Abingdon Care & Rehabilitation Center

Complaint #: 2723631 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 02/11/2026, it was determined that the facility failed to update the care plan (CP) with clear focus, goals, and interventions for a resident (Resident #3) involved in a staff to resident abuse allegation. This deficient practice was identified for 1 of 4 residents reviewed for care plans and was evidenced by the following: According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses including but not limited to: other lack of coordination; muscle weakness; need for assistance with personal care; and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 11/30/2025, revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated that the resident had moderately impaired cognition. Further review of the MDS revealed that Resident #3 was dependent on a helper to move from sitting to standing, and to move from a chair to bed. The Progress Notes (PNs) for Resident #3 were reviewed. A PN dated 11/17/2025 at 10:59 AM, revealed that Resident #3 complained of back pain and asked to be returned to bed by facility staff. The PN revealed that facility staff returned the resident to their bed. Review of an untitled and undated facility document revealed that an insurance case worker reported that Certified Nursing Assistant (CNA) #1 was rough with Resident #3 during the transfer to bed and the resident was saying, ow, while the transfer was taking place. The facility document revealed that CNA #1 was immediately suspended pending an investigation. The document further revealed that the allegation of rough handling was unsubstantiated. A review of Resident #3's CP revealed a focus of Documented Resident/Representative Concerns Documented Resident/ Rep. Concerns the focus was initiated on 11/17/2025. Interventions/Tasks related to this focus included that the nurse would identify area of concern; Nurse would notify appropriate department leaders of concerns per facility protocol; and that the nurse would notify Social Services of the concern and the possible need for a care conference. An interview was conducted with Unit Manager #1 on 02/11/2026 at 12:30 PM. UM #1 stated that after an abuse allegation the CP of the resident involved should be updated so staff could know that allegations were made and know what to do. UM #1 stated that typically he or the Director of Nursing were responsible for updating resident CPs. On 02/11/2026 at 3:18 PM, the surveyor interviewed the Regional Director of Nursing (RDON), who stated that the 11/17/2025 update to Resident #3's CP did not meet her expectations for a CP update after a resident was involved in a staff to resident abuse allegation. The RDON stated that the CP update was not acceptable because the issue being addressed was not clear. Review of the facility's undated policy titled Care Plans revealed under POLICY STATEMENT, An individualized care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Under POLICY INTERPRETATION AND IMPLEMENTATION, 4. Care plans are revised as changes in the resident's condition may dictate. NJAC 8:39-11.2 (e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaints: 2706516, 2743086 Based on interviews, review of the medical records, and review of other pertinent facility documentation on 02/11/2026 and 02/12/2026, it was determined that the facility failed to provide for the medically related social service needs for residents who required assistance with obtaining needed services from outside entities; or who should have received emotional support after an allegation of staff to resident abuse. This deficient practice was identified for 3 of 3 residents (Resident #3, Resident #4, and Resident #5) reviewed and was evidenced by the following:A review of the Resident Council Minutes dated 11/26/20205 revealed that residents inquired about when the facility would have a Social Worker (SW). A review of the Resident Council Minutes dated 12/31/2025 revealed that SW #1 was in the facility a few days a week and that that the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) could help out if residents needed anything. 1. According to the admission Record (AR), Resident #3 was admitted to the facility with diagnoses including but not limited to: other lack of coordination; muscle weakness; need for assistance with personal care; and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 11/30/2025, revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated that the resident had moderately impaired cognition. Further review of the MDS revealed that Resident #3 was dependent on a helper to move from sitting to standing, and to move from a chair to bed. The Progress Notes (PNs) for Resident #3 were reviewed. A PN dated 11/17/2025 at 10:59 AM, revealed that Resident #3 complained of back pain and asked to be returned to bed by facility staff. Review of an untitled and undated facility document revealed that an insurance case worker reported that Certified Nursing Assistant (CNA) #1 was rough with Resident #3 during the transfer to bed. The facility document revealed that CNA #1 was immediately suspended pending an investigation, and the resident was evaluated by Pain Management. The Interventions, section of the document did not reveal that a member of the Social Services (SS) Department monitored the resident's status in response to the incident and investigation. 2. Review of a facility Grievance Report, with a filed date of 01/27/2026 revealed that Resident #5 wanted assistance with community housing. The document further revealed that the Regional Admissions Director met with the resident and provided information on how to get a phone and contact information for community housing programs. According to the AR, Resident #5 was admitted to the facility with diagnoses including but not limited to: Type 1 diabetes mellitus with proliferative diabetic retinopathy (advanced damage to blood vessels in the eye) without macular edema, unspecified eye; muscle weakness (generalized); unsteadiness on feet; need for assistance with personal care; type 1 diabetes with diabetic neuropathy (nerve damage leading to pain and numbness); acquired absence of left leg below knee (amputation). A review of the Quarterly MDS dated [DATE] revealed that Resident #5 had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS revealed that Resident #5 wanted to talk to someone about leaving the facility and living and receiving services in the community. The PNs for Resident #5 were reviewed and revealed the following Social Services notes: A PN dated 09/22/2025 at 10:25 AM, revealed that the resident was admitted and had no physician or pharmacy in the community. A PN dated 10/06/2025 at 2:18 PM, revealed that the resident was presented with a mail-in ballot. A PN dated 01/10/2026 at 10:38 PM, written by the LNHA revealed that the LNHA spoke to a family member of Resident #5 who stated that they would take care of transferring Resident #5 and were waiting to hear from other facilities. No additional SS related PNs were provided. An interview was conducted with Resident #5 on 02/12/2026 at 10:05 AM. Resident #5 stated that they had been requesting assistance from a SW to get a phone and housing since September 2025. Resident #5 stated that they met briefly with a SW from Corporate (CSW) who provided incorrect contact information for community resources. The resident stated that the CSW also provided forms, but the resident was unable to complete the forms due to their neuropathy. The resident stated that they were not comfortable having other facility staff help fill out the forms with their personal information. The resident further stated, I need help and I am not getting it. 3. On 02/12/2026 at 10:35 AM, the surveyor observed Resident #4 in their room with a family member (FM) packing their belongings. Resident #4 and their FM confirmed that the resident had been discharged . An interview was conducted with Resident #4 and their FM on 02/12/2026 at 10:35 AM. Resident #4 stated that the facility's discharge process was tough and that they could not speak to the proper people for arranging their discharge. The resident's family member stated that there had not been a meeting with family or any discussion with a SW about the resident's discharge. The resident's family member further stated that they and another family member had to do most of the arrangements needed for Resident #4's discharge. According to the AR, Resident #4 was admitted to the facility with diagnoses including but not limited to: myelofibrosis (blood cancer characterized by scarring in the bone marrow); chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe); muscle weakness (generalized); difficulty walking not elsewhere classified; bone marrow transplant status; and need for assistance with personal care. A review of the Quarterly MDS dated [DATE] revealed that Resident #4 had a BIMS score of 15 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS revealed that Resident #4's goal was to be discharged to the community; and that active discharge planning was occurring for the resident to return to the community.No SS PNs related the resident's discharge or discharge planning were provided. Entrance conference was conducted with the LNHA on 02/11/2026 at 10:05 AM. The LNHA informed the surveyor that the facility did not currently have a SW, and that the part time SW had left approximately two weeks prior. A follow up interview was conducted with the LNHA on 02/12/2026 12:17 PM. The LNHA stated that the facility should have a full time SW to meet the residents' needs, and that a SW should be part of the interdisciplinary team and care planning for the residents. The LNHA confirmed that Resident #3 was not seen by SS after the abuse allegation involving them. The LNHA stated that Unit Manager #1 assisted with connecting Resident #4 with community resources for discharge. The LNHA stated that a SW would normally assist residents with these issues. The LNHA stated that he spoke with Resident #5's family about finding other living arrangements for the resident. The LNHA stated that a SW would normally assist residents with these issues. Review of the undated facility policy titled, ABUSE PREVENTION PROGRAM revealed under, POLICY INTERPRETATION AND IMPLEMENTATION, that when information concerning a report of abuse was received, the LNHA or their designee will request that a representative from the SS department monitors the resident's psychosocial status in response to the incident and investigation. A review of the facility's undated Social Worker job description revealed The primary purpose of your job position is to assist in the planning, organization, and developing of the Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. Under, Duties and Responsibilities, the job description revealed . Refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. [.] Assure that social service progress notes are informative and descriptive of the services provided and the resident's response to the service. [.] Participate in regularly scheduled reviews of resident discharge plans. NJAC 8:39-39.4(b)(f)(h)

Complaints: 2706516, 2743086 Based on interview and review of facility documentation, it was determined that the facility failed to employ a full-time Social Worker (SW) from August 2024 until 02/12/2026. This deficient practice had the potential to affect all residents and was evidenced by the following:On 02/11/2026 at 10:05 AM, a survey entrance conference was conducted with the Licensed Nursing Home Administrator (LNHA) who stated that the facility did not have a full-time Social Worker (SW) and the facility's part-time SW left approximately two weeks prior. On 02/12/2026 at 9:34 AM, an interview was conducted with the Human Resources Director (HRD) who stated the facility had no full-time SW for the last five months. The HRD stated after the full-time SW left, a part-time or per diem (as needed) SW worked up to 30 hours per week but they left two weeks ago. On 02/12/2026 at 12:17 PM, an interview was conducted with the LNHA. The LNHA reviewed a Director of Social Work job posting dated 08/16/2024 with the Surveyor and stated that it was around that time that the facility lost their full-time SW. The LNHA further stated that the facility should have a full-time SW to meet the residents' needs. Review of facility provided timecards for SW revealed that they worked as follows:For the 11/16/20205 - 11/29/2025 pay period: 8.42 hoursFor the 11/30/2025 - 12/13/20205 pay period: 7.00 hoursFor the 12/14/2025- 12/27/2025 pay period: 7.83 hoursFor the 12/28/2025 - 01/10/2026 pay period: 8.92 hoursFor the 01/11/1016 - 01/24/2026 pay period: 4.25 hours. The facility was on record as being licensed for 180 beds. The CMS guidelines implemented 11/28/17, included but were not limited to a qualified SW full-time for a facility with over 120 beds. A review of the facility's Social Worker job description revealed The primary purpose of your job position is to assist in the planning, organization, and developing of the Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. N.J.A.C. 8:39-39.3(a); 39.2

Complaint #NJ184191/394091Based on, interviews, and record review, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice for 1 of 7 residents (Resident #5).This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. 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 prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem.According to the facility admission Record, Resident #5 was admitted to the facility with diagnoses which included: atherosclerosis of native arteries of other extremities with ulceration ( a condition where plaque buildup in the natural arteries of the limbs narrows the blood vessels, reducing blood flow and causing skin or tissue ulcerations due to a lack of oxygen and nutrients), muscle weakness, and type 2 diabetes mellitus (chronic condition where the body resists insulin or doesn't produce enough, leading to high blood sugar levels ) without complications.A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 09/11/25, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated an intact cognition.On 09/26/25 at 09:10 A.M., the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that his medication process consisted of verifying that he had the correct resident, then checking the order, and then signing out his medications for residents one by one. When questioned regarding if medications should be left at bedside, the LPN stated that it was a no-no to leave medications at bedside because the nurses would not know if the resident took their medications. The LPN further stated that nurses should stay with residents until the nurse could make sure the residents have taken their medications.On 09/26/25 at 10:43 A.M., the surveyor interviewed the Unit Manager (UM) who stated that she expected her staff to go into a resident's room, introduce themselves, verify they have the correct resident, and to check the medication orders. The UM further stated that she expected her nursing staff to inform and educate the residents on the medications being administered and that the nurse administering the medication should stay with the resident to make sure they swallow their medication. The UM also stated that meds should never be left at bedside, under no circumstances.On 09/26/25 at 11:44 A.M., the surveyor interviewed the Director or Nursing (DON) and Licensed Nursing Home Administrator (LNHA) together and they confirmed that LPN #2 left Resident #5's mediation at bedside on 09/14/25.On 09/26/25 at 12:04 P.M., the surveyor interviewed LPN #2 who was the LPN who had left medications at bedside via phone call. LPN #2 stated she left medications at bedside on 09/14/25 while she was looking for Resident #5's eyedrops. She stated that the Assistant Director of Nursing (ADON) notified her that she had left medications unattended at bedside and educated her that medications should never be left at bedside.A review of the facility's policy titled Administering Medications, revealed under Policy Statement, Medications shall be administered in a safe and timely manner, and as prescribed.NJAC 8:39-29.2(d)

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen 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 4/14/25 at 10:05 AM, the surveyor toured the kitchen with the Food Service Director (FSD). The following was observed:
1. Inside the ice machine there was a reddish like substance on the bottom of the white baffle (a flow-directing panel that restrained ice), as well as both sides of the interior walls of the ice machine near screws. The FSD took a clean towel and wiped both areas. The discoloration was removable and the FSD acknowledged that it needed to be cleaned.
2. There was a two door reach in refrigerator in which the FSD stated was for the cooks. The surveyor observed built up debris on the inside and gasket of the left door as well as the bottom of the unit. The FSD acknowledged the debris and stated, It's Monday.
3. There was a large exhaust fan near two prep sinks, which had a heavy buildup a fuzzy grey/brown debris. The FSD acknowledged the debris and stated that maintenance needed to clean it.
4. There were two prep sinks which had a broken handle plastic spatula on the bottom of the right sink. The top of the spatula was discolored and disfigured. The FSD acknowledged it was broken and the front was melted and should not be used. In addition, there was a soiled rag with debris draped over the divider between the two sinks. The FSD acknowledged it was soiled and should not have been there.
5. There was a metal covering to a grease trap on the floor, which had a heavy buildup of a black sticky-like substance, which the FSD acknowledged.
6. There were two green, one blue and one yellow cutting boards observed on a clean dry equipment rack which had gouging. The FSD acknowledged the same and stated they should be changed since gouging was where bacteria can collect and could cause cross contamination.
7. The bottom of the spice rack had built up debris. The FSD stated the rack was old and would, take a long time to clean.
8. There was a soiled mop head on the floor near the right side of a griddle. The FSD stated the griddle leaked grease and they keep the mop head there, so we don't fall or slip.
9. There was a plastic scoop stored inside the flour bin, the handle was in direct contact with the flour. The FSD stated it should not be stored inside the bin.
10. The base of the can opener had a buildup of a black sticky substance. The FSD acknowledged the buildup and stated, it needed to be cleaned.
11. Three wells of a four well steam table, had a heavy buildup of brown debris on the bottom. On top of each the four wells were stainless steel folding covers which had a reddish/brown built up substance. The FSD stated they were old, and that it would take a long time to clean.
12. In the first walk-in refrigerator, the surveyor observed a case of raw eggs stored above a case of liquid pasteurized eggs. The FSD stated that the raw eggs were pasteurized yet was unable to show where that was indicated on the case.
13. In the second walk-in refrigerator, the surveyor observed 3 metal shelves that had a buildup of black debris. The FSD wiped the shelving with a clean wet pink and wipe cloth towel. The debris was removable and the FSD acknowledged it needed to be cleaned.
14. The towel dispenser above the hand washing sink was broken and empty. The towel ring was exposed and placed on the metal post of the spice rack for use, opposite the hand washing sink.
On 4/22/25 at 2:02 PM, the FSD provided the surveyor with vendor invoices from January 2025 to present. Invoices from [name redacted] indicated, MEDIUM EGGS GRADE A were delivered. There was no indication that they were pasteurized.
A review of an undated facility policy Ice Machines and Ice Storage Chests, reflected that ice machines will be used and maintained to ensure a safe and sanitary supply of ice. It also included that ice could become contaminated by unsanitary manipulation by employees, water-borne microorganisms, colonization by microorganisms, and improper storage or handling of ice.
A review of an undated facility policy Sanitation, reflected the food service area will be maintained in a clean and sanitary manner. It also reflected all kitchen areas should be kept clean, including shelves, counters, utensils and equipment. This included maintaining food service items in good repair so as not to affect their use and proper cleaning. Additionally, it reflected that ice that is used in connection with food and drink should be handled in a sanitary manner.
A review of an undated facility policy Food Storage, reflected that food storage areas should be maintained in a clean, safe, and sanitary manner; and that food service staff should maintain clean food storage areas at all times.
NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 4/15/25 at 8:00 AM, during the morning medication administration observation, the surveyor observed a brown stain on two (2) of the ceiling tiles that were to the right of the door when entering inside room [ROOM NUMBER]. The brown stains covered a majority of the tiles.
On 4/15/25 at 8:06 AM, during the morning medication administration observation, the surveyor observed, a brown stain on one (1) ceiling tile above the doorway inside room [ROOM NUMBER]. The brown stain covered the majority of the tile.
On 4/16/25 at 12:25 PM, the surveyor observed again, the same brown stained ceiling tiles, as described above, in room [ROOM NUMBER] and 233.
On 4/17/25 at 12:22 PM, the DMHL acknowledged the brown stained ceiling tiles in room [ROOM NUMBER] and 233 and stated, I will add them to my list.
On 4/22/25 at 4:26 PM the Licensed Nursing Home Administrator (LNHA), Corporate Clinical Officer (CCO), and Director of Nursing were notified of the above concerns. The LNHA stated the facility had a system of non-clinical rounds by the department heads and the DMHL does his own rounds as well. The CCO stated they (the management company) buys buildings that need to be spruced up and then manage or buy them and fix them up, but it takes time, not everything can be done at once.
N.J.A.C. 8:39-31.4 (a) (c) (f)
2. On 4/14/25 at 11:50 AM, the surveyor observed fluid leaking from the ceiling tiles in the hallway that leads to the main dining room on the first floor, in the presence of the Food Service Director (FSD). The FSD acknowledged the leak and stated the Noble unit was above this area and he thought there were leaking sinks on the unit. He further stated the new maintenance director was aware.
On 4/15/25 at 10:00 AM, the surveyor observed the back wall inside the elevator. To the right of a frame there was a large circle-like area that had multiple layers of peeled paint. In addition, the interior wooden guard rails around the perimeter of the elevator were scratched and gouged.
On 4/17/25 at 12:22 PM, the DMHL acknowledge the new pictures in the elevator were covering the peeled paint and stated, I have to do what I have to do.3. On 4/14/25 at 11:52 AM, during the initial tour of the [NAME] unit, the surveyor noted room [ROOM NUMBER] had missing floor tile under the sink and brown discolored ceiling tiles with a vent, that had a buildup of black debris, at the nurse's station.
On 4/15/25 at 11:58 AM, the surveyor observe the corner end of the hand rail, between the [NAME] Nurse's station and the pantry, was missing and the corner piece of the lower portion of the column at the nurse's station was pulled away from the column and there was exposed white spackle and debris.
On 4/15/25 at 12:00 PM, the surveyor interviewed the DMHL, who stated he did environment tours daily. He explained he does a visual inspection of each unit every day. He stated he looks up and down the walls of the units and stands in the doorway of every room looking for something out of place. He stated staff can enter maintenance requests directly into the maintenance computer system.
At that time, the DMHL toured the [NAME] unit with the surveyor. He observed the missing floor tiles in room [ROOM NUMBER] and stated the tiles are [AGE] years old and I can't find matching tiles. He acknowledged the brown discolored ceiling tiles and the black debris on the vent at the nurse's station. He stated, there was a terrible leak here about 2 weeks ago and I did not replace tiles. He stated, the vent was not clean but they should be done quarterly when we do the filters.
On 4/15/25 at 12:22 PM, the DMHL toured the Noble unit with the surveyor. He acknowledged the missing end cap of the hand rail at the nurse's station and stated they are [AGE] year old railings and it's difficult to find replacement pieces. He acknowledged the corner of the column at the nurse's station and stated, it's on my list.
On 4/17/25 at 12:22 PM, the surveyor interviewed the Certified Nursing Aid (CNA #1), who stated he would try to fix things himself and if he couldn't fix it, he would call maintenance.
On 4/17/25 at 12:28 PM, the surveyor interviewed CNA #2, who stated if she identified something was in disrepair, she would report it to the nurse or the supervisor.
On 4/17/25 at 12:32 PM, the surveyor interviewed the Licensed Practical Nurse (LNP #1), who stated if something needed to be repaired she would enter it directly into the maintenance computer system and if maintenance didn't respond within 30 minutes, she would call them because they usually fixed things right away.
Repeat Deficiency
Based on observation and interview it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 2 of 2 units, (Noble and [NAME]) and was evidenced by the following:
1. On 04/14/25 at 10:27 AM, during initial tour of the Noble unit, the surveyor noted dark scuff marks in the hallway outside room [ROOM NUMBER]. Inside room [ROOM NUMBER], the surveyor observed the heater unit with a dark brown/reddish substance noted on the fins of the heater and brownish/blackish marks on the body of the heater unit. At 10:40 AM, the surveyor noted multiple cracked floor tiles in room [ROOM NUMBER]. At 10:49 AM, the surveyor observed the heater in room [ROOM NUMBER] with brown/black substances in fins of unit and on body of heater unit. The closet doors were noted to be off the track and bottom dresser drawer front was broken and askew. Also, in this room the surveyor noted a missing section of floor tile and cracks in the tile were noted under the bed.
On 4/16/25 at 10:34 AM, the surveyor reviewed the work order report dated 4/15/25. Heaters in rooms [ROOM NUMBERS], cracked tiles in room [ROOM NUMBER], and cracked/missing tile in room [ROOM NUMBER] were not found on list.
On 4/16/25 at 12:41 PM, the surveyor interviewed the Director of Maintenance/Housekeeping/Laundry (DMHL). When asked about the floors on the Noble unit, specifically the scuff marks by room [ROOM NUMBER], the DMHL stated the floors are mopped daily and the scuff marks don't come up with mopping. He stated those marks were from bed swaps. When the surveyor asked about the heaters in rooms [ROOM NUMBERS], the DMHL stated they (heater units) all need to be painted. The DMHL further stated regarding the heater units, This is certainly not ok, they're on the list. When the surveyor asked about the closet doors and drawer front in room [ROOM NUMBER], he stated they are currently addressing the closet doors. The DMHL further explained that the closet doors are about forty years old and have exceeded their life expectancy. He went on to explain that the closest doors aren't an easy thing to fix, it's an involved process. When the surveyor asked about the missing tile on floor in room [ROOM NUMBER] and cracked tiles in room [ROOM NUMBER], he stated it's on the list. The surveyor mentioned that these items were not on the list he provided to the team, he stated he has other lists, in addition to the one provided to surveyors the day before. He then showed the surveyor his phone with a long list between himself and his assistant. The DMHL further explained that he stars the priorities and can move the items around as needed. He further explained that he just discovered a cache of tiles that matched the ones on the floors and that the work just needs to be scheduled to be done.
On 4/17/25 at 11:25 AM, the surveyor observed the drawer front and closet doors were repaired. The scuff marks in Noble hallway outside room [ROOM NUMBER] are no longer present and area of lighter colored floor noted in that area.

