. The EC stated all items that have been opened need to be labeled with the open date and use by date. 5. Surveyor observed in the dual door standing refrigerator, an open bag of fresh broccoli and cauliflower, both missing open/use by labels. 6. Surveyor observed a freezer next to the tray line, one bag of frozen tater tots and one bag of premade biscuits, both open and missing open/use by labels. 7. Surveyor observed in the walk-in refrigerator in the main kitchen area, an open bag of shredded carrots missing an open/use by label 8. Surveyor observed in the walk-in freezer in the main kitchen area, an opened package of coffee cake missing an open/use by label. 9. Surveyor observed in the dish washing area, a four shelve storage dish rack with three full size catering dishes with wet nesting. The EC stated all items in the shelving unit should be completely dry before being stored. 10. Surveyor observed in the walk in refrigerator located in the dry storage area, two fans with a black colored debris and an open bag a grated parmesan cheese missing an open/use by label. The EC stated he would alert the maintenance department is responsible for clean the fans. 11. Surveyor observed in the walk in freezer located in dry storage area, frost build up and multiple boxes of frozen food stored higher than 18 inches from ceiling. The EC stated he would alert the maintenance department regarding the frost and would move the boxes to the proper distance from the ceiling. On 5/29/24 at 11:30 AM, the Dining Services Director (DSD) provided the surveyor with multiple facility policies including, Unit pantry stock, Dress guidelines for food service management and clinical nutrition staff, Uniform dress code, Food and supply storage, and Refrigerated storage life of foods. The Unit pantry stock policy with a revised date of 1/2024 states under the procedures section, Label, date and discard outdated items per the food storage policy. Ensure all items are covered, labeled, and dated. The Dress guidelines for food service management and clinical nutrition staff policy with a revised date of 1/2022 states under the procedure section, hair restraints are worn by all when in the kitchen. The Uniform dress code policy with a revised date of 1/2022 states under the procedure section, restrain all facial hair with a beard net/restraint. The Food and supply storage policy with a revised date of 1/2024 states under the procedures section, cover, label and date unused portions and open packages. Complete all sections on the [NAME] orange label or use the Medvantage/Freshdate labeling system. Refer to the food storage chart in this policy to determine discard dates for food items. Store food items 6 inches (in) above the floor and 18in below the ceiling/sprinklers. The food storage chart revealed that re-sealable juice should be discarded after 3 days after opening. On 5/30/24 at 1:31 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assisted Living Coordinator (ALC), and Regional Nurse Consultant (RNC) to review concerns. No comments made by staff regarding kitchen concerns. On 5/31/24 at 10:14 AM, the LHNA met with the surveyor and stated, The kitchen not up to my standards. No further comments made. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 6 of 15 residents reviewed (Resident # 4, 17, 19, 7, 11, 18). This deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #4. According to the Admission Record (AR) (an admission summary), Resident #4 had diagnoses that included but were not limited to: Hypertension, Glaucoma, Anemia and Chronic Obstructive Pulmonary Disease. A Quarterly Minimum Data Set (MDS) assessment, a tool used to facilitate management of care, dated 5/21/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #4 scored 6 out of 15, which indicated the resident had severe cognitive impairment. A review of physician progress notes (PPN) in the hybrid medical record revealed there were no physician progress notes documented by the resident's primary physician. 2. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #17. According to the AR, Resident #17 had diagnoses that included but were not limited to Dementia, Hypotension, and Parkinson's Disease. An Annual MDS assessment, a tool used to facilitate management of care, dated 5/1/24, indicated the facility assessed the resident's cognition using a BIMS test. Resident #17 scored 14 out of 15, which indicated the resident had intact cognitive impairment. A review of PPN in the hybrid medical record revealed there were no physician progress notes documented by the resident's primary physician. 3. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #19. According to the AR, Resident #19 had diagnoses that included but were not limited to Hypertension, Depression and Diabetes Mellitus. A Quarterly MDS assessment, dated 3/6/24, indicated Resident #19 was rarely/never understood and a BIMS test could not be performed to assess the resident's cognition. A review of PPN in the hybrid medical record revealed there were no physician progress notes documented by the resident's primary physician. 46049 4. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #7. According to the AR, Resident #7 had diagnoses that included but were not limited to: dementia, hypertension, anxiety disorder, and chronic atrial fibrillation (type of heart arrhythmia). A Quarterly MDS assessment, a tool used to facilitate management of care, dated 4/11/24, indicated the facility assessed the resident's cognition using a BIMS test. Resident #7 scored 7 out of 15, which indicated the resident had moderate cognitive impairment. A review of PPN in the hybrid medical record revealed there were no physician progress notes documented by the resident's primary physician. 5. 4. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #11. According to the AR, Resident #11 had diagnoses that included but were not limited to: Alzheimer's disease, dementia, major depressive disorder, hypertension, and anxiety disorder. A comprehensive MDS assessment dated [DATE], indicated Resident #11 was rarely/never understood and a BIMS test could not be performed to assess the resident's cognition. A review of PPN in the hybrid medical record revealed there were no physician progress notes documented by the resident's primary physician. 6. The surveyor reviewed the hybrid (paper and electronic) medical records of Resident #18. According to the AR, Resident #18 had diagnoses that included but were not limited to: nontraumatic intracerebral hemorrhage (bleeding in the brain not caused by trauma), anemia, type 2 diabetes mellitus, heart failure, and gastrostomy (a tube surgically inserted through the wall of the abdomen directly into the stomach to provide nutrition and medications). A Quarterly MDS assessment, dated 4/11/24, indicated Resident #18 was rarely/never understood and a BIMS test could not be performed to assess the resident's cognition. A review of PPN in the hybrid medical record revealed there were no physician progress notes documented by the resident's primary physician. On 5/29/24 at 12:30 PM, the surveyor interviewed the Assisted Living (AL) coordinator at the nurses' station about where physician progress notes were documented in a resident's medical records. The AL coordinator stated the physicians would document in the electronic medical record (EMR) under the assessments section. She further explained the facility was transitioning for all physician progress notes to be in the resident's EMR and that some physician progress notes may be found in the resident's paper chart. On 5/30/24 at 1:31 PM, the survey team met with the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the AL coordinator, Regional Nurse Consultant, Corporate Regional Nurse Consultant, and Clinical Analyst. The surveyors informed the facility about the concern of no physician progress notes by the resident's primary physician being found in the hybrid medical records for the residents identified. The DON stated it was expected for physicians to visit and document their progress notes at least every 30 days and every other month when alternating visits with a nurse practitioner. On 5/31/24 at 9:30 AM, the DON and AL coordinator provided the survey team with a copy of physician progress notes from January 2024 to May 2024 for the residents. The DON stated it was faxed from the physician's office yesterday to the facility. The AL coordinator further explained they were transitioning to have the physicians' document in the EMR directly instead of in their own documentation systems. The DON stated that physician progress notes not written in the EMR were to be faxed to the facility within 24 hours of the physician's visit to be placed in the resident's medical records. The DON acknowledged the physician progress notes should have been in the resident's medical records and readily accessible. There was no additional information provided by the facility. The primary physician was unavailable for interview. A review of the facility's policy titled Physician Visits, with a revised date of 5/18/23 read under Procedure: 1. The Attending Physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. A review of the facility's undated policy titled Physician Visits, under Policy Interpretation and Implementation it read: .5. The Attending Physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation . N.J.A.C. 8:39-35.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were removed from the medication room and treatment cart. This deficient practice was identified for 1 of 1 floor inspected and was evidenced by the following: On 05/28/24 7:45 PM, the surveyor inspected the 4th floor medication storage room and treatment cart (high side) in the presence of the Licensed Practical Nurse and found the following expired medication: a. 2 bottles of Adult low dose Enteric Coated 81mg that had 120 tablets each bottle with an expiration date of 8/2023 b. 1 tube of unopened Bacitracin Ointment 1 oz (28.4g) with an expiration date of 1/2024. c. 1 tube of opened Bacitracin Ointment 1 oz (28.4g) with an expiration date of 1/2024 inside the treatment cart. On 5/28/2024 at 8:30 PM, the surveyor discussed the above concern to the facility's Licensed Nursing Home Administrator, Director of Nursing and Assisted Living Coordinator who acknowledged that the above medications were expired. NJAC 8:39-29.2 (d)

Based on observation, interview, and review of facility policy, the facility failed to: 1. ensure food was stored in a sanitary manner; 2. ensure dishes and pans were air dried and not dried by a standing fan that had dust on it; 3. ensure kitchen equipment was clean; 4. ensure proper hand hygiene while handling food; 5. ensure sanitizing buckets used to sanitize counters was adequate; and 6. ensure steam tables had water in them to keep food at the appropriate temperature. These failures had the potential to affect 17 out of the 18 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 Services (DCS) and the Resource Chef (Chef): 1. On [DATE] at 8:30 AM, observation, of the refrigerator revealed one jar of mayonnaise with a cracked lid that prevented it from being sealed closed. On [DATE] at 8:34 AM, observation of the main kitchen area revealed a large plastic bin under the counter that contained rice flour with a dried liquid dripped into the container. The second plastic container under the counter contained sugar that had expired on [DATE]. 