REPEAT DEFICIENCY
Based on observations, interviews and review of pertinent facility documents, it was determined that the facility failed to have a system in place to ensure that facility garbage receptacles were covered, and all garbage was contained and removed timely to prevent a buildup of refuse, and that the receptacles including a trash compactor and the surrounding areas were maintained in a clean manner to prevent the accumulation of debris.
The deficient practice was evidenced as follows:
On 4/14/25 at 9:00 AM, the survey team arrived at the facility. From the parking lot, the surveyor was able to view the dumpster area, in the presence of the survey team. There were two oversized uncovered dumpsters overflowing with waste/debris and had black garbage bags around and between the two dumpsters, as well as debris on the ground. Up against the building loading dock there was a compacter, and an uncovered cardboard dumpster overflowing with cardboard.
On 4/14/25 at 10:05 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD).
During this tour, the surveyor and FSD went outside the building and onto the loading dock to view the receptacle area for refuse. The cardboard container was uncovered and overflowing. The FSD stated it did not need to be covered. The compacter had a buildup of discolored liquid underneath. The FSD stated the compacter was picked up once every week or week and a half. There were two oversized dumpsters overflowing with debris to the right of this area along a back fence. There was debris on the ground around the three dumpsters as well as the compacter. The FSD acknowledged there was debris on the ground and could not speak to who was responsible to ensure the area was clean, maintained and free of debris on the ground.
On 4/22/25 at 2:26 PM, the surveyor interviewed the Director of Environmental Services (DES). He stated he was ultimately responsible to ensure the dumpster area was clean and maintained. He stated he had porters that clean that area however, the observation was made early Monday, and he was unable to get that done. The DES further stated the cardboard dumpster was picked up once a week and when the compacter was picked up, staff would clean underneath. He stated, [name redacted] company was used for removal of the cardboard dumpster and compacter; however, he was unable to speak to the responsibility for the two other oversized dumpsters.
On 4/22/25 at 5:29 PM, the surveyor reviewed the above concern with the Administrative team (Licensed Nursing Home Administrator, Director of Nursing and the Chief Clinical Officer), in the presence of the survey team.
On 4/23/25 at 11:30 AM, the survey team met with the Administrative team for responses or additional information. Nothing further was provided.
A review of an undated facility policy Maintenance Service, reflected that maintenance service would be provided to all areas of the building and grounds, which included the parking lot.
NJAC 8:39-31.4(b)

Based on interview and review of facility documentation, it was determined that the facility failed to employ a full time Social Worker (SW) from 12/7/24 to 4/16/25.
This deficient practice was evidenced by the following:
On 4/15/25 at10:17 AM, the surveyor met with seven residents for a resident council meeting. During that meetin, 6 out of the 7 alert and oriented residents voiced concerns that the facility did not have a full-time social worker. The residents explained for the last 2 or 3 months there was a social worker that worked only Saturdays/Sundays for about 5 hours.
On 4/15/25 at 1:05 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated there was a new social worker starting this week. He confirmed the current social worker (SW#2) usually comes in a few hours on Saturday's and Sundays. He verified the last SW's (SW#1) last day was 12/6/24.
A review of the facility provided time clock punches for SW #2 revealed SW #2 worked as follows:
-12/7/24 to 12/29/24 a total of: 31.5 hours
-1/8/25 to 1/25/25 a total of: 22.58 hours
-2/1/25 to 2/15/25 a total of: 23.41 hours
-3/1/25 to 3/29/25 a total of: 37.61 hours
-4/5/25 to 4/12/25 a total of:10.68 hours
On 4/16/25 at 1:35 PM, the surveyor interviewed SW#2 via telephone. SW #2 stated that he had a full-time position at another facility and had been helping by working on Saturdays for five (5) hours since the middle of January. SW #2 stated that his responsibilities on Saturday were to complete any needed social histories, social determinants of health, Minimum Data Set (an assessment tool used to facilitate the management of care for a resident) requirements and/or obtain signed pertinent paperwork for identified residents. SW #2 added that his responsibilities were based on a list or print out of identified residents he received. In addition, he stated that he would try to spend time with any resident that wished to speak with him. SW #2 also stated, I do what I can in 5 hours. He added that when residents spoke with him and had a concern that he was unable to follow up with, he would refer the resident's concern to a full-time administrative staff that could handle what the resident needed. SW #2 explained for example that if a resident wished to be discharged or transferred then he would let the Admissions staff member know because they worked Monday through Friday and would be able to handle those type of requests.
On 4/22/25 at 11:46 AM, the surveyor interviewed the admission Director (AD), who stated her role was to bring the residents in, and the SW brings them out. She stated if a resident wanted to transfer to another facility the resident or family would let her know what facility and she would facilitate the transfer. The AD explained that the rehabilitation department would set up durable medical equipment if a resident needed to be discharged home and nursing would do the actual discharge paperwork.
On 4/22/25 at 4:28 PM, during a meeting with the survey team, the Corporate Clinical Officer, the Director of Nursing, the LNHA, and the Assistant Administrator were made aware of the above concerns.
The facility was on record as being licensed for 180 beds. The CMS guidelines implemented 11/28/17, included but were not limited to a qualified SW full-time for a facility with over 120 beds.
A review of the facility's Social Worker job description revealed The primary purpose of your job position is to assist in the planning, organization, and developing of the Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis.
N.J.A.C. 8:39-9.3(a); 39.2; 39.4(i)

Based on interview and review of pertinent facility documentation, the facility failed to ensure the required committee members, the Infection Preventionist (IP), was present for two out of four Quality Assurance and Performance Improvement (QAPI) meetings reviewed and was evidenced by the following:
04/23/25 11:33 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated QAPI meetings were held at least quarterly and as needed, he added we also meet monthly. He stated the required members were the administrator (LNHA), the director of nursing (DON), the medical director and other staff were required to attend the meetings at least quarterly. The LNHA stated also will be including a certified nursing assistant in the meetings.
At that time, the LNHA reviewed the facility provided QAPI sign in sheets, he removed the sign in sheets for the quarterly QAPI meetings. A review of the Quarterly QAPI Meeting Attendance sign in sheets revealed meeting were conducted on 4/17/2024, 7/17/2024, 10/16/24 and 1/15/2025. The surveyor asked the LNHA to identify the IP on the sign in sheets. After reviewing the sheets, he was unable to identify the IP was present at the 4/17/2024, 10/16/24 and 1/15/2025 meetings.
During the same interview, the LNHA stated he was not aware the IP was required to be in attendance.
At 12:32 PM, the LNHA provided evidence that the IP was off on 1/15/2025 but was able to provide evidence that infection control was reviewed with the committee. At that time, the surveyor requested evidence of infection control review for the 4/17/204 and 10/16/24 QAPI meetings.
No additional information was provided.
A review of the facility's policy Quality Assurance and Performance Improvement Plan revealed III. Guidelines for Governance and Leadership .b. i. The QAPI committee provides the organization structure for QAPI. This group includes administrator, DON, medical direction and/or designee, at least three other members of the facility's staff and the infection control and prevention officer .ii. Currently QAPI committee maintains record of attendance and minutes with supporting documentation.
NJAC 8:39-33.1(b)

Repeat Deficiency
Based on observation, record review, interview, and review of pertinent facility documents, it was determined that the facility failed to prevent the potential for cross contamination by not placing a resident with open wounds on Enhanced Barrier Precautions (EBP- a gown and gloves be worn when performing high contact care), for one of two residents (Resident #45) reviewed for pressure ulcers.
The deficient practice was evidenced by the following:
On 4/16/25 at 9:33 AM, during a wound treatment observation, the surveyor observed the Certified Nurse Aide (CNA) holding Resident #45 on their right side with their sacral and right heel wound exposed. The CNA was wearing gloves. The surveyor then observed the Licensed Practical Nurse (LPN) cleanse the sacral wound and apply the treatment and dressing. The LPN was wearing gloves. After performing hand hygiene, the LPN donned (put on) gloves and the LPN cleansed the right heel wound and applied the treatment.
The surveyor had not observed EBP signage at the resident's doorway or in the room.
The surveyor reviewed the electronic medical record (EMR) for Resident #45.
A review of the Order Summary Report revealed a physician orders (PO) dated 4/14/25 for Zinc Oxide External Paste 20%. Apply to buttocks . and Medihoney Wound/Burn Dressing External Gel Apply to right heel .
A review of the admission Record, (an admission summary), reflected diagnoses that included but not limited to; Dementia (brain disorder), hypertension (elevated blood pressure) and diabetes (elevated blood sugar).
The Individual Comprehensive Care Plan (ICCP) included a focus area of potential impairment to skin integrity. Interventions included medihoney to left heel after cleansing and zinc oxide to buttocks.
On 4/16/25 at 9:48 AM, the surveyor interviewed the LPN. The LPN stated that Resident #45 should not be on EBP because there was no discharge from the wounds. She further stated that EBP was important if fluid was involved.
On 4/16/2025 at 10:10 AM, the surveyor interviewed the CNA. The CNA stated that she should not have worn a gown when caring for Resident #45. She further added that she knew who was on isolation from report and signage on the door.
On 4/16/2025 at 12:11 PM, the surveyor interviewed the Unit Manager Registered Nurse (UM/RN). She acknowledged that Resident #45 should have been on EBP because they had a wound.
On 4/22/25 at 10:10 AM, the surveyor interviewed the Infection Preventionist/Registered Nurse, who stated that if a resident had a wound, EBP were needed.
A review of facility policy PPE for MDRO Updated December 15, 2024 revealed:
Enhanced Barrier Precautions
Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi-drug-resistant organisms) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.
Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: . Wound care: any skin opening requiring a dressing.
N.J.A.C. 8:39-19.4 (a)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain an effective pest control program so that the kitchen was free of pests.
The deficient practiced was evidenced by the following:
On 4/14/25 at 10:05 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). During this tour, he stated that he used a [name redacted] electronic communication system as well as verbal communication with the Director of Environmental Services (DES) when there was a maintenance concern in the kitchen.
The surveyor observed an open drain on the floor next to a grease trap. The surveyor observed many flies in this area, coming from the drain, in the air and on the wall. The FSD acknowledged this and stated they were drain flies, and that the grease trap needed to be cleaned. In addition, the FSD stated the exterminator treated the area and that it did not help since there was an open drain.
On 4/22/25 at 1:01 PM, the surveyor conducted a second kitchen tour with an additional surveyor and the FSD. The FSD provided a pest control logbook to the surveyor for review. The form indicated the last visit from the exterminating company was on 4/1/25; however, there was no indication of what or where treatment was performed in the kitchen. The FSD stated that the exterminator conducted weekly visits every Tuesday. During this tour, both surveyors observed the same type of flies on the wall just outside the dish machine room.
On 4/22/25 at 2:26 PM, the surveyor interviewed the DES. He stated that the pest control company came in weekly and there was a logbook for the kitchen. He stated that he was unaware there were drain flies in the kitchen.
On 4/22/25 at 3:36 PM, the DES provided the surveyor invoices from the exterminating company from 2/18/25 through 4/8/25 which revealed kitchen pests had not been addressed. In addition, there was an invoice dated 4/15/25, which indicated No service was performed due to state conducting survey.
On 4/22/25 at 3:51 PM, the surveyor interviewed the Regional Property Manager, who was unaware of a fly issue in the kitchen.
On 4/22/25 at 5:29 PM, the surveyor reviewed the above concern with the administrative team (Licensed Nursing Home Administrator, Director of Nursing and the Chief Clinical Officer), in the presence of the survey team.
On 4/23/25 at 11:26 AM, the LNHA stated that the exterminator treated for flies in the kitchen about a month and a half ago but nothing specific to flies were recorded on paperwork.
A review of the facility Work Orders between the kitchen and maintenance department from 3/18/24 through 3/31/25, did not address flies.
A review of an undated facility policy Pest Control, reflected the facility would maintain an effective pest control program. It also reflected the facility maintained an on-going pest control program to ensure the building was kept free of insects.
A review of an undated policy Sanitation, reflected kitchen areas would be kept clean and protected from flies and other insects.
N.J.A.C. § 8:39-31.5