2. Observation on [DATE] at 8:34 AM, revealed a large stand fan where the fan guard was caked with dust. This fan was blowing on the clean dishes that were air drying. 3. Observation on [DATE] at 8:34 AM, revealed the outside of the deep fryer was covered in old grease and food particles. The bottom of the inside of the deep fryer, had a thick residue of grease. Observation on [DATE] at 9:08 AM, revealed the kitchen ice machine filters located on the outside of the machine, to be covered in dust. The inside of the ice machine had a pink slime going across the metal bar that was above the ice. 4. Observation on [DATE] at 8:45 AM, revealed the cook making coleslaw with a glove only on one hand. He was mixing the coleslaw with the gloved hand and holding the bowl with the ungloved hand. The cook then emptied the coleslaw into medium sized containers holding the containers with the ungloved hand. He was touching the coleslaw and wiping his hand on his apron. 5. On [DATE] at 8 :51 AM, one test bucket in the kitchen registered zero for a sanitizing agent. When the DCS checked, the sanitizing bottle that dispenses the sanitizing agent was empty. 6. The Long-Term Care (LTC) unit has its own kitchen. Food is brought up in pans from the main kitchen and placed in steam tables. One out of two steam tables did not have any water in it to maintain the proper temperatures of the food. Interview with the Chef on [DATE] at 8:55 AM, she stated, This sanitizing bucket having no sanitizer in it, is embarrassing and I apologize. The fan should not have been blowing on the drying dishes and the deep fryer was definitely dirty. Interview with the DCS on [DATE] at 1:30 PM, he stated, The cook knew to wear gloves on both hands when preparing the coleslaw. The staff just needs to do what they know how to do and following the regulations of the kitchen. On [DATE] at 9:00 AM, interview with the DCS revealed that maintenance does all cleaning of the ice machines, and they are cleaned once a month. When asked if the kitchen ever inspects the ice machines, he stated, No, this is dirty and there is slime on the inside. Interview on [DATE] at 10:00 AM with the Maintenance Supervisor (MS) and the Director of Plant Operations (DPO) revealed that records indicated the ice machine was cleaned at the end of the month for the past six months. The MS stated, We looked at the ice machine and it should not have been that dirty. We routinely check the filters, clean the coils, sanitize the interior, and delime, as necessary. Review of the facility's policy, Food Handling Guide, dated ,d+[DATE], revealed, .food contact surfaces should be cleaned and sanitized between different food preparation steps .Hands should be scrubbed following appropriate hand washing techniques .Use clean sanitized equipment and food contact surfaces .Single use disposable gloves are to be worn when preparing food and while serving food. Gloves are to be placed over clean hands and changed between tasks. Hands are to be washed after glove removal. Review of the facility's policy, Hand Hygiene, dated ,d+[DATE], revealed, .Hands are washed with soap and water before putting on gloves; after touching hair, skin, or clothing; before each shift; after handling money; after going to the bathroom; after handling garbage; after coughing, sneezing, or blowing nose; after removing gloves. NJAC 8:,d+[DATE].2(g) NJAC 8:,d+[DATE].7(d)

Based on interview, record review, and policy review, the facility failed to obtain a Code Status for one resident (Resident (R) 8) out of a total sample of 10 residents. This failure had the potential for R8 to have unwanted life-sustaining treatments. Findings include: 1. Review of R8's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R8 was admitted to the facility on [DATE]. There was no Advance Directive, Physician Orders for Life Sustaining Treatment (POLST), or a Code Status in the EMR or in the resident's hard chart located in the nursing office. Review of the EMR Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R8 had no cognitive impairment. Interview on [DATE] at 9:00 AM with Registered Nurse (RN) 2 revealed that the facility process was that the code status for Do Not Resuscitate (DNR) was located on the binder of the resident's hard chart in red. If there was not a sticker stating DNR, then the resident was a Full Code which means Cardiac Pulmonary Resuscitation (CPR) would be performed. RN2 stated that the code status was also located in the EMR. RN2 verified that R8's hard chart and EMR did not have a DNR code status documented. On [DATE] at 3:23 PM, interview with the Social Worker (SW) revealed that upon admission, R8 and Family (F1) were given instructions and paperwork for a POLST. F1 stated that R8 had a Power of Attorney (POA) and a POLST and this would be provided to the facility. The SW stated, The information was discussed with the resident and [F1], and that the resident would be a Full Code until the paperwork was provided and documented in the resident's chart. A Care Plan meeting was held on [DATE] with the resident and F1 and I again asked for the POLST. F1 who lives out of state, stated that she would have the caregiver deliver the form to the facility. The SW stated, I do not know the resident's wishes for code status six weeks after admission to the facility. Interview on [DATE] at 3:35 PM with R8, F1 by phone, the Social Worker (SW), and the surveyor, revealed that the resident's wishes were to allow natural death and to not attempt resuscitation. The SW informed R8 and F1 that until a document was provided with her wishes, R8 would be a Full Code. The resident became very upset, and F1 asked if a new POLST could be signed. A POLST was signed by the resident and the nurse practitioner and the