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the nurse staffing report daily. This deficient practice was evidenced by the following:
On 4/14/25 at 9:31 AM, the surveyor did not observe the nursing staffing report posted at the front reception desk, the time clock, the elevator, or at either nursing unit. The receptionist was present at the front desk.
On 4/15/25 at 9:31 AM, the surveyor did not observe the nursing staffing report posted at the front reception desk, the time clock, the elevator, or on the Noble nursing unit. The receptionist was present at the front desk.
On 04/16/25 at 9:44 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/15/25 for the 7-3 shift.
On 4/16/25 at 11:16 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/16/25 for the 7-3 shift.
On 04/17/25 at 9:24 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/17/25 for the 7-3 shift.
On 4/22/25 at 9:32 AM, the surveyor observed the nursing staffing report posted at the front desk dated 4/22/25 for the 7-3 shift.
On 4/15/25 at 11:00 AM, the surveyor interviewed the staffing coordinator (SC), who stated staffing was usually posted at the front desk. She further stated I am responsible, I have been gone for 2 weeks. I just got back yesterday. Nobody posted the staffing while I was gone. The staffing was not posted yesterday or today, until I got it here. I just now printed it. I usually wait until after morning meeting to post it so it's accurate. I give it to the lady at the front desk but doesn't look like she did it.
On 4/22/25 at 4:26 PM, the survey team met with the Director of Nursing (DON), who stated she was not sure who was responsible to post the nursing staffing report when the SC was away. She further stated maybe the receptionist was responsible.
On 4/23/25 at 11:10 AM, the survey team met with the DON, who stated the staffing report was not posted on Monday (4/14/24).
A review of undated facility provided policy Staffing Policy Statement included:
Our facility provides adequate staffing to meet needed care and services for our resident population.
Policy
5. Staffing will be posted in a visible location.
NJAC 8:39-41.2 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility documentation it was determined that the facility failed to: a.) maintain receipt, accountability, reconciliation, secure storage and removal from active inventory of controlled drugs, (Lorazepam (Ativan) (benzodiazepine Schedule IV), Fentanyl Patches (opioid Schedule II), Methadone(opioid Schedule II), Hydrocodone/Acetaminophen (opioid/analgesic Schedule II), and Morphine Sulfate (opioid Schedule II), for three (3) residents, (unsampled Residents #201, #203, #204) that were discharged [DATE], 5/7/24 and 9/6/24 respectively, until surveyor inquiry, stored in one (1) of two (2) medication rooms, b.) maintain accurate accountability, reconciliation and removal from active inventory upon discontinuation for controlled drugs, (Diazepam gel (benzodiazepine Schedule IV) and Nayzilam (Diazepam nasal spray), stored in the medication cart, for one (1) of four (4) medication carts from 2/2/25 and 3/3/23 respectively, until surveyor inquiry for one (1) resident (unsampled Resident #202) and c.) accurately document the disposition of a controlled drug (Buprenorphine (opioid Schedule III) patch) stored in one (1) of four (4) medication carts for one (1) resident, (unsampled Resident #34).
The deficient practices were evidenced by the following:
1. On 4/17/25 at 10:45 AM, the surveyor with a Licensed Practical Nurse (LPN #1) inspected the medications stored in the locked refrigerator on the Noble unit.
At that time, the surveyor with LPN #1 observed a 30 milliliter (ML) opened bottle of Lorazepam (Ativan) solution 2 milligram (MG)/per ML labeled for Resident #201. The bottle had no date when opened and had approximately 20 ML remaining.
On 4/17/25 at 10:47 AM, LPN #1 could not speak to the Ativan bottle for Resident #201 and referred to the Unit Manager/Registered Nurse (UM/RN). UM/RN stated that Resident #201 no longer resided in the facility and that the Ativan bottle should have been dated when opened and discarded 90 days after opening or when Resident #201 was discharged .
At that time, UM/RN was unable to provide the Individual Patient Controlled Substance Administration Record (IPCSAR) for Resident #201 that corresponded with the Ativan bottle. The UM/RN acknowledged that without an IPSCAR, the Ativan was not being counted during the shift-to-shift count of controlled medications.
On 4/17/25 at 11:05 AM, during further inspection of the medication room on the Noble unit, the surveyor, with UM/RN, observed in an unlocked cabinet, a clear plastic bag that contained the following controlled drugs labeled for Resident #204: three (3) unopened boxes of Fentanyl 50 microgram (MCG) patches (5 patches per box), one (1) opened box labeled Fentanyl 50 MCG patches contained three (3) patches (1 patch was 50 MCG and 2 patches were 100 MCG), two (2) unopened boxes of Fentanyl 100 MCG patches (5 patches per box), a bottle of 21 Hydromorphone 2 MG tablets, a bottle of 58 Hydromorphone 4 MG tablets, a bottle of two (2) Hydrocodone/Acetaminophen 5-325 MG tablets, a 20 ML bottle of Morphine Sulfate solution 100 MG/5 ML with approximately 19 ML remaining and 15 unopened and sealed bottles each with 6 ML of Methadone liquid 10 MG/ML.
In addition, in the clear plastic bag, labeled for Resident #203: a bottle of five (5) Alprazolam 0.5 MG tablets.
At that time, the UM/RN stated that she had been the UM for approximately three (3) weeks and was unaware of the clear plastic bag with controlled drugs kept in the unlocked cabinet in the medication room. The UM/RN stated that all the controlled drugs should have been returned to the provider pharmacy or destroyed and that it was ridiculous.
On 4/17/25 at 11:35 AM, the surveyor interviewed the Director of Nursing (DON) who stated she was DON for the past month and had not had any reports of discrepancies regarding controlled drugs. The DON also stated all the above controlled drugs in the bag should have been destroyed by the previous DON with another nurse. The DON acknowledged controlled drugs were not to be stored in the medication room in an unlocked cabinet and required double locked storage. The DON was unable to provide an IPCSAR for Resident #203 and #204 corresponding to each controlled drug in the bag and stated she would have to check. The DON acknowledged the controlled drugs in the bag were not being accounted for during the shift-to-shift count of controlled medications. The DON stated she was unaware of the controlled drugs in the cabinet and would have to begin an investigation.
On 4/17/25 at 1:25 PM, the surveyor interviewed LPN #2 who had completed the admission records for Resident #204. LPN #2 looked at the controlled drugs labeled for Resident #204 in the bag and stated that she could not remember the resident coming to the facility with the medications in the bag.
On 4/17/25 at 1:45 PM, the surveyor interviewed the DON who provided the surveyor with an IPCSAR labeled for Ativan 2 MG/ML for Resident #201. The surveyor with the DON reviewed the IPCSAR which revealed that 30 ML of Ativan was received on 6/26/24 and a declining inventory was documented from 6/26/24 until 7/3/24. The remaining balance was 20.5 ML of Ativan on 7/3/24. Further review of the IPCSAR, revealed the date of disposition was 10/4/24 and signed by the former DON and former ADON. The DON verified the IPCSAR inaccurately documented the Ativan remaining amount of 20.5 ML was destroyed on 10/4/24.
A review of the admission Record (AR) for Resident #201 revealed that the resident had expired at the facility on 7/3/24.
The DON was unable to provide documentation or an IPCSAR that would indicate receipt, accountability and reconciliation of the above listed controlled drugs that were contained in the clear plastic bag.
A review of the AR for Resident #204 revealed that the resident had expired at the facility on 9/6/24.
A review of the AR for Resident #203 revealed that the resident was discharged from the facility on 5/7/24.
On 4/17/25 at 2:06 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Corporate Clinical Officer (CCO) and DON. The CCO stated the UM/RN was new to the facility and would not have knowledge of the controlled drugs found in the medication room. The CCO acknowledged that the medication room should have been checked for proper storage. The DON stated that a unit inspection was performed monthly by the Consultant Pharmacist (CP) and reviewed those reports. The DON acknowledged that controlled drugs should not have been stored in the medication room in an unlocked cabinet and accurate records were supposed to be maintained.
A review of CP Unit Inspection reports from May 2024 to March 2025 had not identified the above findings.
On 4/22/25 at 8:49 AM, the surveyor interviewed the CP via telephone. The CP stated that she was not the CP who had completed the unit inspection reports but was able to speak to any questions. The CP explained that medication room cabinets and medication refrigerators were checked as part of the unit inspection and any concerns identified would be listed on the reports. In addition, the CP stated controlled drug accountability and reconciliation was spot checked once a month, meaning on the day of the inspection at that moment the controlled drugs were reviewed. The CP added that she may not have the knowledge of residents who had been discharged but if the medication was expired would bring that to the attention of nursing right away. The CP could not speak to what happens after bringing expired medications or medications that needed to be disposed of to nursing. The CP also added that the current DON was more receptive to the reports than the previous DON.
On 4/22/25 at 9:56 AM, the survey team met with LNHA, CCO, Assistant Administrator (AA) and DON. The DON stated the controlled drugs for Resident #204 that were in the bag were brought in the facility by the family and there was a nursing progress note indicating that the family was called to pick up the controlled drugs after Resident #204 expired. The DON also stated that usually medications from home would not be accepted and was unable to verify when the controlled drugs were accepted in September 2024. The DON acknowledged there was no system of receipt, accountability and reconciliation that had being done. The DON could not speak to why the Ativan bottle for Resident #201 was not removed from active inventory when there was no corresponding IPSCAR on the unit and the opened bottle had no open date and was expired. The DON also could not speak to why there were no records for the bottle of five (5) Alprazolam 0.5 MG tablets for Resident #203. CCO added that the nurses were inserviced by the DON and the controlled drugs that needed to be destroyed were documented.
A review of the facility undated policy titled Storage of Medications provided by the CCO/RN reflected Controlled Substances will be stored in a separate container under double lock.
A review of the facility policy titled Controlled Substances updated 8/22/24 provided by CCO reflected the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances. In addition, Controlled substances will be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, will count the controlled substances together. Both individuals will sign the designated narcotic record for the pharmacy records. Also, Accurate accountability of the inventory of all controlled substances is maintained. Nursing staff will count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty will complete the count together. They must document and report any discrepancies to the Director of Nursing Services. Further review reflected, When a resident or patient is transferred or discharged , controlled substances may not be given to the resident to take with them and may not be returned to the pharmacy, but must be destroyed in accordance with established policies.
A review of the manufacturer specifications for Lorazepam (Ativan) Intensol Oral Concentrate 2 MG/ML reflected that the Ativan solution be stored in the refrigerator and Discard opened bottle after 90 days.
2. On 4/17/25 at 11:33 AM, the surveyor with LPN #1 inspected the controlled drugs on the medication cart for Resident #202, which revealed an IPCSAR labeled for Resident #202 for Nayzilam spray 5 MG, two (2) solutions and indicated that the remaining balance was one (1). LPN #1 was unable to show the surveyor the remaining one (1) Nayzilam spray. LPN #1 thought there was only one (1) sent by the provider pharmacy. LPN #1 verified that her signature was on the IPCSAR as receiving the drug but had not signed the date received or amount received but the provider pharmacy label indicated two (2) solutions, the number two (2) was circled and there was a Nurse Administering signature for the number (2) indicating removal of one (1) and remaining balance of one (1). LPN #1 stated that she had not reported any discrepancies regarding controlled drugs for the medication cart. LPN #1 verified that she had signed the Resident Controlled Substance Accountability Log for the Incoming Nurse for 4/17/25 for the 7 AM to 3 PM shift with another nurse who signed the Outgoing Nurse and neither had a discrepancy.
Further review of controlled drugs for Resident #202 revealed two (2) IPCSAR for Diazepam gel 20 MG as indicated:
-IPCSAR #1 with a prescription (RX) number ending in 244 dated as received 8/19/24 with an amount received of two (2) indicated that the remaining balance was one (1). The surveyor with LPN #1 observed two (2) Diazepam gel 20 MG rectal dispensers labeled for Resident #202 with corresponding RX number ending in 244.
- IPCSAR #2 with RX number ending in 149 dated as received 10/5/24 with an amount received of two (2) indicated that the remaining balance was (2). The surveyor with LPN #1 observed one (1) Diazepam gel 20 MG rectal dispenser labeled for Resident #202 with corresponding RX number ending in 149. In addition, there was a partially torn paper wrapped around the dispenser titled Return (discontinued crossed out) Medication Form dated 10/15/24. LPN #1 stated she was not sure why the form was there but thought the medication was to be returned to the provider pharmacy.
At that time, LPN #1 verified IPCSAR#1 and IPCSAR#2 were not accurately corresponding to the remaining balances. LPN #1 also verified that the nurses should be corresponding the RX numbers of the controlled drug to the IPCSAR.
On 4/17/25 at 11:35 AM, the surveyor interviewed the DON who stated she was the DON for the past month and had not had any reports of discrepancies regarding controlled drugs.
On 4/17/25 at 11:42 AM, the surveyor interviewed the DON and UM/RN regarding the IPSCAR labeled for Resident #202 for Nayzilam spray with a remaining balance of one (1). The DON stated Resident #202 was admitted to the hospital last night and would have to look for the Nayzilam spray if two sprays were received. DON acknowledged that the Diazepam gel IPCSAR #1 and IPCSAR #2 were inaccurate and that the nurses were to check the corresponding RX numbers. The DON was unable to speak to the paper tilted Return Medication Form. The DON added that controlled drugs were not returned to the pharmacy.
On 4/17/25 at 2:06 PM, survey team met with LNHA, CCO and DON. DON acknowledged that the IPCSAR for Nayzilam spray should be completed for received date and amount received. The CCO stated that they were reviewing the shift to shift Resident Controlled Substance Accountability Log that the nurses signed when counting controlled drugs and had identified that the form was not being completed properly and needed to be changed.
On 4/22/25 at 8:49 AM, the surveyor interviewed the CP via telephone. CP stated that she was not the CP who had completed the unit inspection reports but was able to speak to any questions. The CP explained that medication room cabinets and medication refrigerators were checked as part of the unit inspection and any concerns identified would be listed on the reports. In addition, the CP stated controlled drug accountability, and reconciliation was spot checked once a month, meaning on the day of the inspection at that moment the controlled drugs were reviewed. The CP added that she may not have the knowledge of residents who had been discharged but if the medication was expired would bring that to the attention of nursing right away. The CP could not speak to what happens after bringing expired medications or medications that needed to be disposed of to nursing. The CP also added that the current DON was more receptive to the reports than the previous DON. The CP also stated that the RX number for the IPSCAR must match the controlled drug count for accuracy.
A review of CP Unit Inspections from May 2024 to March 2025 had not identified the above findings.
On 4/22/25 at 9:56 AM, the survey team met with LNHA, CCO, AA and DON. CCO stated that Nayzilam spray for Resident #202 was not found because the night nurse had discarded the Nayzilam spray without documentation and was unsure what had happened. CCO added that the nurse was written up. CCO acknowledged that destruction of controlled drugs was to be documented on the IPCSAR. CCO stated Diazepam gel should not have had a form for return because controlled drugs were not returned to the pharmacy. CCO added that the nurses were inserviced by the DON and the controlled drugs that needed to be destroyed were documented.
A review of the physician's orders for Resident #202 revealed that Nayzilam was discontinued on 3/3/23.
On 4/22/25 at 11:52 AM, the surveyor interviewed a Pharmacist (RP) representative from the provider pharmacy via telephone. The RP stated that Nayzilam spray was dispensed for Resident #202 on 12/6/22 in a box containing two (2) sprays. The RP was unable to identify an expiration date on the nasal sprays dispensed at that time.
On 4/22/25 at 1:19 PM, the surveyor interviewed LPN #3 who stated that she had worked last week 11 PM to 7 AM and on the morning of 4/15/25 she was cleaning out the medication cart for any expired medications. LPN #3 added that when she counted the controlled drug inventory with LPN #1 she had noticed that the Nayzilam spray was expired and remembered removing the spray and carrying other expired medications with her to go to the computer to reorder the Nayzilam spray where she realized there was no current physician's order. LPN #3 then stated that she thinks she accidentally discarded the Nayzilam spray with the other medications that she had removed from the medication cart. I made a stupid mistake.
On 4/22/25 at 4:27 PM, the survey team met with LNHA, CCO, AA and DON. The CCO stated Resident #202 was in the hospital currently and the Diazepam gels were destroyed and documented. The CCO added that she would check regarding the physician's order dating for the Diazepam gel.
A review of the physician's orders for Resident #202 revealed Diazepam gel was discontinued 2/2/25.
A review of the IPCSAR #1 and IPCSAR #2 labeled for Resident #202 for the Diazepam gels provided by the DON indicated that the DON and UM/RN had destroyed the Diazepam gel dispensers on 4/17/25.
On 4/23/25 at 11:14 AM, the survey team met with LNHA, CCO, AA and DON. CCO stated with UM/RN in place now, if a resident was discharged all medications would be removed. The DON added that it was the responsibility of the nurses to remove from active inventory any medications for discharged residents or for any discontinued physician's orders.
A review of the facility policy titled Controlled Substances updated 8/22/24 provided by CCO reflected the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances. In addition, Controlled substances will be counted upon delivery. The nurse receiving the order, along with the person delivering the medication order, will count the controlled substances together. Both individuals will sign the designated narcotic record for the pharmacy records. Also, Accurate accountability of the inventory of all controlled substances is maintained. Nursing staff will count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty will complete the count together. They must document and report any discrepancies to the Director of Nursing Services. Further review reflected, When a resident or patient is transferred or discharged , controlled substances may not be given to the resident to take with them and may not be returned to the pharmacy, but must be destroyed in accordance with established policies.
3. On 4/17/25 at 11:24 AM, the surveyor with LPN #2 inspected the controlled drugs in the medication cart for Resident #34 which revealed a Controlled Substance Administration Record for Patches (CSARP) labeled for Buprenorphine (Butrans) Patch 10 MCG/hour dated as received 4/15/25 with the amount received as three (3) patches. Further review, revealed that at 10:41 AM on 4/17/25 LPN #2 signed on line three (3) indicating the patch was removed from inventory and applied. In addition, on the same date and time the patch the LPN #2 signed for was removed and wasted. LPN #2 stated she had first removed an old Butrans patch from last week and put the new patch on Resident #34. LPN #2 added she had just started the new CSARP and showed the surveyor the remaining balance of (2) patches in the medication cart. The surveyor, with LPN #2, reviewed the current physician's order which indicated a start date of 3/20/25 for Butrans Transdermal Patch Weekly 10 MCG/HR (Buprenorphine) Apply 1 patch transdermally one time a day every Thu (Thursday) for pain management. LPN #3 acknowledged the patch she had applied today, 4/17/25, would be removed and wasted next Thursday. LPN #2 acknowledged that the documentation on CSARP indicated the same patch she applied had been removed and discarded today. LPN #2 stated she would have to review with DON. In addition, LPN #2 stated she had wasted the old patch that she removed from the resident and showed LPN #1, but that LPN #1 had not signed the CSARP yet. LPN #2 acknowledged that when the patch was wasted both signatures were needed.
On 4/17/25 at 11:42 AM, the surveyor interviewed the DON and UM/RN regarding the CSARP labeled for Resident #34 for Butrans patch. The DON stated there should be two nurses' signature for the wastage of the controlled drug. DON acknowledged that the CSARP had not reflected the application and removal properly and would have to look into it.
On 4/17/25 at 2:06 PM, the survey team met with LNHA, CCO and DON. The DON stated that she would have to review and /or change the process of the controlled drug patch wastage signatures.
On 4/22/25 at 9:56 AM, the survey team met with LNHA, CCO, AA and DON. The CCO stated LPN #2 had signed for the removal of the Butrans patch but had not wasted the patch and was holding the patch in a cup in the medication cart until LPN #1 was available to destroy the patch. The CCO added the regulation, and our policy requires signing at the time of destruction. The CCO was unable to speak to the interview with the surveyor and LPN #2 at the medication cart. The CCO stated LPN #2 was on vacation now. The CCO also stated the corresponding IPSCAR for the old Butrans patch that was removed by LPN #2 was not in the controlled drug binder at the time LPN #2 removed the patch to waste. The CCO added that the nurses were inserviced by the DON.
On 4/22/25 at 10:41 AM, the CCO stated that the policy for documenting the destruction of a controlled drug patch was reflected in the policy titled Controlled Substances updated 8/22/24 7. When a resident refuses a non-unit dose medication or it is not given, or receives partial tablets or single dose ampules, or it is not given, the medication shall be destroyed with two witnesses and may not be returned to the container.
NJAC 8:39- 29.4(g), 29.4(i), 29.4(k), 29.7(c)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) the facility's Registered Dietitian (RD) reviewed and approved the four week cycle menus for nutritional adequacy in accordance with nationally accredited standards and the facility provided Diet Manual, b.) residents consistently received the standard serving of the main entrée/protein (16 out of 56 lunch and dinner meals were inadequate) or an alternate item (2 out of 9 were inadequate) for high biological value protein (proteins of high biological value, also known as complete proteins, are those that contain all the essential amino acids in the appropriate proportions that the body needs to carry out its functions optimally), c.) alternate menu items were available as posted, and d.) that a resident (Resident #54) consistently received breakfast meat daily as requested as well as receive a nutritionally equivalent protein food as a menu substitute from the facility Always Available List (a list of foods available for lunch and dinner besides the menu choice for that day). This deficient practice was also identified by 7 out of 7 residents that attended the Resident Council Meeting on 4/15/25.
The deficient practice was evidenced by the following:
On 4/14/25 at 10:05 AM, the surveyor conducted an initial kitchen tour with the Food Service Director (FSD). The surveyor observed an empty metal rack to the right of the kitchen entrance which the FSD identified as a bread rack. The surveyor observed a few cardboard boxes with bread. The FSD stated it was delivered that morning and that they received bread deliveries every three days. He further stated, we have to stay in budget.
Towards the end of this tour, the FSD stated that they followed a four-week cycle menu, and they were currently on cycle 4. He provided the surveyor with a copy of these menus on 4/14/25 at 11:36 AM. There was one meal option offered for lunch and dinner. At that same time, the FSD provided an Always Available Items (only for lunch and dinner) list which included Chicken, Hamburger, Hot Dog, Tuna Sandwich, Ham and Cheese Sandwich, Turkey and Cheese Sandwich, Peanut Butter and Jelly Sandwich, Egg Salad Sandwich, Fruit Cup, Fresh Fruit (Apple, Orange, Banana), Garden Salad, Tuna Platter, and Grilled Cheese.
On 4/14/25 at 10:20 AM, the surveyor conducted an entrance conference with the Director of Nursing (DON) and the Corporate Clinical Officer (CCO). They stated the facility census was 99 residents.
On 4/14/25 at 11:39 AM, the surveyor interviewed Resident #54. The resident stated that they were unable to choose their meals and if they called for something else, the kitchen staff would tell them that one hot dog was available.
On 4/15/25 at 10:17 AM, the surveyor conducted a group meeting with seven residents. 7 out of 7 residents had the following concerns; there were limited food choices, the quality of the food was poor, always available items were not consistently available, sandwiches were available if there was bread, the kitchen never have buns for hamburgers or hot dogs, they can't order something if it's not on the menu, the fish patty had very little fish, the chicken patty was all breading, the burgers tasted like they had fillers and were not real meat, and when spaghetti and meatballs were served they received three meatballs which was not enough and did not taste like real beef.
On 4/16/25 at 9:13 AM, the surveyor interviewed Resident #54, who stated they had spoken to the Registered Dietitian (RD) to request a serving of a breakfast meat each morning. The resident stated they did not always receive breakfast meats daily.
On 4/16/25 at 12:14 PM, the surveyor interviewed Resident #54 who stated there was only one menu choice and even if you requested an alternate item, it was not always available.
On 4/16/25 at 12:36 PM, the surveyor observed Resident #54 in their room who stated they received chili but did not want that and the nurse ordered hotdogs as a substitute.
On 4/16/25 at1:01 PM, the surveyor observed one hotdog in a bun brought up by kitchen staff on a plate for Resident #54.
On 4/22/25 at 1:15 PM, the surveyor observed a food service staff member deliver two hot dogs on bread (not hotdog buns) to a resident on the Noble unit.
On 4/22/25 at 10:24 AM, the surveyor interviewed the FSD who stated he did not have a diet manual, and that the RD may have one. He stated that he thought his Regional FSD and the Regional RD developed and reviewed the menus, but he could not really speak the process.
On 4/22/25 at 5:17 PM, the CCO stated that the menus were developed as a team and the Regional RD approved the menus for adequacy. At this same time the FSD entered the conference room and provided the surveyor with the last three months' worth of food purchase invoices.
On 4/22/25 at 1:01 PM, the surveyor conducted an additional kitchen tour in the presence of a second surveyor. The FSD acknowledged that the facility did not provide residents with a selective menu. He stated the facility made macaroni and cheese from scratch, and they used 2-5 pound (lb.) bags of cheddar cheese to prepare the cheese sauce. He stated that when they served manicotti on the menu, they provided two per serving and they provided four to five ravioli per serving when on the menu. The FSD also acknowledged that on Tuesday mornings they may not have breakfast meats available for resident who requested it daily. He stated that they are light on meat at times because meat deliveries were on Tuesdays.
During this kitchen tour the surveyors reviewed some items on the Always Available list as well as other menu items for nutritional adequacy. There was a box of frozen hamburgers and a box of frozen manicotti (60 per box) that did not have nutritional information nor ingredients listed on the box. There were [name redacted] hotdogs and the nutritional information on the package indicated one hotdog provided 6 gms of protein. The FSD stated that if a resident wanted hotdogs to replace a meal, they would have provided two. He acknowledged 6 gms of protein would not have been adequate and that a minimum of 3 ounces (oz.) of protein should be provided at the lunch and dinner meals. He further acknowledged that 3 oz. of protein was equivalent to 21 gms. The FSD also acknowledged that food items that provided less than that would not be an adequate serving of protein as a main meal or alternate/substitute. There was a plastic 5 lb. sleeve of sliced cheese which had the nutritional information on the package and indicated two slices of cheese provided 4 gms of protein. The FSD stated that when the kitchen prepared cheese sandwiches or grilled cheese, two slices of cheese were used. There were frozen chicken patties and the nutritional information on the box indicated that one patty provided 11 gms of protein. The FSD stated that one patty was served per meal and acknowledged that was an inadequate amount of protein. A few other menu items in question regarding protein content per serving were the breaded fish, meatballs, manicotti and ravioli, which were not available for review. The surveyor requested the FSD for the nutritional information. The surveyor observed that the bread rack did not have hot dog or hamburger buns. The FSD acknowledged the same and stated he would give a slice of bread instead and that a delivery would arrive tomorrow.
On 4/22/25 at 2:40 PM, the surveyor interviewed the RD. She stated that the menus were developed by the Regional FSD and that she and the FSD also reviewed them and collectively they approved the menus for nutritional adequacy. She stated she would provide the surveyor with the Diet Manual for review. She stated that she was aware there were no selective menus and that residents could choose from the Always Available list. The RD stated she was unaware of concerns about always available items not being available as well as bread and buns. She could not speak to who ensured food products were nutritionally adequate. She acknowledged that 3 oz. or 21 gms of protein should be provided for lunch and dinner. She acknowledged that one hotdog which provided 6 gms of protein was not an adequate substitution.
On 4/22/25 at 2:35 PM, the FSD provided the surveyor with copies of the nutritional information for the frozen manicotti, breaded fish and ravioli.
On 4/22/25 at 5:30 PM, the CCO provided the surveyor with a copy of an undated [name redacted] Dietary Manual and a [name redacted] Cycle Menu Recipe Book.
On 4/23/25 at 10:47 PM, the surveyor interviewed the FSD in the presence of the Regional FSD. The FSD stated that when they make pizza for the residents, they used nine-inch round pie crusts and 12-13 lbs. of mozzarella cheese. He acknowledged that if a resident ordered a substitute it was required to be nutritionally equivalent and that some prepared products that were used did not meet protein requirements. He also acknowledged that recipes provided to the surveyor, as an example Breaded Baked Fish, was for a scratch recipe (which was not used) and only had instructions for a one serving recipe and indicated that the fish ingredient would be a four oz. portion of cod fillet (which would have provided 28 gms of protein).
On 4/23/25 at 1:04 PM, the Regional FSD provided the surveyor with a copy of cycle 1 and 2 of the menus signed and undated by the facility RD.
On 4/23/25 at 1:21 PM, the surveyor interviewed the RD and Regional FSD in the presence of the survey team. The RD stated, she signed cycle 1 and 2 within the last week (but could not speak to date) and that her signature attested to the fact that cycle 1 and 2 were nutritionally adequate. Both stated that they were still working on cycle 3 and 4. The RD stated she could not attest to whether or not they were nutritionally adequate. They acknowledged that a 3 oz. portion of protein equaled 21 gms of protein. They acknowledged the surveyor had previously discussed examples of menu items did not meet nutritional requirements for protein. The RD stated the menus were nutritionally adequate for protein.
The Always Available list provided hotdog and grilled cheese; already established to have inadequate protein per serving during survey which yielded 6 and 4 gms of protein, respectively.
During interviews with the FSD, he stated that he used 10 lbs. of cheddar cheese to make macaroni and cheese for the building (99 residents/census). That would yield approximately 12 gms of protein per person. He also stated that when cheese pizza was prepared, he used 12-13 lbs. of mozzarella cheese for the building. If 13 lbs. were used, that would yield approximately 15 gms of protein per person.
A review of the food purchase invoices the FSD provided reflected that on 3/20/25, the facility received 3 cases of frozen manicotti. There were 60 manicotti per case which yielded 180 pieces. That would provide 1.8 manicotti per person. The nutritional information provided to the surveyor indicated that 1 manicotti provided 7 gms of protein. Therefore approximately 2 manicotti provided 14 gms of protein per person.
A review of a food purchase invoice dated 3/27/25, reflected the facility received 3 cases of frozen medium cheese ravioli. The invoice indicated the brand [redacted] and that there were 200 ravioli per case. The FSD provided the surveyor with nutritional information for a different brand [name reacted] and there were 100 ravioli per case and were Jumbo verse the invoice Med (medium). Investigation for the brand [name redacted] ravioli indicated on the invoice, would have provided 9.1 gms of protein per 1 cup portion of those ravioli, which was the portion size indicated on the cycle menus.
A review of the food purchase invoice dated 4/1/25, reflected the facility received 3 cases of 1 oz meatballs from brand [name redacted]. Investigation for the brand [name redacted] meatballs revealed 12 gms of protein would have been provided if 3 meatballs were served, which was the portion size indicated on the cycle menus as well as verbalized by residents in the Resident Council Meeting.
A review of the nutritional information for the Breaded Fish provided by the FSD, indicated a 4 oz. portion (1 piece) provided 14 gms of protein.
A review of the facility's Week-At-A-Glance [name redacted] Spring/Summer 2025 four-week cycle menus reflected the following items served 16 meals out of 56 provided an inadequate amount of protein:
Week 1
Monday
Lunch Cheese Pizza (15 gms)
Dinner Breaded Baked Fish (14 gms)
Tuesday
Dinner Chicken Patty on a Bun (11 gms)
Thursday
Dinner Manicotti (14 gms)
Friday
Dinner 1 All Beef Hot Dog on a Bun (6 gms)
Week 2
Wednesday Lunch Baked Macaroni and Cheese (12 gms)
Thursday
Dinner Manicotti (14 gms)
Week 3
Sunday
Dinner Cheese Ravioli (9.1 gms)
Monday
Lunch Breaded Baked Fish (14 gms)
Dinner Macaroni and Cheese (12 gms)
Friday
Dinner Cheese Ravioli (9.1 gms)
Week 4
Sunday
Dinner Spaghetti with Meatballs (12 gms)
Monday
Lunch Breaded Baked Fish (14 gms)
Dinner Cheese Pizza (15 gms)
Wednesday
Lunch 1 All Beef Hot Dog on a Bun (6 gms)
Friday
Lunch Cheese Pizza (15 gms)
A review of the Dietary Manual [name redacted] provided by the facility, included the Regular diet portion sizes for protein at lunch and dinner should be 3 oz.
In addition, the section titled Quality of Life reflected, The obligation of Nutrition Professionals is to ensure and enhance the quality of life for each resident in the nursing facility by providing appropriate nutrition care and by recognizing and honoring the individuality of each person.
The section titled Resident Rights and Responsibilities included the following rights:
To make choices about where, when and what to eat.
To be served attractive, well-seasoned food in portions acceptable.
To be offered substitutes of similar nutritive value when food served is refused.
NJAC 8:39-17.1 (b), 17.4 (a) (1) (3) (c) (e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 6 of 7 alert and oriented residents (Resident's #4, #22, #53, #58, #70, and #81) during the resident council meeting and was evidenced by the following:
On 4/14/25 at 10:05 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). At the end of the initial tour, the surveyor requested a copy of residents who received labeled snacks, as well as a list of snacks that were sent to the units in the evening to be distributed after dinner. The FSD stated, we really don't send HS (evening) snacks, there was no list. He further stated, we send labeled snacks and if another resident wanted something before the kitchen closed, we would provide it; and if a resident wanted something later there was a key at the front desk, and a supervisor could get a snack.
On 4/15/25 at 9:00 AM, the surveyor reviewed an undated Mealtime and Delivery Schedule, which the facility provided to the survey team. There was more than a 14-hour span between dinner and breakfast service.
On 4/15/25 at 10:17 AM, the surveyor conducted a resident council meeting with 7 residents invited by the President of Resident Council. 6 of 7 residents had a Brief Interview for Mental Status of 15 out of 15, which indicated their cognition was intact.
On 4/15/25 at 10:57 AM, 7 of 7 residents stated that labeled HS snacks were put on the nursing station or in the pantry after dinner. They stated that Certified Nurse's Aides (CNA) were supposed to give out labeled snacks, which was done inconsistently. They agreed that when the snacks were left on the nurse's station, other residents would take the snacks. They agreed that there were no extra items delivered or available to provide to residents without a labeled snack.
On 4/22/25 at 9:36 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 on the [NAME] Unit. They both stated that there was no accountability system in place to account for the provision of HS snacks to residents in the electronic medical record (EMR) or on paper.
On 4/22/25 at 9:50 AM, the surveyor interviewed RN #2, who was the Unit Manager for both the [NAME] and Noble Units. She stated that some residents received labeled snacks, however there was no accountability system to record the provision of HS snacks to residents. She stated residents should be provided HS snacks and if they refused, it should be documented.
On 4/22/25 at 10:24 AM, the surveyor interviewed the FSD. He stated that there should be no more than a 10-12-hour span between dinner and breakfast service. He could not speak to further requirements if the span of time was greater.
On 4/22/25 at 12:43 PM, the Corporate Clinical Officer, stated in presence of survey team, that the facility would be installing kiosks (an electronic accountability system which would provide CNAs the ability to record the provision of HS snacks to residents) for CNAs. At that time, she could not speak to whether or not there was an accountability system on paper.
On 4/22/25 at 2:40 PM, the surveyor interviewed the Registered Dietitian (RD). She stated that if there was more than a 14-hour span between dinner and breakfast service, the residents should be provided with a nutritious snack like a half of a sandwich. The RD stated there should be accountability; however, she stated there was no accountability in the EMR and she did not think there was accountability on a paper system.
A review of the minutes from Resident Council Meetings dated 1/30/25, 2/26/25 and 3/27/25, all included [name redacted], and other residents reported CNAs do not distribute the snacks when the kitchen brings up the snacks.
The facility was unable to provide policy's related to mealtimes and HS snacks.
NJAC 8:39-17.2 (f) )(1) (i) (ii)