POA documentation was emailed to the facility with the resident's wishes. A physician's order was written for R8 to have the code status of Do Not Resuscitate after the POLST was signed. On [DATE] at 3:52 PM, interview with the Assistant Executive Director (AED) revealed, My expectations are that when a resident is admitted , a POLST should be on file with their end of life wishes. We should abide by the wishes of the resident at all times. Review of the facility's policy titled, Advance Directives, undated, revealed, Advance Directives include: POLST, Living Will, or a Durable Power of Attorney for Healthcare. If you do not have any Advance Directives, the facility can provide you with a POLST form to fill out . Review of the facility's policy titled, CPR-Cardiopulmonary Resuscitation, DNR-Do Not Resuscitate, dated [DATE], revealed, .CPR will be performed at all times until a facility approved DNR Order Form has been completed by the physician and entered into the resident's medical record .Social Services will review the explanation of CPR/DNR and complete the discussion form .If the decision is DNR, the physician must write a DNR order on the DNR form. The nurse will transpose the order to the physician order sheet in the EMR. NJAC 8:,d+[DATE].6(a)

Based on interview, record review, and facility policy review, the facility failed to provide timely a completed Centers for Medicaid and Medicare Services (CMS) Form CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to one of three residents (Resident (R) 64) reviewed for liability notices out of a total sample of 10 residents. This failure prevented the resident or responsible party the ability to make an informed decision related to the cost of continued services. Findings include: 1. Review of R64's Face Sheet, undated and located in the resident's electronic medical record (EMR) under the Profiles tab, indicated a current admitted to the facility of 03/08/22, with diagnoses which included; acute on chronic congestive heart failure (CHF), difficulty in walking, and unsteadiness on feet. Review of R64's Progress Notes, located in the EMR under the Assessments tab, indicated R64 was admitted to Medicare part A therapy services on 03/08/22. Further review of R64's EMR indicated R64's last covered day of Part A therapy services was 03/31/22. A SNFABN was issued to R64 on 03/30/22. During an interview on 09/28/22 at 3:00 PM, the Social Worker (SW) stated she was the responsible person for providing the SNFABN notices to residents. The SW stated for R64 she provided the notice on 03/30/22 as R64 was discharging home on 04/01/22. The SW verified with this surveyor the SNFABN stated skilled services would end on 03/31/22, but since R64 was discharging home, the SW stated she did not need to give 48 hours notice as the SW knew R64 would not want to appeal. The SNFABN also did not reflect the cost of the non-covered services for R64 to make an informed decision. The SW further stated she was not aware the specific costs needed to be listed on the SNFABN. During an interview with the Assistant Executive Director on 09/28/22 at 3:30 PM, he stated all SNFABN notices were to be given/provided to residents at a minimum of 48 hours prior to when covered services ended for residents to have the opportunity to appeal, if they wanted to. The Assistant Executive Director also stated all costs, with specific monetary amounts, should be listed on the notices. The Assistant Executive Director further stated they did not have a facility specific policy regarding ABN/NOMNC notices, they followed the language on the CMS forms. NJAC 8:39-4.1(a)8

Based on observation, interview and review of documentation provided by the facility, it was determined the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This is a repeat deficiency. This deficient practice was evidenced by the following: On 3/4/20 at 8:13 AM, in the presence of Supervisor the surveyor observed the following: 1. The surveyor observed a Utility Aide (UA1) with 1/2-inch-long beard hair with no beard covering. The surveyor asked UA1 if his beard should be covered, he stated that is should have been covered and proceeded to obtain a beard restraint and apply it. 2. In the dish washing area the following items that were in circulation for use: - 13 steam table half pans stacked with water between them. - Eight steam table quarter pans stacked with water between them. - 12 steam table shallow half pans stacked with water between them. - 11 full sheet pans stacked with water between them. - Seven steam table half pans stacked with water between them. - 20 steam table full pans stacked with water between them. - Three steam table deep pans stacked with water between them. - Five plastic deep cambro's stacked with water between them. - Five small plastic cambro's stacked with water between them. - One large plastic hydration tank stored right side up with water visible inside. - Three coffee carafes that were stored upright and with water pooled at the bottom. The Supervisor stated that the pans should have been completely dried before stacking and that the hydration tank as well as the coffee carafes should have been dried and stored upside down. 3. At the dish machine the surveyor observed UA1 run a rack of flatware through the dish machine. The flatware was laying flat and laying overtop each other. Then UA1 removed a hand full of wet silver wear and started drying the items with a paper towel. The Supervisor stopped UA1 and reported that a special flatware rack should have been used when running the flatware through the machine. The supervisor also stated that the flatware should have been allowed to air dry and the staff should never dry dish wear with a towel. 