Based on observation, interview, and document review, it was determined that the facility failed to provide education and assess staff competencies for staff who provided care for residents who received dialysis [a type of treatment used to clean the blood when kidneys do not function properly] as identified as residents with skilled needs per the Facility Assessment. The deficient practice was evidenced by the following:
On 10/19/23 at 10:55 AM, the surveyor observed Resident #90 lying in bed awake, watching television with snacks on his/her bedside table. Resident #90 stated that he/she had been going to hemodialysis for a while. The resident stated that he/she used to have a catheter in his/her chest, while pointing to his/her right side of chest and neck area, but now had a fistula in his/her right arm, pointing to his/her right upper arm. The surveyor did not observe any catheter or permacath in resident's right chest wall. The surveyor observed 2 bulging sites on the resident's right upper arm. There were no dressings on the 2 sites and some bruising was noted. Resident #90 stated it hurts to get the needles put in. The resident added that he/she goes to hemodialysis every Monday, Wednesday and Friday and takes a communication binder to his/her treatments, which the facility staff kept at the nurse's desk.
A review of the admission Record reflected that Resident #90 was admitted to the facility with diagnoses which included, but were not limited to, end stage renal disease (ESRD) (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and anemia (a condition in which the blood doesn't have enough healthy red blood cells and leads to reduced oxygen flow to the body's organs.)
A review of the Quarterly Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care, dated 08/18/2023, revealed that Resident #90 received a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of intact cognition. Section O of the MDS titled Special Treatments, Procedures, and Programs revealed that the resident received dialysis outside the facility.
A review of the Facility Assessment indicated that the intent was the services and care provided assist people to reach their highest level of practicable potential and maintain their ability to participate in life activities as long as they are able. The facility assessment collects information about the facility's resident population to identify, but not limited to, the care required and the staff competencies. The facility's resources are identified and evaluated to ensure that care can be provided to meet residents' needs during the day to day and emergency operations. The facility assessment indicated that residents requiring hemodialysis are treated at the dialysis center in the community. Care and treatment for these residents is a joint effort of the facility and the dialysis center staff. The Facility Assessment would include staff competencies that are necessary to provide the level and types of care needed for the resident population.
On 10/19/2023 at 12:59 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) any documentation of competencies, education, or training for their staff nurses regarding care of dialysis residents.
During an interview with the surveyor on 10/23/2023 at 10:47 AM, the DON stated that her expectations of the nursing staff in caring for residents that receive dialysis was to check the resident's vital signs, follow the physician's orders for medications, and to know what medications to hold prior to going to hemodialysis. The DON added to also monitor the resident's diet, to check the access and monitor the access for any signs of infection, bleeding, or swelling. The nurses should document in the communication binder that accompanies the resident to the dialysis facility and communicate any changes with the resident to the hemodialysis center. The DON stated that when the resident returns from their hemodialysis treatment, the nurses should check the resident's vital signs, check the access, and note any changes in the communication binder from the dialysis center. She revealed that the nurses would check the thrill and bruit of the access site. If the resident had a permacath, the permacath would have a dressing so should only check the site for swelling or bleeding and not do anything else with the access. The surveyor asked if the nurses were trained in the checking of the thrill and bruit of a fistula? The DON stated that she would expect the nurses to already know how to do that. The DON revealed that she was not sure if any facility education regarding hemodialysis residents was provided to the nursing staff. The DON stated that there should be a physician's order for checking the thrill and bruit of an AV fistula and should also be included in the resident's care plan. The surveyor requested from the DON for any documented education or training for their staff nurses regarding hemodialysis.
During an interview with the surveyor on 10/23/2023 at 10:51 PM, the LNHA stated that her expectations of the nursing staff in caring for residents receiving dialysis was to document in the dialysis communication binder the resident's vital signs, checking of the access site, weight, dietary changes, and any unusual occurrences. She stated that the nurses should also check the thrill, bruit and bruising or signs of infection of the access. The LNHA added that if the resident had a permacath, the nurses should check for signs of infection or swelling at the site. The permacath dressings are changed at the dialysis center. The facility nurses do not change the dressings or do anything else with the permacath. The LNHA confirmed that there should be a physician's order to check the thrill and bruit of a fistula and should also be care planned. The surveyor requested from the LNHA again for any staff education, training, or competencies related to dialysis residents.
On 10/23/23 at 01:50 PM, in the presence of the survey team, the surveyor asked the DON if the staff had been trained on dialysis? The DON stated, No. The DON revealed that there were no staff competencies related to hemodialysis and stated that it was important based on the dialysis patient population.
On 10/26/2023 at 09:37 AM, The facility was unable to provide any documentation of licensed nurse competencies, signed in-services, education, or training regarding care of dialysis residents.
NJAC 8:39-33.4

Based on interview and review of facility documentation, it was determined that the facility failed to ensure the surety bond contained sufficient funds to protect the residents' trust funds. This deficient practice had the potential to affect all residents who resided in the facility that had Personal Needs Account (PNA) funds and was evidenced by the following:
On 10/19/23 a 12:45 PM, the Licensed Nursing Home Administrator (LNHA), provided the surveyor with a three-page document labeled Checking Account Statement, Statement Type: Bank, Trust Account [number redacted]. The document was dated 07/25/23 through 10/18/23. The document revealed a beginning balance $144,211.45, on 07/25/23, and a balance of $129,340.81 on 10/18/23. Additionally, the surveyor was provided with a 2-page Checking Account Statement dated 07/20/23 through 10/18/23 which was labeled as Petty Cash Account [number redacted].
On 10/19/23 1:10 PM, the LNHA provided a copy of the Surety Bond. The document revealed a Renewal Verification/Continuation Certificate for an anniversary premium Period dated 4/1/23 - 4/1/24 in the amount of $85,000. The surveyor observed that the Surety Bond did not cover the balance of the funds in the account labeled Trust Account by more than a $44,000 deficit as of the 10/18/23 balance.
On 10/19/23 at 1:26 PM, the surveyor interviewed the LNHA regarding the purpose of the PNA. The LNHA stated the PNA was to ensure that any resident money for resident's that had over $50.00 was held in an interest-bearing account. The LNHA stated the resident would have access to their money 7 days a week and 365 days per year and and the person who handled the PNA would be able to explain things further.
On 10/19/23 at 1:44 PM, the surveyor interviewed the Revenue Cycle Manager (RCM) in the presence of the LNHA. The RCM stated she was the person responsible for the centralized oversight of the business office functions for the facility which included the PNA funds. The RCM stated that the resident's PNA was kept the in an interest-bearing account. The surveyor asked the RCM about the purpose of the surety bond. The RCM stated it was an insurance policy because the money in the account does not belong to us. She stated that each facility had a surety bond, and the bond should cover what is in the trust, normally we don't have that much money in the account. The RCM stated that from 2020 through 2021 each resident received 3,000 from the Covid money and maybe there had been money left in the account.
On 10/26/23 at 1:52 PM, the surveyor interviewed the RCM in the presence of the LNHA. The RCM stated to the surveyor that there was an oversight, and the facility surety bond did not cover the full amount of funds as documented in the resident PNA account statement. The RCM confirmed that facility had not been aware of the surety bond was not meeting the total amount of the PNA funds held by the facility until brought to the facility's attention during the survey.
NJAC 8:39-9.5(c)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to maintain resident common areas, resident rooms and equipment in a clean, sanitary and safe functional manner as evidenced by the following:
During the initial tour of the Noble unit on 10/18/23 at 10:14 AM, the surveyor observed in room [ROOM NUMBER] the air conditioner unit with blue tape and card board around the bottom of the unit.
On 10/18/23 at 10:30 AM, the surveyor toured the [NAME] unit day room and observed an unsampled resident (UR #1) ambulating independently and was looking out of a window that was above an air conditioning unit, and another unsampled resident (UR #2) was sitting at a table watching the television. Upon entering the day room, the surveyor observed a row of wooden cabinets that appeared visibly soiled on the exterior, and the cabinet door appeared to be loose on its hinges. At 10:32 AM, the Activity Director entered the day room, and the surveyor showed her the debris on the wooden cabinets and upon opening the cabinets there was debris observed inside along with a black garbage bag. The surveyor asked the AD if the cabinets were clean and she stated, not clean. The surveyor observed that there were three window air conditioner units in the day room. All three units were visible soiled, one was missing an entire grate and one had a broken grate. The unit closest to the wooden cabinets had a lifted and broken piece that the surveyor touched and observed that it was a sharp and jagged hard piece of material and showed it to the AD. The surveyor asked the AD if the jagged hard piece posed a safety concern to the residents and the AD stated, yes, that is unsafe. The surveyor also observed a stained beige chair and the round table bases were soiled. When asked about the UR #1 who was peering out of the window, the AD stated the resident likes to look out of the window and people walk in and out of the day room.
On 10/18/23 at 11:20 AM, the surveyor toured the Noble unit shower rooms. At that time, the surveyor interviewed a Licensed Practical Nurse (LPN) who confirmed that the residents utilize the shower rooms. The shower room closest to the elevator contained a shower chair with a blue mesh back that was soiled and had a pink substance on the seams.
On 10/18/23 at 11:32 AM, the surveyor entered the 2nd shower room with the Registered Nurse and observed ripped cushions with exposed foam on both shower chairs. One was a large burgundy colored chair and the other one was a teal backed chair. Both chairs were also soiled, and the burgundy chair had a broken knob with sharp edges in the leg area. In addition, the drain cover was missing and a broken tile was observed. The surveyor showed the RN the ripped cushion and the broken knob and asked if that was okay. The RN stated that the cushion was an infection control problem and the broken knob was a potential injury problem for sure and the RN confirmed that one of the Certified Nurse Aides used the shower room that morning to shower a resident.
On 10/18/23 at 11:31 AM, the surveyor interviewed three Certified Nurse Aides (CNA). One CNA stated she used the big chair yesterday, however, she did not any rips or broken areas.
On 10/20/23 at 8:03 AM, the surveyor observed Resident #14's room on the Noble unit. The resident was in bed, eyes were open, and the resident was not responsive to the surveyor. It was observed that the resident received a tube feeding for nutrition support, and the pump and the pole were visibly soiled with stuck on splatters, including the black base. The bed had visible splatters on it and was visibly soiled. The wall behind the bed had drips stuck to it, ripped areas and splatters throughout. The mechanical pump for the bed and the black tubing was visibly dusty with debris. The windowsill was visibly soiled as was the air conditioner unit. Both nightstands were also soiled with visible debris. There was a large black wheelchair in the resident's room that appeared soiled with various debris throughout the metal part of the wheelchair, the leg rests, and the wheels. The Registered Nurse accompanied the surveyor during the observations and confirmed the areas were not clean, including the tube feeding pump, and the resident used the wheelchair yesterday.
On 10/27/23 at 10:46 AM, the Licensed Nursing Home Administrator, Director of Nursing, Regional Director of Operations Regional Clinical Nurse and Regional Infection Preventionist were made aware of the surveyor's observations.
A Resdident Room Cleaning and Bathroom Policy, both undated revealed: Purpose: To provide a detailed description of the steps that are to be completed daily in the cleaning of a resident room. Daily cleaning will ensure optimum levels of cleanliness and sanitation, prohibit and control the spread of infection and bacteria and maintain the outward appearance of the facility .
NJAC 8:39 - 31.2(e); 31.4(a)

Based on interview, record review and review of pertinent documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) two incidents for one resident (08/20/23 & 09/23/23) for injuries that resulted in fractures. The deficient practice was identified for 1 of 2 (Resident #52) residents reviewed for reportable events and was evidenced by the following:
On 10/23/23 at 12:24 PM, the facility provided incident reports for Resident #52. The documents revealed Resident #52 had a fracture of the distal phalanx (bone) of the third finger to the left hand (middle finger of the left hand) which occurred on 08/20/23. Resident #52 also had an incident dated 09/23/23, which resulted in a right nasal bone fracture, minimally displaced nasal septum fracture, and nondisplaced left nasal bone fracture (3 bones in the nose).
On 10/25/23 at 12:41 PM, Surveyor #1 interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The DON spoke to the incident/accident process, stating that an investigation should start immediately, statements would be collected and if warranted, the incident/accident must be reported to the NJDOH within a two-hour window. The LNHA stated, it is important to get statements for a full account of what occurred and need to report to the NJDOH because it is regulatory and a moral obligation. The LNHA acknowledged that there were no statements and that both incidents should have been reported to NJDOH, and then confirmed both had not been reported.
On 10/26/23 at 10:51 AM, Surveyor #1 interviewed the LNHA. The LNHA confirmed she had been aware of both incidents that occurred on 08/20/23 and 09/23/23, resulting in major injuries of fractures. The LNHA stated that the previous DON informed her that both incidents had been investigated and it was concluded that there were no findings of abuse. The LNHA stated that she only received verbal re-assurance that the incidents had been completed, but that no documentation was provided to her. The LNHA stated that it was ultimately her responsibility to ensure that an investigation was conducted and that the injuries were reported to NJDOH.
On 10/27/23 at 12:30 PM, Surveyor #1 reviewed the facility provide policy, Abuse, Neglect and Mistreatment of The Elderly, undated, which included but was not limited to; Section F (reporting) which revealed:
1.) The Director of Nursing/Administrator or designee reports to the New Jersey Department of Health and Senior Services immediately any occurrences of suspected abuse, neglect or mistreatment. The facility maintains records of all documentation sent to the (NJ) DOH including the name of the person the records were sent to and the date sent.
2.) Any incidents of suspected or actual abuse that is reported to the police must be called into the New Jersey Office of Ombudsman and the New Jersey State Department of Health and Senior Services Licensure office immediately followed by written notification within 72 hours of verbal confirmation.
3.) If there is a finding against a staff member, the (facility) notifies the State Nurse Aide Registry and/or other licensing authority of any knowledge it has of any actions taken by a court of law which would indicate that an employee is unfit for service.
NJAC 8:39-9.4(f)