4. On the shelf next the the three compartment sink there was a layer of cardboard, that was completely saturated with water. UA2 stated that the cardboard was there to hold up pans for drying because they would just slip down. The supervisor stated that there should not be cardboard there being used for that purpose and removed in immediately. 5. The following was observed in the food preparation area: - The candy stove was soiled with dried drippings of a brown/black grease-like substance and food debris. - The large range hood over top of all of the cooking appliances was soiled with a light brown grease-like substance. - The steam table backsplash was soiled with food drippings and food debris. - One of two ovens was soiled with dried drippings of a brown/black grease-like substance and charred food debris. - The stove cook top backsplash was soiled with dried drippings of a brown/black grease-like substance. - The grill top was soiled with a brown/black grease-like substance and charred food debris. - The broiler was soiled brown/black grease-like substance and charred food debris. The supervisor stated that these items should have been cleaned on Saturday however they should also have been cleaned as needed. The surveyor reviewed an undated facility policy titled, Employee Sanitary Practices. Under procedure number one the policy revealed that All employees will: Wear hair restraint (hair net and/or beard restraint) to prevent hair from contacting exposed food. The surveyor reviewed an undated facility policy titled, Food Safety-Director of Food and Nutrition Services Responsibility. Under procedure number two the policy revealed that Dishwashing guidelines and techniques will be understood by staff and carried out in compliance with state and local health codes. The surveyor reviewed an undated facility policy titled, Cleaning Dishes/Dish Machine. Under procedure numbers six, and nine through 10 the policy revealed that Flatware should be pre-soaked prior to washing, and loaded into cylinders with mouthpiece exposed. Flatware should be washed twice, with mouthpiece down during the second washing. Flatware should not be nested prior to washing in cylinders. Dishes should be air dried on the dish racks. Do not dry with towels. Inspect for cleanliness and dryness, and put dishes away if clean. Dishes should not be nested unless they are completely dry. NJAC 8:39-17.2(g)

Based on observation, interview and review of documentation provided by the facility, it was determined the facility failed to a.) prepare and store potentially hazardous foods in a manner to prevent the development of food borne illness and b.) maintain the kitchen in a sanitary manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 04/16/19 from 7:40 AM to 9:30 AM, Surveyor #1 and #2, observed in the presence of Cook #1, Cook #2, the Assistant Food Service Director (AFSD) and the Culinary Director (CD), the following: Inside the walk-in refrigerator: 1. A small container with a red colored sauce like substance that was dated 4/8, no year was specified. Cook #1 stated it was tomato paste and further stated that she was going to throw it out because after three days everything is thrown out. 2. A package of hot dogs was opened, partially rewrapped and not dated. 3. Three partially wrapped turkey burgers were open to the air and were not dated. 4. One package of uncooked duck was not dated. 5. A small pan containing six individually packaged tilapia was dated 04/3/19. Cook #1 stated this has to be thrown out. 6. Three packaged pork loins were in a pan and were not dated. 7. Two large uncooked turkey breasts were on a sheet pan on the bottom shelf and four additional large uncooked turkey breasts were on two separate sheet pans, located on a movable rack. All six turkey breasts were not fully covered and there was a large amount of reddish colored liquid that the turkey breasts were sitting in. The turkey breasts were not dated. Cook #1 stated the turkey breasts should have been covered and dated and that these were going to be cooked today. 8. A box of fish placed on a pan with a date of 04/11/19. The box was saturated with a clear liquid and liquid was on the pan. The box was not sealed exposing the fish to the air. The AFSD stated once the fish was open it should have been taken out of the box, placed in another pan and dated. 9. A tray of individually packaged defrosted yellow fin tuna fillets was on a sheet pan in a liquid and not dated. 10. On the bottom shelf there was one bag of uncooked chicken that was open to air and was stacked on top of a container filled with uncooked chicken with a plastic covering. The container and bag of chicken was not dated. 11. One open bag of whole assorted yellow squash and zucchini was not dated. 12. One open box of uncooked bacon and one uncovered pan of uncooked green beans, raw carrots, two red onions was not dated. 13. Underneath the uncooked bacon and vegetables were two pans of cooked mashed potatoes. One of the pans of mashed potatoes had a hole in the covering and neither pan was dated. Surveyor #1 & #2 observed inside the walk-in freezer the following: 14. Six five-gallon assorted ice cream containers were stored on the floor. 15. One package of frozen chicken breast, one frozen bag of breaded oysters, one frozen bag of vegetable burgers and one frozen bag of pepperoni were open to air and not dated. 16. The external walk-in freezer door was weeping water droplets and had a build-up of frost around the inside of the door frame. Surveyor #1 and #2 observed the food preparation areas, dish machine area and cooking areas and noted the following: 17. A large blender was stored upright, covered with a lid and was visibly wet inside. 18. A storage rack contained a white cutting board that was very worn with black marks imbedded into the board, two brown cutting boards were worn with grooves and discolored, and a red cutting board had black spots. 19. The storage rack contained a large frying pan that was charred and had a broken handle. 20. A storage rack contained: 37 sheet pans that were wet nested, six black charred sheet pans, six small square black 1/8th size pans visibly wet nested, three full size metal pans which were all wet nested and one was broken; 16 black ½ size salad pans were wet nested with sticker residue. 21. The self-dispensing paper towel dispenser located next to the hand-washing sink was not working. 22. A rack contained seven two-liter pump coffee pots was stored upright and visibly wet. 23. A large open tray cart stored by the dish machine was visibly soiled with food like substances. 24. Two three-tier and one two-tier cart that are used to transport food were visibly soiled with food debris and dark substances throughout. 25. The food preparation table directly opposite the three compartment sink had a grease like feel to the touch. Cook #2 stated she used the table to set up trays. 26. Observed the kitchen walls, the grill top and behind the ovens, and the floor was visibly soiled with dried food splatter. 27. The can opener in the cook's area was very soiled with a dark sticky to the touch caked on debris on the blade and insert. The surveyor reviewed the facility's Food Storage Policy and Procedure dated (YEAR). The policy revealed under Policy, Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure, 7c, revealed Food should be dated as it is placed on the shelves if required by state regulation. Under Procedure #14f Refrigerated Food Storage, revealed All foods should be covered, labeled and dated. All will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Under Procedure, #15c. Frozen Foods, revealed All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. The surveyor reviewed the facility's Cleaning Dishes/Dish Machine Policy and Procedure dated (YEAR). The Policy, under Procedure #11 revealed, Dishes should not be nested unless they are completely dry. The surveyor reviewed the facility's General Food Preparation and Handling Policy and Procedure updated 05/23/18. The Food Preparation Procedure, under #3a. revealed, Meats, fish and poultry will be defrosted using safe thawing practices. In the refrigerator in a drip proof container, in a manner that prevents cross contamination. The Food Preparation Procedure, under #3k. revealed, The can opener will be cleaned and sanitized daily and/or as needed. The Food Service Procedure, under #4d. revealed, Leftovers must be dated, labeled, covered, cooled and stored properly in a refrigerator. The Equipment Procedure, under #5a. revealed, All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. On 04/17/19 at 12:15 PM, the surveyors discussed the above concerns with the Acting Facility Administrator and Director of Nursing. No additional information was provided. NJAC 8:39 17.2(g)

Complaint #: NJ 6 Based on interviews and record review, as well as review of pertinent facility documents on [DATE], it was determined that the facility failed to ensure that the Resident who was transferred using a mechanical lift was transferred with sufficient staff for assistance to prevent accident and injury for 1 of 3 residents (Resident #2), reviewed for incident and accident with injury. On [DATE], Resident #2, who required assist of two (2) during transfer via mechanical lift was transferred by 1 staff which resulted in a fall and Right Femur Fracture, requiring emergency room services and admission. The deficient practice is further evidenced by the following: 1. According to the Face Sheet Resident #2 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2 was readmitted on [DATE] (after the fall), with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment tool dated [DATE], revealed Resident #2 has moderate impairment in cognition and required extensive assist to total assist of two (2) with Activities of Daily Living (ADL). The Baseline Care Plan (BCP) initiated on [DATE], identified Resident #2 as a total dependent during transfer with assist of two. Intervention included: Hoyer lift (HL) with two staff assist. The CP was revised on [DATE], showed that on [DATE], Resident #2 had an actual fall and sustained Right Femur Fracture. Interventions included but were not limited to: palliative care for comfort, application of splint to right leg/femur daily, and apply abductor pillow daily. Resident #2's fall risk assessment on [DATE], scored at a high risk for falls. The readmission (after the fall) Physician orders [REDACTED]. On [DATE]: [MEDICATION NAME] 10 milligrams (mg)/5 millimeter (ml), give 1.3 ml as needed every 4 hours [DIAGNOSES REDACTED]. On [DATE]: Palliative care On [DATE]: Oxygen at 2 liters via nasal cannula [DIAGNOSES REDACTED]. According to the Occurrence Report, dated [DATE], documented by the Licensed Practical Nurse (LPN), showed that on [DATE] at 2:46 p.m., the LPN found Resident #2 lying on the floor with the HL on top of the Resident. CNA #1 was in the room with the Resident at this time of the incident. The Resident was yelling in pain and when asked to rate the pain from scale of 1 to 10, the Resident stated, it's a pain I don't want to experience. The Resident was medicated for pain and 911 (emergency service) was called. The 911 emergency staff arrived, and the Resident was transferred to the stretcher screaming in pain. The Resident was sent to the Acute Hospital. According to the Investigation of Report (IR), dated [DATE], documented by the Director of Nursing (DON) on [DATE], Resident #2 was being transferred