b. On 10/20/23 at 10:31 AM, Surveyor #3 conducted a review of the closed EMR for Resident #356 which revealed the following:
A Health Status Nursing Note, Effective Date: 3/4/2023 at 18:51:37
Note Text:
This nurse went to check resident's blood sugar prior to dinner. Blood sugar= 507, resident was refuse [refused] coverage and was seen with a syringe administering to [him/herself]. This nurse asked [him/her] what insulin [he/she] used, resident reply in [his/her] own words how do you know its insulin. Resident was very hostile and confrontational, yelling and screaming at this nurse. Resident refuse coverage and said go get my nurse .
On 10/23/23 at 12:41 PM, Surveyor #3 conducted a telephone interview with the Nurse who documented the 03/04/2023 note. The Nurse stated he recalled the incident and stated he watched Resident #356 give him/herself and injection. The nurse stated he reported it to the supervisor and the Director of Nursing (DON) at the time. The surveyor asked the Nurse if he was asked to write a statement or participated in an investigation. The Nurse stated, I don't think they ever asked to write a statement. When asked if the Nurse knew what the resident injected him/herself with he stated, well we assumed it was insulin, but we cannot definitely know it was insulin.
On 10/25/23 at 9:36 AM, Surveyor #3 interviewed the Director of Nursing (DON) about what type of investigations would be completed. The DON stated, incidents including a fall, a bruise of unknown origin, or an injury of unknown origin, and abuse allegations. The surveyor asked if there would be an investigation for the incident that occurred with the resident injecting him/herself with an unknown substance. The DON stated, that would be investigated as well. The surveyor requested any investigations for Resident #356 regarding the incident with the syringe.
10/31/23 10:34 AM at 10:20 AM, Surveyor #3 interviewed the Regional Clinical Operation Nurse. The RCO stated that she spoke to the Nurse who observed Resident #356 inject self with a syringe and the RCO stated it was the our duty to investigate and stated that she had a conversation with the former DON who stated there was an investigation completed and was in the DON's office. The RCO then stated there was no investigation located in the DON's office and confirmed that there was no investigation or incident report located that had been completed when Resident #356 injected him/herself with an unknown substance.
NJAC 8:39-4.1 (a) (5), 27.1 (a); 35.2 (c)
Based on interview, record review and review of pertinent documents it was determined that the facility failed to complete and document a thorough investigation and follow the facility Abuse Policy for a.) two incidents that resulted in two different fractures for one resident who resided on a secure unit with a diagnosis of Dementia, and b.) failed to conduct an investigation for a resident who was observed self-injecting with an unknown substance. This deficient practice occurred for 2 residents (Resident #52 and Resident #356) reviewed for accidents and incidents and was evidenced by the following:
a.) On 10/18/23 at 9:47 AM, Surveyor #1 observed Resident #52 seated in a chair next to the bed. The Resident was alert but unable to answer questions asked due to the resident being confused. At that time, the RN (Registered Nurse) was present and explained the resident can get confused at times and needed re-direction often. The RN also stated the resident had a diagnosis of Dementia.
On 09/20/23 at 9:50 AM, Surveyor #2 reviewed the Electronic Medical Record (EMR) and reviewed a nurse's documentation of an injury as follows: Resident chief complaint (c/o) pain about middle finger of left arm, noted discolored, cold to touch, painful at touch. Vitals stable, called placed to MD (Medical Doctor), new order for x ray of middle finger of left hand for c/o pain and discoloration, telephone order, family called and made aware, waiting for x ray company. The x ray results concluded on 08/20/23 at 3:21 PM, read as follows: Portable left hand 3 views. There is a fracture of the distal phalanx of the third finger without dislocation. The remainder of the bony and articular structures are unremarkable.
On 9/23/23 at 4:26 PM, the surveyor reviewed a nurse's documentation of an injury as follows: at approximately 3 PM, writer heard a load thud coming from the dining room area, on getting to the dining room resident was found lying over the piano and bleeding profusely from his/her nose, resident had a cut above the bridge of his/her nose, resident was conscious, verbally responsive at the time of the fall, PRN (as needed) Tylenol was given for pain, resident's nose was pinched, and cotton buds applied to minimize bleeding, but bleeding couldn't just be controlled. MD was made aware, MD [physician] advised resident should be transferred to the ER (emergency room) for treatment and further evaluation. Resident was transferred to the ER via stretcher and accompanied by two EMT (emergency medical transporters) at 3:30 PM. Residents [family] was also made aware of incident and subsequent transfer to the ER.
On 09/25/23 at 4:00 PM, a review of the Physician progress note documented the following: resident was seen for a f/u (follow up) post ER visit post fall on 09/23/23. CT (computed tomography scan- several X-ray images and computer processing to create cross sectional images) of the face showed acute commuted right nasal bone fracture, minimally displaced nasal septum fracture, and nondisplaced left nasal bone fracture. CT of the head was negative for intracranial abnormality. He/she returned with accommodations for Keflex (antibiotic) 500 MG (milligrams) BID (twice a day) x 5 days and f/u with otolaryngology (ears, nose, and throat doctor) and plastic surgeon. He/she is in bed awake, alert, and forgetful. Laceration in the ridge of the nose dry with no bleeding noted. Ecchymosis (bruising) in both cheeks and right hand, an abrasion in the right shin. Denied pain when asked. Primary medical condition that includes Dementia, Anemia, HTN (hypertension-elevated blood pressure), Major Depression moderate recurrent, Type 2 diabetes, PVD (peripheral vascular disease), Chronic purities, abdominal aortic aneurysm, cystic mass of right kidney, and CAD (coronary artery disease).
On 10/25/23 at 11:35 AM, Surveyor #1 conducted a telephone call to interview LPN #1 (Licensed Practical Nurse) who provided care for Resident #52 on 9/23/23. The surveyor left a message for a call back. The surveyor was unable to interview LPN #1 who provided care on Resident #52 on 9/23/23.
On 10/25/23 at 12:41 PM, Surveyor #1 interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The DON stated that after an incident or an accident, an investigation would start immediately. The DON stated statements would be collected. Per the DON, the incident or an accident would then be reported to the NJDOH (New Jersey Department of Health) within two hours. The LNHA stated, It is important to get statements for a full account of what occurred and need to report to NJDOH because it is regulatory and moral obligation.
On 10/26/23 at 10:51 AM, Surveyor #1 interviewed the LNHA. The LNHA stated that the facility did not have a policy for injuries of unknown origin. The LNHA stated she had knowledge of both incidents on 08/20/23 (fracture of the left middle finger) and 09/23/23 (fracture of the nose). The LNHA stated both incidents were discussed in morning meeting with the previous DON who informed her that he conducted and initiated the investigations. The LNHA stated that she was informed by the previous DON that the incident/accident was concluded for both dates and there were no signs and symptoms of abuse. The facility was unable to provide a completed and thorough investigation for either incident conducted on 08/20/23 and 09/23/23. Per the LNHA, the previous DON gave the LNHA verbal re-assurance that both incidents were concluded. The facility failed to provide a determination of any causal factors or provide any statements. The LNHA acknowledged that Resident # 52's investigations dated for 08/20/23 and 09/23/23 had no follow up, no summary, no conclusion, and confirmed that there was no thorough investigation completed.
On 10/26/23 at 12:00 PM, Surveyor #1 interviewed LPN #2 who provided care for Resident #52 on 08/20/23. LPN #2 stated he was familiar with the incident that happened on 08/20/23. LPN #2 informed the surveyors that Resident #52 ambulated to his/her room when he/she hit their left hand on the door frame pretty hard and said ouch. After Resident #52 hit his/her left hand the LPN #2 went to get the resident and assisted the resident to the chair. LPN #2 stated there was no discoloration or pain until an hour and a half later when he noticed the discoloration and resident had a c/o pain at which time he reported to the previous DON via telephone. LPN #2 stated, I did not document that resident hit [his/her] hand in the EMR. LPN #2 acknowledged that he needed to get all the information together and should have documented in the EMR, and he did not. He stated he only documented on paper. LPN #2 stated he did not have a copy of his written incident report that he stated had happened on 08/23/23. The facility was unable to provide the survey team with investigation reports of the incident that occurred on 08/23/23.
On 10/27/23 at 10:46 AM, the above concerns were addressed with the facility. The facility had no documented evidence to provide regarding a completed and thorough investigation for both incidents.
On 10/27/23 at 12:30 PM, Surveyor #1 reviewed the facility provided policy, Abuse, Neglect and Mistreatment of The Elderly, undated, which included but was not limited to; Section D (Investigation) which read as followed:
1.)
The Director of Nursing/designee is designated as the individual who conducts the investigation.
2.)
He/she:
A)
Reviews the accident/incident report
B)
Obtains written statements of staff assigned to the resident for the shift during which the allegation is noted, and 16 hours prior if indicated
C)
Interviews witnesses if any
D)
Reviews the residents record
E)
If a formal report is made attaches the following:
Face Sheet; Current related MDS (minimum data set) standardized assessment that measures health status; Current applicable portions of the comprehensive care plan; Progress notes, which include events 48 hours prior to allegation; Copy of x-ray report, if applicable; Copy of the most recent psychiatric evaluation/progress note; Copy of current physical order sheet; Copy of current Medication Administration Record; Proof of staff assignment for that time; Reviews staff performance; Takes corrective action including but not limited to progressive counseling; in-services; and increased supervision; Re-evaluates policies and revise if necessary to prevent recurrences; Reports all findings to the Administrator.

Complaint # NJ 162113
Based on interview, and record review it was determined that the facility failed to ensure that resident temperatures were documented per physician order for 1 of 1 closed record (Resident #356) reviewed for physician orders. The deficient practice was evidenced by the following:
On 10/20/23 at 10:31 AM, a review of the closed medical record for Resident # 356 revealed a Physician Order dated 02/18/23 for Blood pressure (BP) monitoring every shift, HR [heart rate], RR [respiratory rate], Temp [Temperature], SPO2 [Pulse Oximetry], Pain every shift for BP monitoring.
The Electronic Medical Record (EMR) documentation of Temp was reviewed from 02/18/23 through 03/04/23 when resident was transferred to the hospital and indicated the following:
Date:
Time:
Temp:
3/4/2023
09:04 [7AM-3PM shift]
97.4 °F
3/3/2023
23:27 [3PM-11PM shift]
97.3 °F
3/3/2023
13:20 [3PM-11PM shift]
97.4 °F
3/3/2023
00:25 [11 PM-7AM shift]
97.7 °F
3/2/2023
14:45 [7AM-3PM shift]
97.5 °F
3/2/2023
00:15 [11 PM-7AM shift]
97.5 °F
3/1/2023
19:37[3PM-11PM shift]
97.6 °F
3/1/2023
00:59[11 PM-7AM shift]
97.6 °F
2/28/2023
17:07[3PM-11PM shift]
97.9 °F
2/28/2023 01:33[11 PM-7AM shift]
97.6 °F
2/26/2023 20:47[3PM-11PM shift]
97.4 °F
2/25/2023 23:41 [3PM-11PM shift]
97.8 °F
2/25/2023 12:45 [11 PM-7AM shift]
97.7 °F
2/25/2023 01:12 [11 PM-7AM shift]
97.4 °F
2/24/2023 17:13 [3PM-11PM shift]
97.5 °F
2/24/2023 15:38 [3PM-11PM shift]
97.2 °F
2/23/2023 20:25 [3PM-11PM shift]
97.4 °F
2/23/2023 15:03[3PM-11PM shift]
97.6 °F
2/23/2023 04:28[11 PM-7AM shift]
97.6 °F
2/22/2023 20:18[3PM-11PM shift]
97.6 °F
2/22/2023 14:37[7AM-3PM shift]
97.7 °F
2/22/2023 00:14[11 PM-7AM shift]
97.6 °F
2/21/2023 13:56[7AM-3PM shift]
97.4 °F
2/20/2023 22:18[3PM-11PM shift]
97.7 °F
2/20/2023 12:57[7AM-3PM shift]
97.9 °F
2/19/2023 23:25[3PM-11PM shift]
97.5 °F
2/19/2023 19:34[3PM-11PM shift]
97.9 °F
2/19/2023 13:43[7AM-3PM shift]
97.5 °F
A review of the TEMP documentation from 02/20/23 to 03/04/23 revealed that Resident #356's temperature was not documented 6 times on the 7AM-3PM shift, 5 times on the 3PM-11-PM shift, and 6 times on the 11PM-7AM shift.
On 10/25/23 at 09:12, the Registered Nurse Unit Manager (RN UM) stated that it was important for a resident's vitals to be monitored and documented on the Medication Administration Record (MAR) so the nurse would know how the resident was doing. She added that it was important to know the resident's vitals because if the resident had an elevated temperature, it would be a concern and could be a sign of infection.
NJAC 8:39- 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. On 10/18/23 at 10:05 AM, the surveyor observed incontinence care provided to Resident #13, who was in bed, the head of the bed was elevated, and the resident was able to answer questions. The surveyor observed the resident was unshaven and the facial area was covered with flakes. The CNA informed the surveyor that Resident #13 required total care for all ADLs, including to be fed all meals and the surveyor observed that there were no sacral wounds observed on the resident or reddened areas at that time. The surveyor observed while the lower extremities were exposed, and large number of dry callus type skin were observed on the bed.
On 10/19/23 at 8:30 AM, the surveyor observed Resident #13 in bed. The head of the bed was elevated. The resident was still unshaven, and the dry flakes were still observed.
On 10/20/23 at 10:30 AM, the surveyor returned to the room and observed the resident in the same position. The resident indicated that he/she had received care this morning.
On 10/20/23 at 10:45 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had Resident #13 on her assignment. The CNA revealed that she had been on vacation for two weeks, she reported to work this morning and observed some changes regarding Resident #13's care.
On 10/23/23 at 9:00 AM, the surveyor observed Resident #13 in bed. Upon inquiry, the resident stated that he/she had not received morning care yet.
On 10/23/23 at 9:20 AM, the resident informed the surveyor that he/she was itchy and would like to be washed. The surveyor alerted two CNAs of the request and the surveyor then observed the care provided to the resident. The surveyor along with the CNAs, who changed the resident had observed that Resident #13 was wearing two incontinent briefs, and both were saturated with urine and bulging from the back. The gown including the pulled sheet were also saturated and yellow stained. Resident #13 could not elaborate if he/she was cared for on the prior shift.
On the same day, at 9:52 AM, another surveyor entered the room with the Director of Nursing (DON). At the surveyor's request, the resident's incontinent brief was checked by staff. The resident was observed to be saturated with urine. Also observed were some scratch marks on the back and redness to the buttock area which was not observed on 10/18/23 during the surveyor's observations. The DON was asked about her expectations for incontinence care and the DON replied, better then what I just observed. The surveyor attempted to interview the resident a short while later, but he/she could not elaborate on any care received on 10/22/23 during the 11:00 PM-7:00 AM shift.
On 10/26/23 at 11:55 AM, the surveyor interviewed the DON regarding the observation of Resident #13 wearing two incontinence briefs. The DON stated Resident #13 should not have had two incontinence briefs on. The DON stated the facility's protocol was to provide incontinence care every two hours and as needed. The DON further stated that she would address the above concerns.
On 10/26/23 at 12:30 PM, the surveyor interviewed the CNA who cared for Resident #13 on 10/23/23. The CNA stated that she reported to work on 10/23/23 at 6:50 AM. The CNA stated she had to care for another resident that was saturated with urine at that time. The CNA stated, It was so bad, I had to call the clinical director to verify that care was not provided on the prior shift.
On 10/26/23 at 12:45 PM, the surveyor reviewed Resident #13's electronic medical record (EMR).
Resident #13's admission Record (AR) revealed, Resident #13 was admitted to the facility with diagnoses which included but were not limited to: Quadriplegia, Parkinsonism, unspecified, contracture left elbow, psoriasis and unspecified Dementia.
The Annual Minimum Data Set (MDS) assessment tool used by the facility to prioritize care, dated 07/18/23, revealed that Resident #13 was moderately cognitively impaired. Resident #13 received a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which referred to Activities of Daily Living (ADLs) revealed that Resident #13 was totally dependent on staff for care.
Review of the Care Plan for Resident #13 initiated on 02/08/18, included a Focus for ADL Self Care Performance Deficit related to: quadraparesis, limited physical mobility. The goal was for Resident #13 to maintain current level of function in bed mobility, transfers, eating , dressing, toilet use and personal hygiene through the review date. The interventions were to assist with feeding for all meals. Encourage to get out of bed. Resident #13 required the total assistance of one care partner for help with turning and repositioning while resting in bed. The care plan did not specify when staff were to provide care to the resident and the frequency for staff to turn, change and reposition the resident.
c. On 10/23/23 at 11:00 AM, the surveyor observed Resident # 14 in bed. The surveyor left the room to review the assignment sheet. The staff informed the surveyor that the assigned CNA was on break. The surveyor asked the Licensed Practical Nurse (LPN) and 2 random CNAs to assist with a care tour observation. The CNAs repositioned the resident to the left side. The surveyor observed that the resident's mid-back and buttocks were covered with feces. Feces were expelling from both side of the adult brief. Resident #14's sacral wound was covered with embedded feces. The staff informed the surveyor that morning care had not yet been provided. The resident was nonverbal and could not be interviewed.
On 10/23/23 at 12:30 PM, an interview with the LPN assigned to the Noble Unit, revealed that staff should have checked the resident at the start of shift to ensure that the resident was not soiled.
The surveyor then reviewed Resident #14's EMR which revealed the following:
Resident #14 was admitted to the facility with diagnoses which included but were limited to: Quadriplegia, heart failure, right and left-hand contracture, pressure ulcer of sacral region, stage 4, dependence on supplemental oxygen.
The Quarterly Minimum Data set (MDS) an assessment tool used by the facility to prioritize care dated 09/08/23, revealed that the resident was nonverbal and totally dependent on staff for all Activities of Daily Living (ADLs). All needs must be anticipated. Resident #14 required two persons physical assist for bed mobility and toilet use.
Resident #14's Comprehensive Care Plan dated 02/07/18 with a revision date of 03/09/21 reflected a focus for ADL Self Care Performance Deficit and is totally dependent on staff for all ADLS related to impaired mobility and cognition. The MDS also reflected that Resident #14 had a Texas (Condom Type) Catheter in place and was always incontinent of stool. The goal was for staff to anticipate and meet all Resident #14's needs with Target date of 09/21/2023. The interventions included: for personal hygiene: Resident #14 required total assistance with personal hygiene.
According to the MDS) dated [DATE], Resident #14 had a BIMS score of 00 out of 15 which was indicative of severe cognitive impairment.
On 10/23/23 at 12:30 PM, the surveyor interviewed the assigned CNA who stated that she did not check the resident that morning and she was not aware that the resident was not changed during the prior shift.
On 10/23/23 at 12:45 PM, the surveyor interviewed the RN/UM who stated that the facility's protocol was for all CNAs to check and provide incontinence care to their residents right after morning report. The UM further stated that she was not aware that some of the residents were not provided with incontinence care during the prior shift.
d. On 10/18/23 at 10:45 AM, the surveyor observed Resident #41 sitting in bed. The resident was wearing a brightly colored gown on and informed the surveyor that they were at the facility for rehabilitation.
On 10/19/23 at 12:55 PM, the surveyor observed Resident #41 in bed the same gown and the Resident stated that they had lunch already.
The surveyor reviewed Resident #41's EMR which revealed: the resident was admitted to the facility with diagnoses which included but were not limited to; adult failure to thrive, difficulty in walking, need for assistance with personal care and unspecified severe protein-calorie malnutrition.
On 10/20/23 at 10:29 AM, the surveyor returned to the unit and observed the resident in bed and was wearing the same gown.
On 10/20/23 at 10:35 AM the surveyor interviewed the Unit Manager (UM) who revealed that she was not aware that the resident had not been changed. The surveyor escorted the UM to Resident #41's room where the resident confirmed to the UM that they had not been changed and agreed to have their clothing changed.
On 10/23/23 at 9:42 AM, the surveyor observed Resident #41 in bed, their feet appeared dry and scaly with large amount of dry callus type skin on the bed. The surveyor escorted the DON to the room where we all observed the same. The surveyor asked the DON how the facility would address dry/scaly skin. The DON showed to the surveyor the cream at the Resident's bedside.
On 10/23/23 10:43 AM, the surveyor again visited the resident after AM care was provided. The resident stated, They put some cream on my legs today, it feels like a smoothing feeling, they had not done it for a while.
On 10/23/23 the surveyor reviewed Resident #41's EMR which revealed:
Resident #41 had a care plan initiated on 08/23/23 and last revised 08/24/23 for Self-Care Performance Deficit related to reconditioning. The goal was for resident #41 to improve current level of function in ADL tasks through the review date (09/06/23). The interventions were for Resident #41 to participate in Physical and Occupational Therapy to promote strengthening. Encourage to participate to the fullest extent possible with each interaction.
Resident #41 also had a care plan for impaired skin integrity related to physical mobility, anticoagulant use, dry skin to bilateral lower extremities, cellulitis to bilateral lower extremities. The goal was for Resident #41 to be free from skin injury. The interventions included: Avoid scratching and keep hands and body parts from excessive moisture. Keep skin clean and dry. Use lotion on dry skin. (The care plan was not being followed).
On 10/24/23 at 10:01 AM, the surveyor asked the UM who is directing the resident care to ensure it is happening. The UM stated, myself and the DON. The surveyor then interviewed the UM regarding her responsibilities. The UM stated that her role was to ensure the care was being delivered, communicate with staff, check assignment, and make rounds. The surveyor then asked the UM if she made rounds this morning to ensure the residents had received care. The UM replied, No
e. On 10/26/23 at 9:04 AM, the surveyor smelled a strong urine odor that permeated the hallway and detected a stronger odor while approaching Resident #73's room. The surveyor asked a CNA to assist the surveyor with a care observation. The CNA identified the urine odor as coming from Resident #73's room. The surveyor then entered Resident #73's room and observed the resident seating in the wheelchair eating breakfast. The top sheet was visibly soiled with dried feces. The resident's incontinent brief along with the pants were noted to be on the floor and were saturated with urine. The padding to protect the bed was observed on the floor saturated with urine. When inquired if the resident was assisted with incontinence care prior to breakfast, the CNA stated that the resident was not on her assignment. The surveyor then exited the room to review the daily assignment and identified the CNA assigned to the resident that day. The surveyor escorted the UM to the room where we all observed Resident #73 eating breakfast in the same manner and the UM stated that should not happened. The UM proceeded to remove the soiled/ saturated clothing from the floor and then stripped the resident's bed.
On 10/26/23 at 9:30 AM, the surveyor interviewed the CNA assigned to Resident #73 who stated that she did not serve breakfast to the resident.
On 10/26/23 at 10:00 AM the surveyor went to the kitchen and inquired regarding tray delivery in the morning. The kitchen aid provided the signed log that the breakfast trays was delivered on the Noble Unit (high side at 8:32 AM.
On 10/26/31 at 11:15 AM, the UM informed the surveyor that the activity staff delivered the tray to Resident #73.
On 10/26/23 at 12:30 PM, an interview with the activity staff revealed that she did not observe the soiled clothing on the floor. She stated that the resident was in bed, she did not realize that the sheet was soiled with feces. She did not comment on the urine odor that permeated in the hallway and became stronger while approaching Resident #73's room.
On 10/31/23 at 9:00 AM, during an interview with the UM, she stated that staff were to complete resident rounds, and check the resident for incontinence care prior to serving breakfast.
On 10/26/23 the surveyor reviewed Resident #73's EMR which revealed:
Resident #73 was admitted to the facility with diagnoses which included but were not limited to: major depressive disorder, mild intellectual disability, and alcohol dependence.
According to the Quarterly Minimum Data Set (MDS) dated [DATE], Resident #73 had a BIMS score of 15 out of 15 which was indicative of intact cognition. However, Resident #73 had intellectual disability and was unable to communicate their needs. When asked how he/she felt regarding eating breakfast without being changed, he/she just waived their hands and did not offer any comment.
The MDS also indicated that Resident #73 required limited assistance for Activities of Daily Living (ADL) and was occasionally incontinent of urine.
An additional interview with the CNA revealed that the resident did not use the bathroom during the night. The CNA added that the resident would be soaked with urine most of the time. She could not provide the rationale for not checking the resident for incontinence prior to breakfast.
Review of the Care Plan for Resident #73 initiated on 09/26/22 and last revised 09/26/22, revealed a focus for ADL self-care performance deficit related to limited physical mobility. The goal was for Resident #73 to maintain current level of function in ADL tasks through the review date 08/23/23. The interventions included: Encourage to participate to the fullest extent possible with each interaction. Resident to use bell to call for assistance. The care plan did not provide specifics to the direct care staff regarding the resident care.
The above concerns with incontinence care and hygiene were discussed during the survey and again on 10/27/23 again on. The DON indicated that the staff were in -serviced. The surveyor then asked the facility what had been done to improve the care, if any investigations were done regarding residents not being changed and turned and wound not being cared for after incontinence care was provided. The DON indicated she would continue to address the above concerns.
A review of the facility provided, ADL Care policy, revised 10/2023, included but was not limited to; Policy: to provide ADL care to residents requiring such assistance to ensure all ADL needs are met on a daily basis. Guidelines: 3. The level of assistance needed for any ADL activity will be included on the resident's plan of care. 5. The CP will include approaches to address distress triggers or behaviors and to facilitate completion of ADL tasks. 6. A variety of approaches will be utilized in assisting the dementia unit residents with ADLs.
NJAC 8:39-27.2 (g)
Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to consistently provide appropriate Activities of Daily Living (ADLs) care, for residents dependent on staff assistance for care, by failing to provide: a) nail care, b) assistance with dressing, c) personal hygiene care, and d) provide incontinence care, including prior to delivering a meal tray. This deficient practice was identified for 5 of 21 residents reviewed for ADLs (Resident #7, #13, #14, #41, and #73) on 2 of 2 resident care units (Noble and [NAME]). This deficient practice was evidenced by the following:
a. On 10/18/23 at 9:40 AM, Surveyor #1 toured the [NAME] unit and observed Resident #7 lying in his/her bed. The surveyor observed Resident #7's fingernails to be long and jagged with a brown substance under the fingernails. Resident #7's right hand ring finger had a long fingernail that was curled over and inward and in direct contact with the resident's fingertip.
On 10/19/23 at 10:42 AM, Surveyor #1 observed Resident #7 lying in bed with his/her fingernails visibly soiled, long, and jagged. Resident #7's right hand ring finger's fingernail was curled over and inward and in direct contact with the resident's fingertip.
A review of the medical record revealed Resident #7 had diagnoses that included but were not limited to; dementia, hypertension (elevated blood pressure), chronic kidney disease, and palliative care. A review of the quarterly Minimum Data Set (MDS) an assessment tool to facilitate care, dated 09/22/23, included but was not limited to; a Brief Interview for Mental Status (BIMS) documented as not conducted resident is rarely/never understood. Section G Functional Status documented that Resident #7 required extensive assistance with one-person physical assist for personal hygiene. Section E Behavior indicated that the resident did not exhibit rejection of care. A review of the person-centered comprehensive Care Plan (CP) included but was not limited to; a focus area revised 07/18/19, ADL (activities related to personal care, including bathing, dressing, getting in and out of bed, using the toilet and eating) self-care performance deficit with interventions that included to encourage the resident to participate; and a focus area revised 07/14/22 impairment to skin integrity related to fragile skin Interventions included avoid scratching and keep fingernails short; a focus are revised 06/20/23 hospice services and interventions that included to adjust provision of ADLs to compensate for the resident's changing abilities and to work cooperatively with the hospice team. A review of the My Daily Rhythm of Life form dated 10/23, included but was not limited to; I trust that you will assist me with all my needs (getting dressed, fixing my hair, shaving, cutting my nails) to get ready for the day or night.
On 10/19/23 at 11:21 AM, a Certified Nursing Assistant (CNA) #1 stated he was not Resident #7's care giver. He further stated that the hospice aide comes in the mornings to care for the resident.
On 10/19/23 at 11:35 AM, Surveyor #1 observed the Licensed Practical Nurse (LPN) #1 in Resident #7's room. The LPN was encouraging the resident who was feeding themselves lunch. LPN #1 exited the room.
On 10/19/23 at 12:17 PM, LPN #1 stated that she was not familiar with the resident as she usually worked on the other unit.
On 10/19/23 at 12:20 PM, CNA #2 stated she was familiar with Resident #7. She stated that the resident was total care, could move around in their bed, was somewhat alert, and that hospice usually came in the morning. CNA #2 entered Resident #7's room with the surveyor. When asked about the resident's nail care, CNA #2 stated, they need to be cut. She stated that hospice would clean the resident up in the morning. CNA #2 further stated that if hospice did not provide care, the facility staff would be responsible for Resident #7's care.
On 10/19/23 at 12:22 PM, LPN #1 entered Resident #7's room with the surveyor. When asked about the resident's nail care, LPN #1 stated, The nails need to be cut. I don't do that. When asked where the documentation of nail care would be, LPN #1 stated there was a book on the unit. LPN #1 showed Surveyor #1 the CNA book for resident care but was unable to locate any documentation for Resident #7.
On 10/19/23 at 12:30 PM, the Director of Nursing (DON) stated that the hospice staff was not the only staff responsible for the resident's care. She stated that nail care should be completed at least once per week and as needed. She further stated that filing the fingernails may need to be done by a nurse. The DON was in Resident #7's room with the surveyor. The DON stated the resident's fingernails were too long and should not look like that. The DON further stated that the reason would be for personal hygiene, skin integrity, and dignity. When asked about the documentation of fingernail care, the DON stated she had only been at the facility a few weeks and was not sure where the documentation would be located.
On 10/20/23 at 8:13 AM, the hospice aide stated that Resident #7 was total care which consisted of changing him/her but that he/she could feed him/herself. The hospice aide further acknowledged that Resident #7's fingernails needed to be trimmed but that she did not complete nail care for the resident.
On 10/23/23 at 8:44 AM, Surveyor #1 observed Resident #7 lying in bed. Resident #7 held both hands out, motioned with one hand that he/she was scratching the other arm and was simultaneously shaking his/her head to indicate no. When asked if he/she enjoyed his/her nails shorter and clean, the resident shook his/her head to indicate yes.
On 10/31/23 at 10:00 AM, upon interview, the DON stated that there was no documentation in the Progress Notes or in the Resident #7s Care Plan (CP) that the resident was resistant to nail care. She further stated that moving forward the facility would make multiple attempts to provide nail care, document any refusal, and update the CP as needed. The DON stated that the reason for keeping residents nails shorter and clean was for infection control purposes.

b. 1.) On 10/18/23 at 10:35 AM, Surveyor #2 toured the Noble Unit (High side), and observed Resident #13 in bed. Their eyes were open and the resident was able to communicate with the surveyor. A care tour was completed with the Certified Nursing Assistant (CNA) assigned to the unit and revealed the following: Resident #13 was unshaven, the skin on the face was covered with flakes. The lower extremities extended to the toes had areas that were covered with callus type skin areas with dry skin flakes which were noted on the bed also. The adult incontinent brief that the resident was wearing, was secured properly and was not soiled. The skin on the back and buttocks was intact and there were no open areas. No redness was noted. There was no documentation that Resident #13 had been non-compliant with care.
An interview with the CNA revealed that the resident required extensive assistance of two staff for bed mobility and transfer. The CNA added that the resident remained in bed and would refuse to get out of the bed. When the surveyor inquired about the dryness noted on the face and the lower extremities, the CNA stated, There is a skin remedy that could be applied.
On 10/19/23 at 8:45 AM, Surveyor #2 observed the resident in bed. The resident was unshaven and the skin was dry. An interview with the Registered Nurse Unit Manager (RN/UM) revealed that the podiatrist visited the resident on 10/18/23, and there were no new orders.
On 10/20/23 at 7:45 AM, Surveyor #2 observed the resident in bed, their eyes were closed, and the side-rails were elevated. The surveyor returned during lunch and observed the resident was in bed, unshaven, and large number of flakes and dry calluses were noted on the bed.
On 10/23/23 at 9:00 AM, Surveyor #2 returned to the unit and observed Resident #13 in bed. A CNA was at the bedside assisting Resident #13 with the breakfast meal. The resident was unshaven, and their face was covered with white flakes. The surveyor asked the resident if he/she would consider getting out of the bed today. The resident replied, Not really. I am itchy. I would like to get washed.
On 10/23/23 at 9:30 AM, after breakfast Surveyor #2 asked two CNAs to assist with a care tour. The surveyor observed that Resident #13 was wearing two incontinent briefs which were both saturated with urine. The gown that the resident was wearing was brown and stained. The pulled sheet was also brown and stained. Resident #13 was noted with scratch marks and redness to the sacrum and buttock areas. The Registered Nurse Unit Manager (RN/UM) was not available on the Noble Unit. The surveyor summoned another surveyor to the room along with the Director of Nursing (DON). On 10/23/23 at 9:52 AM, the DON in the presence of Surveyor #2 verified that incontinence care had not been provided on the prior shift. (11:00 PM-07:00 AM shift).
Surveyor #2 left the room and reviewed the 11:00 PM-7:00 AM staffing. The Census was 52, and only 1 CNA had been assigned to care for 52 residents.
On 10/26/23 at 11:00 AM, Surveyor #2 conducted a telephone interview with the CNA who worked the prior 3:00 PM-11:00 PM shift. The CNA revealed that she provided care to Resident #13 on 10/22/23 at 6:30 PM and applied two adult incontinent briefs on the resident. The CNA stated that at 6:30 PM, she had to change the sheets including the gown, as Resident #13 was saturated with urine. The CNA confirmed that she applied two adult incontinent briefs prior to finishing her shift. She informed the surveyor that she clocked out at 7:00 PM.
On 10/26/23 at 12:53 PM, Surveyor #2 conducted a telephone interview with the 3:00 PM -11:00 PM Registered Nurse (RN) who worked on the Noble Unit. The RN stated that two CNAs left at 7:00 PM, and the other CNA on the unit did not ask for assistance with care. He stated that staffing was lacking but he would assist if requested. He could not elaborate on whether incontinence care had been provided.
On 10/27/23 at 9:25 AM, Surveyor #2 checked Resident #13 again and observed the sacral redness was still present. A small open area to the left buttock was observed and there was no documentation regarding the newly open area which was not measured or provided a treatment.
On 10/27/23 at 9:32 AM, Surveyor #2 asked the RN/UM to measure the affected area. The sacrum measured: 9 centimeter (cm) x 8.5 cm. The left buttock measured 6.5 cm x 1.5 cm.
On 10/27/23 at 9:49 AM, Surveyor #2 conducted an interview with the RN/UM regarding the process to ensure that the residents were being cared for. The RN/UM stated that in the morning, she would get a verbal report from the 11:00 PM-7:00 AM shift and would follow up on anything important. She stated she would assign nurses and gave report to CNAs. The CNAs should check the residents as soon as they received their report. Residents' dependent on staff for care should be checked at minimum every two hours and as needed. The RN/UM further stated that she was not aware that some of the residents did not receive care during the 11:00 PM-7:00 AM shift. In the morning during report, she was informed that adequate staffing was an issue, and the night nurse did not elaborate further. She went on to state, if she was made aware of residents not having received care, she would have asked the CNAs to check and change the residents that were not changed during the prior shift immediately.
On 10/27/23 at 7:50 AM, Surveyor #2 conducted a face-to-face interview with the Licensed Practical Nurse (LPN) who worked the 11:00 PM-7:00 AM shift on 10/22/23. The LPN informed the surveyor that staffing had been an issue at the facility for the last 5 years. The LPN made it clear that on 10/22/23 during the night, they provided safety and answered call lights. When inquired regarding if she aided the CNAs to change and turn some of the residents, she stated, No, I was busy also. We provided safety that is all we could do. When asked if the administrative staff was aware of the staffing issue, she stated, yes.
On 10/27/23 at 8:40 AM, Surveyor #2 conducted a telephone interview with the CNA who cared for the resident during the 11:00 PM -7:00 AM shift on 10/22/23. The CNA confirmed that he did not provide incontinence care to the resident during the shift (8 hours). The CNA told the surveyor he was overwhelmed and could not get to the resident. He stated that for that shift he provided care for 30 residents. The CNA stated he provided safety and ensured the call lights were being answered.
On 10/27/23 at 10:55 AM, the DON revealed she was not aware that the facility had one CNA working for the 11:00 PM- 7:00 AM shift. She further stated, if she had been made aware, she would have call to get more staff. She added that she was not aware that incontinence care had not been provided. Her expectations were that all residents looked cleaned and received the care they deserve.
A statement from the LPN assigned to the 7:00 AM-3:00 PM shift indicated that she was informed by the CNA that Resident #13 was heavily saturated with urine and had 2 adult briefs on. She informed the DON and applied periguard cream to the skin. She rechecked the resident in the afternoon after care was provided and there was no skin breakdown observed.
On 10/27/23 Surveyor #2 reviewed Resident #13's EMR. The admission Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; Quadriplegia, Parkinsonism, unspecified, contracture left elbow, psoriasis and unspecified Dementia. Review of R 13's most recent annual MDS with an Assessment Reference Date (ARD) of 07/18/23, reflected that Resident #13 had moderate cognitive impairment. Resident #13 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS). Section V. Care Area Assessment (CAA) Summary, Section V 02000. CAA and Care Plan (CP) decision, documented cognitive loss, urinary incontinence, Activities of daily living, nutritional status, pressure ulcer, psychosocial well-being, and psychotropic drug use were triggered and identified to develop a care plan. Record Review (RR) of Resident #13 revealed that R #13 did not have a pressure sore. Section M which addressed skin condition, coded Resident #13 to be at risk.
Surveyor #2 reviewed Resident #13's Care Plan (CP), last reviewed/revised on 07/17/23. The CP had a focus area for impaired skin integrity related to healing Stage 4 Sacrum, incontinence and impaired mobility and chronic circulatory insufficiencies. The goal was for Resident #13 to develop no new areas of skin breakdown. The interventions included, keep skin clean and dry. Apply lotion on dry skin. Turn and reposition at frequent intervals while in bed. The care plan did not reflect that Resident #13 had a pressure injury to the sacrum extended to the buttocks areas.
A review of an interdisciplinary (IDCP) meeting conducted by the facility on 10/24/23, timed 15:44 (3:44) PM, reflected the following: IDCP met to review Quarterly plan of care. Resident had not had a significant change(s) in condition. Resident is compliant with care and takes his/her meds. Skin is intact at present . Despite the observed skin injury verified by the facility staff on 10/23/23, there was no documentation that the physician or the Resident Representative (RR) was informed of the issue with incontinence care resulting in skin injury. The care plan was not revised.
On 10/31/23 at 9:30 AM, the RN/UM informed Surveyor #2 that the resident was seen by the wound team and provided the following progress notes dated 10/30/23 timed 13:06 (1:06) PM. Resident was seen on wound round. Left buttocks redness resolved. Right buttock redness measuring 9 centimeter (cm) x 6.5 cm. Skin is intact. Treatment, Antifungal cream. Sacrococcyx MASD (Moisture Associated Skin Damage) measuring 0.3 cm x 0.5 cm x 0.1 cm. 100% epithelization tissue present. Scant serous drainage present. Treatment with Silvadene twice daily.
b. 2.) On 10/23/23 at 11:00, Surveyor #2 entered Resident #14's room with two CNAs for a care tour. The surveyor observed that Resident #14 was not provided with incontinence care. Large amount of secretions was noted on the sheet. Strong feces odor was noted in the room. During the care tour at 11:15 AM, the surveyor along with facility's staff observed Resident #14's sacrum and bottom which were covered with feces. Resident #14 had a stage 4 pressure ulcer that was covered with feces. The gauze covering the dressing was noted in the incontinent brief covered with feces exposing the open areas of skin that were also covered with feces.
On 10/23/23 at 12:30 PM, Surveyor #2 interviewed the CNA assigned to Resident #14. The CNA confirmed that she had not checked or changed the resident prior to go on break at 11:00 AM.
On 10/27/23 at 8:40 AM, Surveyor #2 conducted a telephone interview with the 11:00 PM-7:00 AM CNA. The CNA informed the surveyor that he checked the resident possibly at 6:00 AM and the resident was not soiled. When inquired about who assisted him with the resident, he stated, I did it alone. (Resident #14 required extensive assist of two persons for bed mobility. The surveyor then asked the CNA what he observed on the resident backside area, he stated there was nothing in place. Resident #14 had a wound and a protective dressing was to be in place but was missing per the CNA.
On 10/27/23 the 11:00 PM- 7:00 AM CNA provided the following statement, I was the only CNA on the unit last night. I did rounds, offered water to the residents but did not provide incontinent care. I was alone and it was difficult. I did not ask for assistance from the nurse. It just escaped my mind. I must be honest, I made rounds, offered water but I did not change or check the residents.
A telephone statement from the LPN dated 10/25/23, indicated the following: I was the only nurse and he was the only CNA. I helped the CNA with residents that he could not change alone. I have one CNA who could not do the entire floor. The LPN stated that at 6:00 AM, she observed that Resident #14 was in bed, appeared to be comfortable and he/she was covered. I did not noticed any odor during my rounds.
The surveyor reviewed Resident #14's clinical record. The admission Face Sheet reflected that Resident #14 was admitted to the facility with diagnoses which included but were not limited to; Quadriplegia, heart failure, right and left hand contracture, pressure ulcer of sacral region, stage 4, dependence on supplemental oxygen. The Quarterly Minimum Data set (MDS) an assessment tool used by the facility to prioritize care dated 09/08/23, revealed that the resident was non verbal and totally dependent on staff for all Activities of Daily Living (ADLs). All needs must be anticipated. Resident #14 required two persons physical assist for bed mobility and toilet use. Resident #14's Comprehensive Care Plan dated 02/07/18, with a revision date of 03/09/21, reflected a focus for ADL Self Care Performance Deficit and is totally dependent on staff for all ADLS related to impaired mobility and cognition. The goal was for staff to anticipate and meets all Resident #14's needs with Target date of 09/21/2023. The interventions included: for personal hygiene: Resident #14 required total assistance with personal hygiene.
Resident #14 also had a focus for impairment to skin integrity on sacrum related to stage 4, incontinence, immobility. The goal was for the wound to show sign and symptoms of healing through the review date of 09/21/23. Interventions included: Daily skin checks with care initiated 02/07/18. Follow facility protocols for treatment of injury. Identify causative factors and eliminate/resolve where possible. keep skin clean and dry revision date 02/07/18. Air mattress to relieve pressure to pressure points. (02/07/18). Turn and reposition every 2 hours. Weekly skin assessments by licensed nurse with a revision date of 02/07/18.
On 10/20/23 at 11:15 AM, Surveyor #2 conducted a face to face interview with Resident #14's Representative (RR). The RR revealed concerns with the care delivery. The RR stated that the facility did not have enough staff to care for the residents. The RR went on to state that during visits, the RR would observe the resident soiled and laying in bed with a soiled brief for long periods of time and could not find any available staff to change the resident. The RR stated this had been discussed with the RN/UM and the prior Director of Nursing.
On 10/23/23 at 11:00 AM, Surveyor #2 conducted a care tour with two CNAs assigned to Noble Unit (high side).
On 10/23/23 at 11:15 AM, in the presence of the LPN assigned to the unit and two CNAs, Surveyor #2 observed that Resident #14 was heavily soiled with feces. The adult brief and the pads were covered with feces. The CNA assigned to the resident was on break and could not be interviewed.
On 10/23/23 at 12:30 PM, the surveyor interviewed the CNA assigned to the 7:00 AM- 3:00 PM. The CNA revealed that she reported to work at 6:50 AM, and had not yet checked the resident during the shift. Statements from the CNA who worked the 11:00 PM-7:00 AM shift indicated that incontinence care was not provided during the prior shift because he was the only CNA.
Resident #14 was totally dependent on staff for care. Resident #14 was not provided incontinence care for over 12 hours. During wound care on 10/23/23 at 11:30 AM, a new open area of skin was noted on the right buttock which was not measured by the nurse. The nurse dressed the wound with Periguard and secured the wound with the adult brief. A review of the indication for Periguard (skin barrier) indicated the following: Do not use on open and punctured wound. The LPN did not have an order to apply Periguard to the open wound.
On 10/23/23 at 12:40 PM, during an interview with the Director of Nursing, she stated that the nurse should have applied a wet to dry saline dressing until she got an order from the physician.
Review of the skin evaluation dated 10/23/23, provided by the facility, revealed that the resident had a stage 4 pressure ulcer to the sacral area. The pressure injury to the left buttock was identified on 10/23/23, during care and wound treatment. Review of the Physician Order Sheet (POS) dated 10/01/23, reflected an order to cleanse the sacral wound with saline and pat dry. Apply Calcium Arginate Silver to wound, cover with gauze and dry dressing daily. Silvadene 1% (Silver Sulfadiazine) was to be applied to the right buttock. There was no order to apply Periguard to the left and right buttocks.
A Progress Notes dated 10/23/23 timed 6:20 PM, revealed the following: Left buttock MASD measuring 9.0 centimeter (cm) 4 cm x 0.1 cm. Right buttock MASD superior MASD measuring 1.0 cm x 0.5 cm x 0.1 cm. Right buttock inferior MASD measuring 1.0 cm x 0.5 cm x 0.1 cm. Treatment ordered with Silvadene.
The facility provided, Skin Evaluation dated 10/23/23, indicated that a new issue was identified: Noted with stage 4 sacrum, MASD to left buttock and reopening of MASD to right buttock. A review of the Comprehensive Care Plan did not include documentation of the skin injury identified on 10/23/23. The rationale for not revising the care plan after the pressure injury was identified was not provided.
The above concerns were discussed with the administrative staff during the survey and again on 10/30/23, during the pre-exit conference. The DON added that she started the investigation and would provide the investigation on 10/31/23. The DON provided the investigation on 10/31/23. All staff involved with Resident #13's and #14 care on 10/22/23 and 10/23/23, were interviewed. The 3:00 PM-11:00 PM shift confirmed she provided care to Resident #13 at 6:30 PM, and applied 2 adult briefs on the resident. The 11:00 PM-7:00 AM CNA provided a statement which reflected that he did not provide incontinence care to the residents. Resident #13 and #14 did not receive care according to their plan of care. The resident (#13)was last changed at 6:30 PM on 10/22/23.
On 10/31/23 at 11:30 AM, in the presence of the survey team, the DON acknowledged that based on the investigation and her observation specifically for Resident #13, incontinence care was not provided. The DON further stated that all residents dependent on staff for care should have been checked and changed every 2 hours and as needed.
A review of the facility provided, Abuse, Neglect and Explotation, policy revised 09/2022, included but was not limited to; Policy: to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Neglect is defined as the failure of the facility to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
A review of the facility provided, Abuse, Neglect and Mistreatment of the Elderly Policy, undated, included but was not limited to; B. Prevention: 4. adequate staffing levels are maintained at all times so that the needs of residents are met. D. Identification: 2. examples of neglect may include: a. pressure sores, b. poor personal hygiene, e. dirty, soiled bed, fecal or urine odor.
A review of the facility provided, Certified Nurse Aide position summary, undated, included but was not limited to; Responsibilities: handles and attends to residents in a manner conductive to their safety and comfort; bathes the resident cleans and cuts fingernails and gives shampoos; and reports changes in resident's condition to the charge nurse or supervisor.
A review of the facility provided, Licensed Practical Nurse position summary, undated, included but was not limited to; Responsibilities: takes an active role in direct resident assessment and care; assesses each resident daily and implements a change in the course of action as needed; maintains accurate resident care records and documents pertinent data; ensure that residents receive the highest quality of service .promoting dignity and respect;
A review of the facility provided, Registered Nurse, position summary, undated, included but was not limited to; takes an active role in direct resident assessment and care; must have the ability to recognize and identify symptoms and to make decisions quickly in emergencies; assess each resident daily and implements a change in the course of action as needed; ensures that residents and families receive the highest quality of service .promoting dignity and respect.
A review of the facility provided, Director of Nursing Services, position summary, undated, included but was not limited to; monitors nursing care to assure that all residents are treated fairly, with kindness, dignity and respect; completes daily rounds on the unit to observe residents and determine if nursing needs are being met; reviews nursing progress notes to ensure they are informative and descriptive of the nursing care provided; and provides direction to the nursing staff.
NJAC 8:39-27.1 (a), 27.2 (c)(d)(g)(h)(j)
Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure: a) a resident assessment was completed to rule out injury, and the physician was immediately notified when staff witnessed a resident who banged finger hard on a door frame and yelled ouch. This resulted in a delay in treatment for one and a half hours, and the resident experienced pain and was subsequently diagnosed with a fracture of the third finger left hand, and b) appropriate incontinence care and related services were provided for two residents dependent on staff for care. The deficient practice was identified for 1 of 2 residents reviewed (Resident #52) for accidents and 2 of 6 residents who were dependent on care and reviewed for provision of incontince care (Resident #13 who did not have a sacral pressure ulcer prior to not being providedd with incontinence care for 15 hours which then resulted in a facility acquired pressure ulcer, and Resident #14 who had not been provided with incontinence care for over 12 hours and was left saturated with urine and embedded feces and had a Stage IV Pressure Ulcer. and Resident #14) and was evidenced by the following:
a.) On 10/18/23 at 9:46 AM, the surveyor observed Resident #52 in his/her room. The resident looked at the surveyor but did not speak to the surveyor. The resident had one shoe on and was wearing a non-skin sock on the other foot.
On 10/19/23 at 11:07 AM, the surveyor observed Resident #52 wearing non-skid socks and ambulating around the nurse's station with staff holding his/her arm for assistance. Resident #52 was easily redirected.
On 10/20/23 at 7:54 AM, the surveyor observed the resident in a wheelchair in front of the nurse's station.
A review of the EMR revealed that Resident #52 had diagnoses which included but were not limited to; other symptoms and signs involving the musculoskeletal system, history of falling, vascular dementia, and muscle weakness.
A review of the most recent quarterly Minimum Data Set (MDS) an assessment tool used to facilitate a resident's treatment, dated 07/01/23, included but was not limited to; was rarely or never understood so a Brief Interview for Mental Status (BIMS) could not be conducted, severely impaired cognition, continuous behaviors of inattention and disorganized thinking, wandering daily, required limited assistance of at least one staff member when ambulating in the hallway, and as having had a fall with injury since admission or readmission.
A review of the Order Summary Report included a physician's order dated 02/02/23, for Tylenol (used for pain) 325 milligrams (mg) give two tablets by mouth every 6 hours as needed for pain. An order dated 08/20/23, to refer the resident to a hand surgeon for a fracture of the third finger left hand.
A review of the August 2023, Medication Administration Record (MAR) included but was not limited to; the Tylenol 325 mg order to administer two tablets every 6 hours for pain. There was no documentation on 08/20/23, that Tylenol had been administered for pain.
A review of the person-centered comprehensive Care Plan (CP) included but was not limited to; a focus area of being at risk for falls with actual falls on 08/31/23 and 09/23/23. Interventions included but were not limited to; ensure the resident is wearing appropriate footwear, review information on past falls and attempt to determine cause of falls .pain management. A focus area of having a potential for pain. Interventions included but were not limited to; monitoring/record pain characteristics, monitor/record/report any s/sx (signs and symptoms) of non-verbal pain (grunting, moaning, yelling out).
On 10/26/23 at 12:00 PM, during an interview with Surveyor #1, the Licensed Practical Nurse (LPN) #1 stated he was familiar with Resident #52 and remembered the incident on 8/20/23. LPN #1 stated he saw the resident getting up and hit his/her left hand pretty hard on the door frame. LPN #1 stated he had not documented what happened in the electronic medical record (EMR), and stated I went to get [him/her] and I assisted [him/her] to the a chair and stated Resident #52 yelled ouch when the resident hit [his/her] hand on the door frame. LPN #1 stated, I sat him/her back in his/her chair and took his/her vital signs. LPN #1 then stated, It was an hour and a half later that the resident's finger was discolored and the resident was in pain. When the surveyor inquired if an assessment was immediately conducted upon observing the resident hit [his/her] hand or any care that had been provided to Resident #52, the LPN stated, I don't have the documentation of assessing the resident's hand. LPN #1 stated he only placed Resident #52 in a chair. LPN #1 confirmed that he had not contacted the physician at the time the resident hit [his/her] hand and stated he should have maybe done something. When inquired to LPN #1 what should be done when a resident has a potential injury, the LPN stated further the process would have been to assess the resident, call the nursing supervisor or Director of Nursing (DON), call the physician, and notify the family. LPN #1 stated that an assessment should have been completed and documented, and confirmed it had not been completed.
A review of the Progress Notes (PN) revealed documentation by the LPN #1 dated 08/20/23 at 9:50 AM, revealed Resident c/o [complaint of] pain about middle finger of left arm, noted discolored, cold to touch, painful at touch. Vitals stable, called placed to md [medical doctor], new order for x ray of the middle finger of the left hand for c/o pain and discoloration.
On 10/26/23 at 12:30 PM, the Medical Director (MD) during a telephone interview with the surveyors, stated that she was Resident #52's physician. The MD stated she was aware Resident #52 had falls but could not remember everything about the 08/20/23 incident. The MD stated her expectations would be that if a resident fell, the staff should tend to the resident, call the physician, and describe the injury so she would know the course of action. The MD further stated that if a staff member witnessed the resident hit their hand, she would expect a call immediately. She accessed her EMR and informed the surveyors that she was informed the finger was fractured on 08/23/23, three days ago and the staff was not sure how the injury occurred.
On 10/27/23 at 10:46 AM, the above concern was addressed with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations, and the Regional Clinical Nurse (RCN).
On 10/31/23 at 8:21 AM, during an interview with the surveyor, LPN #2 stated if she witnessed a resident fall into something or injury themselves, she would assess their whole body, write an incident report, but give first aid immediately in case the resident had pain and next call the doctor.
On 10/31/23 at 8:22 AM, LPN #3 stated if she witnessed a resident injury themselves, she would immediately assess the resident and provide first aid and inform the doctor. She stated she would provide first aid definitely right away to protect the resident.
On 10/31/23 at 10:24 AM, the Regional Clinical Nurse (RCN) stated LPN #1 should have called the doctor, used ice and pain management immediately given the resident yelled ouch. She stated the expectation would have been to assess for pain and administer the already ordered Tylenol for pain.
The facility had no additional documentation or policies to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure a.) a resident who was dependent on supplemental oxygen via a tracheostomy was provided with respiratory services to maintain their oxygenation status according to the physician's order and the facility's policy, b) that a resident received oxygen as ordered by the physician, and c) oxygen related treatments were provided in a manner to prevent the spread of infection. This deficient practice was identified for 2 of 2 residents reviewed for respiratory services, Resident #14 and #92 and was evidenced by the following:
1.) On 10/18/23 at 09:10 AM, the surveyor observed Resident #14 in bed. The resident was non verbal. The resident had a tracheostomy (a surgical opening in the anterior neck providing an alternate airway for breathing), and was connected to an oxygen concentrator. The concentrator was set to deliver oxygen at 4 liters per minute via the trachea collar. The surveyor observed the label on the tubing dated 08/10/23.
The following observations were made of Resident #14:
10/18/23 at 9:10 AM, Resident #14 was observed lying in bed with humidified oxygen at 4 liters per minute via the trach collar. The date/label on the oxygen tubing reflected that the oxygen tubing was last changed 08/10/23.
On 10/19/23 at 9:33 AM-Resident #14 was observed lying in bed with humidified oxygen at 4 liters via the trach collar and the oxygen concentrator. The tubing dated 08/10/23.
On 10/19/23 at 11:33 AM-Resident #14 was observed lying in bed with humidified oxygen at 4 liters per nasal cannula via oxygen concentrator. The date on the tubing indicated that the tubing was changed 08/10/23.
On 10/20/23 at 07:17 AM, the surveyor (#1) reviewed the New Jersey Universal Transfer Form (NJUTF) dated 07/01/23 which revealed that the resident was sent to the hospital for sepsis, fever and vomiting on 06/23/23 and readmitted on [DATE].
The physician order dated 07/02/23 was for Resident #14 to receive O2 inhalation at 45% 6 L PM via trach humidifier every shift for SOB to maintain SPO2 (Oxygen Saturation) Oxygen at or greater that 92% with O2 inhalation.
On 10/20/23 at 7:15 AM an interview was conducted with the Registered Nurse (RN) #1 who worked the 11:00 PM-7:00 AM ). Nurse #1 confirmed she was the nurse responsible for Resident #14. Nurse #1 stated the oxygen tubing, and the humidification bottle was to be changed every week on Wednesday and as needed. Nurse #1 reported the weekly change was completed by the 11:00 PM-7:00 AM nurse and it was documented on the Treatment Administration Record (TAR). Nurse #1 reviewed the TAR and stated there was no documentation on the TAR of the tubing being changed and it must have accidentally been omitted when the resident returned from the hospital (07/04/23).
On 10/20/23 at 8:03 AM, a surveyor (Surveyor #2) entered Resident #14's room and observed the resident in bed with eyes open and the resident did not respond to the surveyor. There was an blue oxygen concentrator machine observed upon entering the room and there were visible beige and various colored splatters embedded on the machine. Next to the visible splatter, an oxygen tubing that delivered oxygen to the resident, had a piece of tape on it that had 8/10/23 written on it. There was also a humidifier machine that was observed with caked with on beige debris and was in on the nightstand. The surveyor observed a nurse enter the room, she identified herself as RN #1 for the 11:00 PM to 7:00 AM shift and stated she was the night supervisor. The surveyor brought her attention to the oxygen concentrator and she knelt down to read the label, looked at the date and stated, oh, then looked at the humidifier and stated a little stained. At that time the night supervisor RN left the room and the day shift RN entered. The surveyor brought her attention to the concentrator and the date. The day RN stated, that needs to be cleaned for infection control, asked if it was clean and stated, no. The surveyor then asked the RN about the tubing that was on the opposite nightstand, into a drawer and on the floor, and was attached to a white machine. The RN stated, no, the way this it, it should not be on the floor it it is infection control, and I will replace it. The RN stated that the tubing should be rapped up and put into the drawer.
On 10/20/23 at 8:13 AM, the RN responded to Surveyor #2 about the tubing dated 8/10/23 and stated it should be changed weekly on the 11-7 shift.
On 10/20/23 at 8:15 AM, the surveyor interviewed the Licensed Practical Nurse ( LPN) regarding the label on the tubing. The LPN stated that the oxygen tubing was scheduled to be changed on the 11:00 PM -7:00 AM shift and she did not look at the tubing. She further stated that the order to change the tubing should have been entered into the Electronic Patient Point of Care (EPOC). The LPN and the RN both reviewed the October EPOC and confirmed that the order to change the oxygen tubing was not populated into the Physician Order Sheet (POS). Further review of the POS for August, September and October did not include an order to change the oxygen tubing.
On 10/20/23 at 9:46 AM, surveyor #2 interviewed the Director of Nurisng (DON) regarding the soiled humidifier and who was responsible for cleaning, in addition to the tubing dated 08/10/23. The DON stated that nursing should have cleaned the humidifier, not housekeeping.
On 10/20/23 at 9:51 AM, the surveyor reviewed the Physician Order Sheet (POS ) dated 10/01/23, with the Unit Manager. The UM revealed that the resident did not have an order for the oxygen tubing to be changed. When asked regarding the facility's policy, the UM stated, It is a blanket statement that all oxygen tubing to be changed weekly on the 11:00 PM- 7:00 AM shift. She was not too sure if the facility had a policy. The UM further stated, Because there was no order, that does not mean it should not have been done.
On 10/20/23 at 11:15 AM, the LPN on the medication cart reviewed the POS and informed the surveyor that the order to change the oxygen tubing was not populated after the last admission. When inquired regarding monthly Recap ( Reviewing the new MARS against the physicians orders to ensure accuracy before the start of the next month), the LPN stated that the 11:00 PM-07:00 AM shift was responsible to check the orders. The LPN indicated that she was not sure if any other shift will review the chart for missing orders. The LPN stated, They have a supervisor on the 11:00 PM-7:00 AM shift. I do not know.
On 10/20/23 at 11:30 AM, during an interview with the Director of Nursing (DON) she stated that she was made aware of the date on the oxygen tubing. The DON was unable to provide documented evidence that the oxygen tubing had been changed prior to 08/10/23. The DON did not speak to whether the resident's order for oxygenation therapy/or method of oxygen delivery was verified upon readmission from the hospital.
A review of the Physician Order Sheet (POS) for October 2023 reflected an order dated 07/02/23 to administer oxygen at 45%/6 liter per minute via trach humidifier every shift for shortness of breath. Maintain oxygen saturation at or greater than 92% with oxygen inhalation.
A review of the Treatment Administration Record did not include an order to change the disposable inner cannula, respiratory tubing of the tracheostomy.
A review of the resident's individualized care plan reflected that the resident has Tracheostomy related to impaired breathing mechanics, Chronic Obstructive Pulmonary Disease, Anoxic brain injury. Interventions included to administer humidified oxygen as ordered by the physician, on at all times while the resident was resting in bed. (The intervention was not implemented. Resident #14 was observed with oxygen titrated at 4 liters per minute for 3 days. Oxygen saturation was verified to be at 92% on 10/20/23).
The above concerns were discussed with the administrative staff on 10/20/23 and again 10/30/23. The DON stated that her expectation was that the oxygen tubing be changed weekly and documented in the Treatment Administration Record (TAR).
2.) On 10/18/23 at 9:56 AM, the surveyor was conducting a tour on the Noble Unit and observed Resident #98, awake and alert, sitting in a high back chair in their room and was being administered oxygen (O2) by way of (via) nasal cannula at 3 liters per minute (3 L/min). The surveyor observed that the O2 was hooked up to an oxygen concentrator located next to the resident's bed. This was observed again on 10/19/23 at 10:57 AM
The surveyor reviewed the Resident's Physician Order Summary (POS) which reflected orders for:
- O2 at 2 l/min via nasal cannula every day shift for SOB ( Shortness of breath) dated 10/06/23.
On 10/20/23 at 10:21 AM, the surveyor observed Resident #98 sitting in a high back chair wearing oxygen via nasal cannula at 3L/min. The resident stated it should be on 3 L/min. At that time, the surveyor accompanied by the assigned Licensed Practical Nurse (LPN), entered Resident #98's room. The LPN confirmed that the resident was wearing oxygen via a nasal cannula set to 3L/min. The LPN then checked the Physicians Order (PO) in the Electronic Medical Record (EMR) and stated the order says 2 L/min and it should be on 2 L/min. The LPN stated that when a resident was ordered oxygen the nurse should check that the oxygen was set at the level that the doctor had ordered.
During an interview with the surveyor on 10/20/23 at 10:39 AM, the Registered Nurse Unit Manager (RN UM) stated that when a resident is on oxygen, the nurses should verify the oxygen physicians order including the the right flow and the right route. The nurses should document in the resident's Treatment Administration Record (TAR) and in the progress notes in the EMR. The RN UM stated that if the resident was not wearing the prescribed oxygen, then the nurse should assess the resident for any SOB or respiratory distress, notify the doctor and obtain a new physicians' order. The RN UM further stated that the facility had a respiratory therapist who would come to the facility weekly to evaluate all residents on respiratory therapy. The surveyor reviewed the EMR and the paper chart and was unable to find any respiratory therapy notes for Resident #98.
According to the admission Record, Resident #98 was admitted to the facility with the diagnoses which included but was not limited to Acute Respiratory Failure with Hypoxia (loss of oxygen), and Chronic Obstructive Pulmonary Disease,
The admission Minimum Data Set (MDS-an assessment tool utilized to facilitate the care of a resident), dated 10/12/23, indicated that the resident was cognitively intact and required moderate assistance with mobility and transfers. The MDS also indicated that the resident was on oxygen.
The surveyor reviewed the October 2023 Treatment Administration Record (TAR) which reflected a physician's order for O2 at 2 L/min via nasal cannula every day shift for SOB.
On 10/23/23 at 9:41 AM, the surveyor observed Resident #98, awake and alert, sitting in a high back chair wearing oxygen via a nasal cannula at 3 L/min. Again, the resident stated It should be at 3 L/min.
On 10/23/23 at 9:56 AM, the surveyor reviewed Resident #98's POS and the physician order date 10/06/23 was still active for oxygen at 2 L/min via nasal cannula every day shift for SOB.
During an interview with the surveyor on 10/24/23 at 10:17 AM, the Director of Nursing (DON) stated during the nurses' rounds, the nurses should monitor the resident's oxygen saturation and lung sounds as well as that the level of oxygen on the oxygen concentrator matches the physician's order. The nurse should document the oxygen level in the TAR and in the progress notes. If the nurse observed the resident was not wearing the correct oxygen per physician's order , I would expect them to assess the resident and call the doctor to clarify the physician order. When the resident returned from the hospital, I would have expected a respiratory therapist to evaluate the resident.
On 10/24/23 at 12;31 PM, the surveyor observed Resident #98, awake and alert, sitting in a high back chair wearing oxygen at 3L/min via nasal cannula. The resident stated, what it's on, 2 L/min? When asked if the resident adjusted the oxygen level, he/she stated No, I don't touch it, the nurses adjust the oxygen level on the concentrator.
During an interview with the surveyor on 10/24/23 at 12:35 PM, the LPN stated that the nurse has to make sure that the resident is wearing the correct oxygen level that was prescribed by the doctor. The LPN stated that the resident kept adjusting the oxygen level to 3 L/min because he/she thought he/she felt better on 3 L/min. We have to keep educating him/her. The LPN stated that the nurse should have documented in the progress notes that the resident adjusted the oxygen level and that education was provided to the resident.
The surveyor reviewed the October 2023 progress notes which did not indicate that the resident was observed wearing oxygen at 3L/min via nasal cannula, the doctor was notified, or education was provided.
A review of Resident #98's care plan revealed an intervention to give oxygen therapy as ordered by the physician. The care plan did not include that the resident was adjusting his oxygen level, noncompliance of the oxygen level or education was provided to the resident.
On 10/24/23 at 12;39 PM, the surveyor observed the Respiratory Therapist (RT) in Resident's # 98s room. At that time, the surveyor interviewed the RT who stated that this was the first time evaluating the resident and she was just consulted for him/her. She stated that her role was to assess the resident, review what level of oxygen the resident should be ordered according to the assessment and provide education to the resident.
A review of the facility's policy titled, Oxygen Administration, reviewed 09/2023, revealed oxygen was to be administered under orders of a physicians except in cases of an emergency. The staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy .Staff shall notify the physician of any changes in the residents condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. The policy als0 included to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.
NJAC 8:39-19.4(a)