from the chair to bed via a Hoyer lift (HL) by Certified Nurse Aides (CNA #1 and #2). CNA #1 positioned the Resident, who was in chair, next to the bed, then CNA #1 attached the HL sling to the lift pad. CNA #2 (who was primary CNA assigned to Resident #2), came in to the Resident's room to assist in transfer. CNAs #1 and #2, using the HL lifted the Resident from the chair closer to the bed. However, CNA #2 left CNA #1 in the middle of completing the transfer because CNA #2 had to assist another resident that she left in the bathroom. CNA #1, who was left alone to complete the transfer, pushed the HL further closer to the bed. However, the HL tipped and the Resident who was inside the HL pad landed on the floor with the HL on top of the Resident. On the same IR form, the DON documented under Conclusion: Resident #2 fell from Mechanical Lift, which was not being operated per policy . Attached with the IR, a statement from CNA #1(CNA who assisted CNA #2), dated [DATE] at 1:40 p.m., she indicated that she attached the HL's sling on to the HL pad, which the Resident was sitting on in the chair. CNA #1 together with CNA #2 pushed the Resident closer to the bed. Then CNA #2 left the room. As CNA #1 proceeded to push the HL closer to the bed, the HL tipped and assisted the Resident to the floor. CNA #1 left the room to call for help. Attached with the IR, a statement from CNA #2, dated [DATE], she indicated that she assisted CNA #1, to transfer Resident #2 to bed via HL and when they got the Resident closer to the bed, she left CNA #1 to complete the transfer alone with the Resident because she had to assist another Resident that she left in the bathroom. The Skilled Nursing Documentation (SND), dated from [DATE] to [DATE] (post fall) revealed that the Resident was in bed at all times. The SND documented by the DON dated [DATE], showed that on [DATE] she met with the Resident's family and discussed Palliative care and routine pain management. The family agreed on Palliative care. During an interview with the Administrator on [DATE] at 11:52 a.m., she confirmed the aforementioned incident involving Resident #2 on [DATE]. During an interview with the DON on [DATE] at 2:02 p.m., she stated that CNAs #1 and #2 did not follow the plan of care for Resident #2. She stated that both CNA's were given immediate in-service on [DATE], regarding HL transfer. She went on to state that CNAs #1 and #2 were terminated from employment on [DATE]. On [DATE] at 2:06 p.m., CNA #3 was interviewed. She stated that residents being transferred via HL must have assist of 2 or more staff at all times and not necessarily CNAs, but nurses could also help. A significant change in MDS was initiated on [DATE], showed severe impairment in cognition. Prior to fall incident of [DATE], the Resident required extensive assist to total assist of two (2) with Activities of Daily Living (ADL) including getting in and out of bed. However, during readmission on [DATE], the significant change in MDS revealed that Resident #2, was confined to bed and required total assist of two in all areas of ADL due to right Femur Fracture and Palliative care (program aim to ease pain.) During an interview with the Minimum Data Sheet (MDS) Coordinator on [DATE] at 3:21 p.m., she stated that the Resident had a significant change in status after the fall on [DATE]. She revealed that the resident sustained [REDACTED]. The MDS Coordinator provided a CAA (Care Area Assessment), documented and completed by the Social Worker (SW) on [DATE]. The CAA showed: Cognitive Loss: After the fall, the Resident had a change in functional status. Psychosocial well-Being: Since the [MEDICAL CONDITION], the Resident remained in the room on comfort care Activities: Resident #2 was on comfort care, in the room and did not get out of bed due to recent Fracture. Falls: The Resident had recent fall with [MEDICAL CONDITION], in bed and on Palliative care. The Resident had Significant change. Additional Comment: A significant change meeting was scheduled on [DATE], however, the Resident died on [DATE]. The Acute Hospital records dated [DATE] at 3:38 p.m., showed that Resident #2 was admitted with [DIAGNOSES REDACTED]. The same Hospital record dated [DATE] at 8:49 a.m., under Assessment and Plan, showed that the Resident was seen by Orthopedic, splint was applied. Non-operative management recommended due to a very advanced age, and multiple comorbidities, non-weight bearing of right lower extremity, severe deconditioning/sarcopenia (loss of muscle tissue as natural part of the aging process). The facility's policy titled, Mechanical Lift For Transfers was revised on [DATE], showed: To safely transfer residents who are unable to stand and pivot (turn) and/or require lifting to move from bed to chair. The same policy under Procedure showed: 1. Ask a co-worker to help you. At least two people are required to transfer a resident using a mechanical lift . NJAC 8:,[DATE].(a)

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain proper kitchen sanitation practices, properly store fresh, frozen and potentially hazardous foods and maintain safe food equipment services and areas in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was observed during the initial tour of the kitchen and was evidenced by the following: On 5/22/18 at 8:20 AM, during the initial tour of the kitchen in the presence of the Food Service Supervisor (FSS) and the Executive Chef (EC) the surveyor observed the following: 1. Access to two hand washing sinks was blocked due to the storage of large pieces of portable food service equipment. 2. Multiple pieces of various sized hotel pans and sheet pans were wet nested on a storage rack in the center of the preparation center of the kitchen. 3. A 1 pound opened to air package of salmon was in the walk-in refrigerator and not wrapped, labeled or dated. 4. Two small square metal containers filled with a brown [MEDICATION NAME] liquid in the walk-in refrigerator were not labeled or dated. The EC identified the two items as gravies used at dinner. 5. An opened package of sliced yellow cheese on a shelf in the walk-in refrigerator was not dated or labeled. 6. Thirty 5-gallon bulk containers of ice cream, multiple 1 quart containers of assorted ice creams and 2 cases of 4 ounce portion controlled ice cream cups in the walk-in freezer were soft to touch and in varied stages of defrost. One of the 5-gallon bulk containers was on the soiled floor in the freezer and 6 of 30 containers were open to air on a portable cart in the unit. Bags of assorted frozen vegetables were also soft to the touch. The internal thermometer in the unit registered 0 degrees Fahrenheight (F). At 9:05 AM, the surveyor placed a calibrated thermometer inside the unit and after 5 minutes the thermometer registered +13.2 degrees F. When the EC was interviewed at 9:15 AM, he stated there had been problems with the walk-in freezer for about a week. The outside vendor was called and came to the facility on Monday 5/21/18 and stated there were no problems with the unit. The EC stated that the vendor stated it just needs time for the temperature to adjust after it's been opened. On 5/22/18 at 10:45 AM, the surveyor reviewed the Freezer and Refrigerator Temperature Forms/Logs for the walk-in Freezer #11 for the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR). The log for the month of (MONTH) (YEAR) indicated that the unit was above 0 degrees F for 26 of the 31 days in the month. The log for the month of (MONTH) (YEAR) indicated that the unit was above 0 degrees F for 23 of the 30 days in the month and the log from (MONTH) 1 through (MONTH) 22, (YEAR) indicated the temperature was above 0 degrees F for 20 of the 22 recorded days. 7. There was a significant build-up of ice around the water pipe in the walk-in freezer unit, about 5-6 inches thick and 12 inches in length and width with large blocks of fallen ice on the floor of the freezer. 8. The underneath section of the shelf above two 5 bay steam tables was soiled and in direct contact with cooked, uncovered, ready to serve food. 9. One of six lights were out in each of the front and the back hoods. 10. The ice scoop was not covered and on a soiled shelf in the kitchen. 11. The interior sides and bottom of the 2-sided semi-filled plate lowerator (plate dispenser) was soiled with a very large build-up of dried, splattered, caked on food debris on both sides and bases of the unit. At 12:30 PM, the surveyor interviewed the Assistant Food Service Director (AFSD) who stated he did not know when the last time the unit was cleaned because the unit is not listed on the equipment cleaning log. 12. The left side of the covered, filled fryer, which was not in use on 5/22/18, was soiled with debris floating on top and the AFSD did not know how frequently the oil was changed or the last time it was changed. 13. The walk-in freezer located in the Dry Storage room was over crowed with cases of food piled too high and within 1-2 inches of the ceiling which prevented adequate air circulation. 14. There was a large build-up of ice around the water pipe of the above-mentioned unit and a white, deep, square container was on the shelf under the water pipe filled with frozen ice. At 10:55 AM, the surveyor reviewed the Food Storage policy and procedure (P&P) dated (YEAR) which stated food should be dated as it is placed on the shelves if required by state regulation. Perishable food such as dairy products must be stored in the freezer at a temperature to keep food frozen solid. All foods should be stored to allow for air circulation and leftover food will be stored in covered containers or wrapped carefully and securely and each item should be clearly labeled and dated before being refrigerated. NJAC 8:39 17.2(g)

Based on observation, interview and record review, it was determined that the facility failed to maintain professional standards of clinical practice for the transcription of physician's orders [REDACTED].#2) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. On 5/22/18 at 9:00 AM, the surveyor observed Resident #2 sitting up in the bed, awake and watching television. The surveyor observed that Resident #2 was not receiving oxygen (O2) and there was no oxygen concentrator in the room. The surveyor reviewed Resident #2's medical records. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Minimum (MDS) data set [DATE] indicated that Resident #9 was able to understand and able to be understood. The surveyor reviewed Resident #2's (MONTH) (YEAR) Physician order [REDACTED]. The surveyor reviewed the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The PO for the continuous use of oxygen was not transcribed on the MAR indicated [REDACTED] The surveyor reviewed Resident #2's Assessment Notes for the period of 5/8/18 to 5/22/18. There was no documentation in these notes that the resident exhibited any shortness of breath or respiratory distress during the time when they should have been receiving oxygen. On 5/8/18 at 11:00 AM, the surveyor interviewed the nurse who was assigned to Resident #2. The nurse stated that she thought the PO for the use of oxygen was discontinued. The nurse then reviewed the resident PO's and was unable to find a discontinuation order for the use of [REDACTED] On 5/8/18 at 11:10 AM the surveyor met with the Director of Nursing (DON) about the above concerns. The DON stated that the facility did not follow through on the PO for the use of oxygen. NJAC 8:39-27.1(a)