Based on observation, interview and review of facility documentation, it was determined that the facility failed to: a.) ensure that staff were competent and appropriate care was provided for the hemodialysis (the filtration of waste when the kidneys are no longer able to do so) access sites, and staff were trained to differentiate between an AV (Arteriovenous) Fistula (an abnormal connection between an artery and a vein), and a Permacath (tunneled hemodialysis catheter) a flexible tube used for dialysis treatment, and b.) ensure that staff were trained to properly assess, and document care of the hemodialysis access sites which includes the auscultation/palpation of the AV fistula for Bruit (an abnormal sound generated by turbulent arterial blood flow) and Thrill (a palpable sensation of blood flow) to assure adequate blood flow and to monitor the hemodialysis access site for bleeding, signs of infection and pain. This deficient practice was identified for 1of 4 residents (Resident #90) reviewed for hemodialysis treatment and was evidenced by the following:
On 10/19/23 at 10:55 AM, the surveyor observed Resident #90 laying in bed awake, watching television with snacks on his/her bedside table. Resident #90 stated that he/she had been going to hemodialysis for a while. The resident stated that he/she used to have a catheter in his/her chest, while pointing to his/her right side of chest and neck area, but now had a fistula in his/her right arm, pointing to his/her right upper arm. The surveyor did not observe any catheter or permacath in resident's right chest wall. The surveyor observed 2 bulging sites on the resident's right upper arm. There were no dressings on the 2 sites and some bruising was noted. Resident #90 stated it hurts to get the needles put in. The resident added that he/she goes to hemodialysis every Monday, Wednesday and Friday and takes a communication binder to his/her treatments, which the facility staff kept at the nurse's desk.
A review of the admission Record reflected that Resident #90 was admitted to the facility with diagnoses which included, but were not limited to, acute ischemic heart disease (sudden reduction or blockage of blood flow to the heart), end stage renal disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and anemia (a condition in which the blood doesn't have enough healthy red blood cells and leads to reduced oxygen flow to the body's organs.)
A review of the Quarterly Minimum Data Set (MDS) an assessment tool used by the facility to prioritize care dated 08/18/2023, revealed that Resident #90 received a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of intact cognition. Section O of the MDS titled Special Treatments, Procedures, and Programs revealed that the resident received dialysis outside the facility.
A review of Resident #90's physician's orders dated 06/08/2023 indicated: Monitor AV shunt to right upper chest wall for signs and symptoms of infection and bleeding every shift for monitoring.
A review of Resident #90's Dialysis Communication Records in the resident's dialysis communication binder dated 10/02/2023 to 10/18/2023 revealed on each record documentation: Pre-dialysis (sending facility nurse) Graft Site: intact. The pre-dialysis documentation did not indicate type of access, location of access and what kind of access assessment was performed by the nurse. Post-dialysis (Receiving Facility nurse) Graft Site: intact. The post-dialysis documentation did not indicate type of access, location of access, and what kind of access assessment was performed by the nurse.
A review of Resident #90's Medication Administration Record (MAR) dated 10/01/2023-10/31/2023 indicated: Monitor AV shunt to right upper chest wall for signs and symptoms of infection and bleeding every shift for monitoring. Surveyor observed check marks for each shift from 10/01/2023 to 10/23/2023 indicating documentation that nurses administered or signed off for monitoring of the resident's access.
During an interview with the surveyor on 10/19/23 at 11:27 AM, the assigned Licensed Practical Nurse (LPN) for Resident #90 stated that the resident had a fistula in his/her chest, while pointing at his arm, and that the thrill and bruit must be checked, while pointing at his chest, before and after the resident's dialysis treatment and then documented.
During an interview with the surveyor on 10/19/23 at 11:41 AM, another LPN on the same unit stated that the protocol for dialysis residents was to monitor their dialysis site for thrill and bruit. The LPN demonstrated on her arm with 2 fingers how to feel the bruit, and added that if it was in the neck, she would check for swelling or bleeding and can change the dressing if needed. The LPN stated that the facility educated the staff regarding monitoring and notifying the doctor or the dialysis center of any problems or issues.
During an interview with the surveyor on 10/19/23 at 11:42 AM, the Registered Nurse/Unit Manager (RN UM) stated that her expectations of the staff for hemodialysis residents was to take vital signs, assess and monitor the access site, and check the fistula in the arm for thrill and bruit, while pointing to her chest. The RN UM stated that there should be a physician order to listen and check the thrill and bruit of a fistula. The RN UM revealed that the staff were educated on how to care for hemodialysis residents and how to monitor and check for the thrill and bruit of a fistula.
During an interview with the surveyor on 10/19/2023 at 12:03 PM, an LPN from another unit stated that the process for a dialysis resident was to check the vital signs and monitor the site. The LPN added that should also check the thrill and bruit of the fistula. The surveyor asked if the nurse used a stethoscope to check for thrill and bruit of a fistula? The LPN responded, No. The LPN demonstrated by placing her 2 fingers on her upper arm and stated to feel for the pulsating fistula. She also stated that if a resident had a catheter in the neck that staff do not touch the catheter and to only check for bleeding or swelling at the site and that the dressing is okay.
A review of Resident #90's care plan indicated a focus that Resident #90 needed hemodialysis related to renal failure. -New AV fistula created 06/06/2023, -Right Chest Permacath with an initiation date of 02/11/2023 and a Revision date of 06/08/2023. The care plan did not clearly indicate the resident's type of access and location of the access. Interventions included but not limited to check and change dressing at access site per MD's (medical doctor's) order and document. The interventions did not include checking of thrill and bruit of the fistula as stated by the nursing staff interviewed by the surveyor.
A review of the Facility Assessment, with an effective date of 11/2017, indicated that residents requiring hemodialysis are treated at the dialysis center in the community. Care and treatment for these residents is a joint effort of the facility and the dialysis center staff. The facility assessment would include staff competencies that are necessary to provide the level and types of care needed for the resident population.
A review of the facility's Dialysis Policy ,with a revision date of 03/2023, indicated that the nurse will ensure the type and location of the dialysis access device in the resident's medical record. In addition, monitoring for patency of the dialysis access will be documented in the resident's medical record.
A review of the Nursing Services and Sufficient Staff policy ,with a revised date of 09/2022, revealed that the facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessment and described in the plan of care.
On 10/19/2023 at 12:59 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) orientation packets or any documentation of competencies, education, or training for their staff nurses regarding care of residents who received dialysis .
During an interview with the surveyor on 10/23/2023 at 10:47 AM, the DON stated that her expectations of the nursing staff in caring for residents that receive dialysis was to check the resident's vital signs, follow the physician's orders for medications, and to know what medications to hold prior to going to hemodialysis. The DON added to also monitor the resident's diet, to check the access and monitor for any signs of infection, bleeding, or swelling. The DON stated the nurses should document in the communication binder that accompanied the resident to the dialysis facility and communicate any changes with the resident to the hemodialysis center. The DON stated that when the resident returned from their hemodialysis treatment, the nurses should check the resident's vital signs, check the access, and note any changes in the communication binder from the dialysis center. She revealed that the nurses would check the thrill and bruit of the access site. The DON stated if the resident had a permacath, the permacath would have a dressing and the nurses should only check the site for swelling or bleeding and not do anything else with the access. The surveyor asked if the nurses were trained in the checking of the thrill and bruit of a fistula? The DON stated that she would expect the nurses to already know how to do that. The DON revealed that she was not sure if there was any facility education regarding residents who received hemodialysis that was provided to the nursing staff. The DON stated that there should be a physician order for checking the thrill and bruit of an AV fistula and that should also be included in the resident's care plan. The surveyor requested from the DON for any documented education or training for their nursing staff regarding hemodialysis.
During an interview with the surveyor on 10/23/2023 at 10:51 PM, the LNHA stated that her expectations of the nursing staff in caring for residents receiving dialysis was to document in the dialysis communication binder the resident's vital signs, checking of the access site, weights, dietary changes and any unusual occurrences. She stated that the nurses should also check the thrill, bruit and for any bruising or signs of infection of the access site. The LNHA added that if the resident had a permacath, the nurses should check for signs of infection or swelling at the site. The LNHA stated the permacath dressings were changed at the dialysis center, and the facility nurses did not change the dressings or do anything else with the permacath. The LNHA confirmed that there should be a physician's order to check the thrill and bruit of a fistula and should also be documented on the resident care plan. The surveyor, again, requested from the LNHA any staff education, training, or competencies related to dialysis.
On 10/23/2023 at 12:01 PM, the surveyor observed Resident #90 in bed awake with oxygen on at 2-liter nasal cannula and watching television. The resident stated that he/she just returned from hemodialysis. The surveyor observed residents right upper arm AV fistula sites with no dressings on the sites. Resident #90 stated that he/she removed the dressings because they were itchy. The resident stated, they are always itchy when I come back so I remove them. The resident revealed that his/her access had not been assessed yet today since returned from dialysis.
On 10/23/2023 at 12:27 PM, the surveyor reviewed Resident #90's communication binder and observed that the post-dialysis (receiving nurse section) was not completed. The surveyor asked the assigned LPN what time Resident #90 returned from his/her dialysis treatment? The LPN stated that she wasn't sure if the resident had returned back from dialysis yet, they may still be working with him/her. The surveyor informed the LPN that the resident had returned back from dialysis and was in his/her room.
On 10/23/23 at 1:57 PM, the surveyor observed Resident #90's assigned LPN perform an assessment of the resident's right upper arm (RUA) AV fistula. The LPN sanitized a stethoscope and then applied gloves. The LPN did not perform hand hygiene before applying the gloves to her hands. The LPN explained to the resident that she will be checking his/her access. The LPN had resident extend his/her right arm and stated to the surveyor, You take 2 fingers to feel the bruit. The LPN applied 2 fingers on the antecubital (crook of the elbow) area of the resident's right arm and the LPN stated that she could feel the area pulsating. The LPN then placed the stethoscope to the resident's antecubital area and stated to the surveyor that she could hear the thrill. The LPN then removed and discarded her gloves, closed the resident's overhead light and thanked the resident. The LPN did not perform hand hygiene after removing her gloves or sanitize the stethoscope after performing an assessment of the resident's access site. In addition, the LPN failed to place her fingers just above the access sites to feel for the thrill (the vibration caused by the blood flowing throught the fistula), and did not place the stethoscope near the fistula incisison sites to listen for the bruit (a whooshing sound generated by blood flow).
On 10/23/2023 in the presence of the survey team, the DON stated that there was no specific time requirement for the pressure dressing to be removed from the AV fistula. The DON added that when a resident returned from dialysis and there was no bleeding at the access site, the nurses could remove the dressing.
During an interview with the surveyor on 10/25/2023 at 9:40 AM, the charge nurse at Resident #90's dialysis center stated that she was familiar with Resident #90. The charge nurse stated she would expect the facility nurses to visually check a fistula access post hemodialysis which included to check the fistula for bleeding, check the thrill and bruit, and remove the dressing the following day; in 24 hours. The charge nurse added that if there was no thrill and bruit and/or the nurses have difficulty assessing the thrill and bruit of a fistula access, the nurses can call the center and the center can help with the access and/or set-up for the resident to be seen by the access center if needed. For a Permacath, the facility nurses should not touch the access and do not change the dressing and to monitor the access site for bleeding, swelling or pain and notify the center. If a resident was pulling at a permacath or pulled out a permacath even slightly, notify the center and the resident would need to be sent out for an X-ray to check for placement or for a catheter exchange. The surveyor asked the charge nurse if the facility should notify the center if Resident #90 removed the dressings from his/her AV fistula sites due to itching when he/she returned to facility after her dialysis treatment? The charge nurse stated that the nurses should notify the dialysis center because the dressings should not be removed for 24 hours, and the center could possibly change the tape on the dressings to hypoallergenic tape. The charge nurse added that the nurses should not apply any creams or lotions to the access sites due to the possibility of infection to the sites. The charge nurse stated that she would expect the communication form to be accurate and complete and the nurses should immediately assess the dialysis resident upon return to the facility from their dialysis treatments.
On 10/26/2023 at 09:37 AM, the facility was unable to provide any documented proof for nurse competencies, signed in-services, education, or any training regarding the care of dialysis residents.
During a phone interview with the surveyor and in the presence of the survey team on 10/26/2023 at 12:48 PM, the Medical Director (MD) stated that she was familiar with Resident #90 and would expect the nurses to know how to care for any resident's access, either a permacath or a fistula, and to keep the access clean and monitor for infection.
On 10/27/2023 at 10:47 AM, in the presence of the survey team, the LNHA stated that it was important for the nurses to know about the access sites for hemodialysis and perform hand hygiene when checking the access sites to prevent infection of the access site. The Infection Preventionist (IP) stated that it was important for the nurses to know what body part to assess, check the vital signs, and make sure no bleeding at the site. The IP revealed that the facility would need to educate the nursing staff regarding assessment of a permacath and a fistula.
On 10/31/2023 at 10:52 AM, and in the presence of the survey team, the IP confirmed that the nursing staff should have identified Resident #90's hemodialysis access in the physician orders and it should have been discovered and/or corrected on the 24-hour chart check. The IP informed the survey team that, since surveyor brought to the facility's attention, in- service education was done regarding care of the residents receiving dialysis treatment and identification and care of access sites.
NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 00162113
Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure sufficient staff were available to (a) provide assistance dressing, provide personal hygiene and incontinence care for residents who were dependent on staff for Activities of Daily Living (ADLs), b) provide nail care for a resident who was dependent on staff for ADLs, and c) respond to call lights in a timely manner. This deficient practice was identified for 5 of 21 residents (Resident #13, #14, #41, #73 and #7 ) on 2 of 2 nursing units. This deficient practice was evidenced by the following:
Refer to 684G and 677F.
Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21:
One Certified Nurse Aide (CNA) to every eight residents for the day shift.
One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and
One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties.
On 10/18/23 at 9:24 AM, Surveyor #1 interviewed the Registered Nurse Unit Manager (RN UM) of the Noble Unit who stated that the unit's census was 51 and staffing today was 2 Licensed Practical Nurses (LPN)s and 5 Certified Nursing Assistants (CNA)s.
During the initial tour of the [NAME] Unit on 10/18/23 at 9:51 AM, the surveyor interviewed an LPN who stated that they are usually short staffed, not only on the weekends but during the week too.
During an interview with the surveyor on 10/18/23 at 10:32 AM , the CNA stated that she has worked at the facility for 18 years. The CNA stated that staffing was an issue. She further stated that on that day she had 10 residents and 5 of those residents were total assists (needed total assistance with all activities of daily living). We usually have a lot more residents, sometimes there are only two CNAs on the unit and sometimes there are 3 or 4 CNAs on the day shift.
During an interview with the surveyor on 10/18/23 at 10:35 AM, the CNA on the Noble Unit stated that she had 10 residents for day shift. The CNA further stated that sometimes there are only 2 CNAs on the unit.
A review of the staffing sheet provided by the facility for the 11 PM-7 AM shift on Sunday 10/22/23 on the Noble Unit revealed one Registered Nurse (RN), one LPN and one CNA were scheduled to provide care for all residents on the unit.
a).A review of the medical record revealed Resident #13 had a diagnosis, including but not limited to: Quadriplegia, Parkinsonism, and unspecified Dementia, had moderately impaired cognition, and required total dependence on staff for all ADLs.
On 10/23/23 at 9:30 AM, Surveyor #1 asked two CNAs to assist with a care tour and observed Resident #13 wore 2 briefs which were saturated with urine. The gown including the pulled sheet were brown stained. Resident #13 could not elaborate if he/she was cared for on the prior shift. At 09:52 AM, another surveyor entered the room with the Director of Nursing (DON). At the surveyor's request, the resident's incontinent brief was checked by staff. The resident was observed to be saturated with urine. Also noted were some scratch marks on the back and redness to the buttock area which were not observed on 10/18/23 during the observed incontinence tour. When asked about her expectations, the DON replied, better then what I just observed. The DON verified that the incontinence care had not been provided on the prior shift (11:00 PM-7:00 AM).
On 10/26/23 at 11:55 AM, Surveyor #1 interviewed the DON who stated that Resident #13 should not have had two incontinence briefs on. The facility's protocol was to provide incontinence care every 2 hours and as needed.
On 10/26/23 at 11:00 AM, the surveyor completed a telephone interview with the CNA who provided care to Resident #13 on 10/22/23 3:00 PM-11:00 PM shift. The CNA stated that she had applied 2 adult incontinent briefs on Resident #13. The CNA confirmed that she had provided incontinence care to Resident #13 at 6:30 PM on 10/22/23 which included changing the resident and their sheets due to being saturated with urine. The CNA stated she clocked out at 7 PM.
On 10/26/23 at 12:53 PM, the surveyor conducted a telephone interview with the Registered Nurse (RN) who worked the 3:00 PM-11:00 PM shift on 10/22/23 who confirmed that that 2 CNAs had left at 7 PM on that shift and the other CNA on the unit did not ask for assistance with care.
On 10/26/23 at 12:30 PM, Surveyor #1 interviewed the CNA who cared for Resident #13 who stated that she reported to work on 10/23/23 at 6:50 AM and had to care for another resident that was saturated with urine. The CNA stated, It was so bad, I had to call the clinical director to verify that care was not provided on the prior shift.
On 10/27/23 at 7:50 AM, the surveyor interviewed the LPN who had worked the 11:00 PM -7:00 AM shift on 10/22/23 who stated that she did not assist the CNAs to change and turn some residents. The LPN stated No I was busy also. We provided safety that is all we could do.
On 10/27/23 at 8:40 AM, the surveyor interviewed the CNA who cared for Resident #13 during the 11:00 PM-7:00 AM shift on 10/22/23 who stated that he did not provide incontinence care to the residents during the 8 hr. shift. The CNA stated that he provided care for 30 residents that night and he was overwhelmed and could not get to the resident.
b) A review of the medical record revealed Resident #14 had a diagnosis, including but not limited to :Quadriplegia, heart failure, right and left hand contracture, pressure ulcer of sacral region, stage 4, dependence on supplemental oxygen, had sever cognitive impairment, was nonverbal and required total assistance for all ADL care.
.
On 10/23/23 at 11:00 AM, Surveyor #1 observed Resident # 14 in bed and was informed that the CNA assigned to this resident was on break. The surveyor asked the LPN and 2 random CNAs to assist with a care tour.
The CNAs repositioned Resident #14 to the left side. The surveyor observed that the resident's mid-back and buttocks were covered with feces. Feces were expelling from both side of the adult brief. Resident #14's sacral wound was covered with feces. The staff informed the surveyor that morning care had not been provided yet.
On 10/23/23 at 12:30 PM, Surveyor #1 interviewed the LPN assigned to the Noble Unit who stated that staff should have checked the resident at start of shift to ensure that the resident was not soiled. Surveyor #1 interviewed the assigned CNA who stated that she did not check the resident this morning. She was not aware that the resident was not changed during the prior shift.
On 10/23/23 at 12:45 PM, Surveyor #1 interviewed the RN/UM who stated that the facility's protocol was for all CNAs to check and change their residents right after morning report and that she was not aware that some of the residents were not provided with incontinence care during the prior shift.
On 10/27/23 at 8:40 AM, Surveyor #1 conducted a telephone interview with the 11:00 PM-7:00 AM CNA. The CNA informed the surveyor that he checked the resident possibly at 6:00 AM and the resident was not soiled. When inquired about who assisted him with the resident, he stated,' I did it alone.( Resident #14 required extensive assist of two persons for bed mobility.)
c)A review of the medical record revealed Resident #41 was admitted to the facility with diagnoses which included but were not limited to; Adult failure to thrive, difficulty in walking, need for assistance with personal care and unspecified severe protein-calorie malnutrition.
On 10/18/23 10:45 AM, Surveyor #1 observed Resident #41 sitting in bed dressed in a colorful gown. The resident informed the surveyor that she was here for rehabilitation.
On 10/19/23 at 12:55 PM, Surveyor #1 observed Resident #41 in bed with same clothing as day prior. Resident stated that she had lunch already.
On 10/20/23 at 10:29 AM, Surveyor #1 returned to the unit and observed Resident #41 in bed with the same clothing as days prior.
On 10/20/23 at 10:35 AM, Surveyor #1 interviewed the Registered Nurse Unit Manger (RN UM) who stated that she was not aware that the resident had not been changed. The surveyor escorted the RN UM to the Resident #41's room where the resident confirmed she had not been changed and agreed to have her clothing change.
On 10/23/23 at 09:42 AM, Surveyor #1 observed Resident#41 in bed, their feet were dry and scaly with large amount of dry callus type skin on the bed. The surveyor escorted the DON to the room where we all observed the same. The surveyor asked the DON if they have any skin remedy for the resident skin. She stated yes and showed to the surveyor the cream at the bedside.
10/23/23 10:43 AM, Surveyor #1 revisited the resident after AM care was provided. The resident stated, They put some cream on my legs today, it feels like a smoothing feeling, they had not done it for a while. The resident observed with the same colorful gown noted on in bed this morning.
10/24/23 10:01 AM, Surveyor #1 asked the RN UM who was directing the care, she stated, Myself and the DON. The RN UM stated that her role was to ensure the care was being delivered, communicate with staff, check assignments, and make rounds. The surveyor then asked the RN UM if she made rounds this morning. The RN UM replied, No.
d)A review of the medical record revealed Resident #73 was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder, mild intellectual disability, and alcohol dependence, was cognitively intact but unable to communicate his/her needs, required limited assistance for ADLs and occasionally incontinent of urine.
On 10/26/23 at 9:04 AM, Surveyor #1 smelled a strong urine odor permeated the hallway and was stronger while approaching Resident #73's room. The surveyor asked a random CNA to assist with a care tour and when they entered Resident #73's room, they observed the resident seating in the wheelchair eating breakfast. The top sheet was visibly soiled with dry feces. Resident #73's adult brief along with the pants were noted on the floor saturated with urine. The padding to protect the bed were noted on the floor saturated with urine. When inquired if the resident was assisted with incontinence care prior to breakfast, the CNA stated that the resident was not on her assignment.
The surveyor left the room to review the daily assignment and identified the CNA assigned to the resident that day. The surveyor escorted the RN UM along with the assigned CNA to the room where we all observed Resident #14 eating breakfast in an unsanitary environment. The RN UM stated that should not have happened and proceeded to remove the soiled clothing from the floor and removed the linens from the bed.
On 10/26/31 at 11:15 AM, the RN UM informed the surveyor that the activity staff delivered the breakfast tray to Resident #73.
On 10/26/23 at 12:30 PM, Surveyor #1 interviewed the activity staff who delivered the breakfast tray who stated that she did not observe the soiled clothing on the floor. She stated that the resident was in bed, and she did not realize that the sheet was soiled with feces.
Resident #73 was not checked for incontinence care prior to receiving the breakfast tray. Staff reported to work at 7:00 AM and had not checked the resident until the surveyor brought the issue to their attention.
On 10/27/23 at 10:44 AM, Surveyor #1 interviewed the RN UM who stated that the CNAs were to check the residents and provide care prior to breakfast.
On 10/27/23 at 11:15 AM, Surveyor #1 interviewed the CNA and inquired about the soiled clothing observed on the floor the morning of 10/26/23. The CNA stated, I did not check the resident, nor provided care yet. The CNA further stated that the resident would be combative with care. There was no documentation in the clinical record regarding rejection of care.
2.) A review of the medical record revealed Resident #7 had diagnoses that included but were not limited to; dementia, hypertension (elevated blood pressure), chronic kidney disease, and palliative care, resident is rarely/never understood and required extensive assistance with one-person physical assist for personal hygiene.
On 10/18/23 at 9:40 AM, Surveyor #2 observed Resident #7 lying in his/her bed. The surveyor observed Resident #7's fingernails to be long and jagged with a brown substance under the fingernails. Resident #7's right hand ring finger had a long fingernail that was curled over and inward and in direct contact with the resident's fingertip.
On 10/19/23 at 10:42 AM, Surveyor #2 observed Resident #7 lying in bed with his/her fingernails visibly soiled, long, and jagged. Resident #7's right hand ring finger's fingernail was curled over and inward and in direct contact with the resident's fingertip.
On 10/19/23 at 11:21 AM, Surveyor #2 interviewed the CNA who stated that he was not Resident #7's care giver. He further stated that the hospice aide comes in the mornings to care for the resident.
On 10/19/23 at 11:35 AM, Surveyor #2 observed an LPN in Resident #7's room and was encouraging the resident who was feeding themselves lunch then the LPN exited the room.
On 10/19/23 at 12:17 PM, the surveyor interviewed LPN #1 who stated that she was not familiar with the resident as she usually worked on the other unit.
On 10/19/23 at 12:20 PM, CNA #2 stated she was familiar with Resident #7. She stated that the resident was total care, could move around in their bed, was somewhat alert, and that hospice usually came in the morning. CNA #2 and the surveyor entered Resident t# 7's room and when asked about the resident's nail care, CNA #2 stated, they need to be cut. She stated that hospice would clean the resident up in the morning. CNA #2 further stated that if hospice did not provide care, the facility staff would be responsible for Resident #7's care.
On 10/19/23 at 12:22 PM, LPN #1 and the surveyor entered Resident#7's room and when asked about the resident's nail care, LPN #1 stated, The nails need to be cut. I don't do that. When asked where the documentation of nail care would be, LPN #1 stated there was a book on the unit. LPN #1 showed Surveyor #1 the CNA book for resident care but was unable to locate any documentation for Resident #7.
On 10/19/23 at 12:30 PM, the DON stated that the hospice staff was not the only staff responsible for the resident's care. She stated that nail care should be done at least once a week and as needed. The DON was in Resident #7's room with the surveyor. The DON stated the resident's fingernails were too long and should not look like that.
On 10/20/23 at 8:13 AM, the surveyor interviewed the hospice aide who acknowledged that Resident #7's fingernails needed to be trimmed but that she did not do that for the resident.
On 10/31/23 at 10:00 AM, the DON stated that there was no documentation in the Progress Notes or in the CP that the resident was resistant to nail care.
3. On 10/19/23 at 10:59 AM, Surveyor #3 observed the call light illuminated outside room [ROOM NUMBER] and room [ROOM NUMBER] which were located at the end of the hallway. At 11:05 AM, the surveyor observed room [ROOM NUMBER]'s call light was turned off, but the surveyor did not observe any staff had entered the room. (Total 6 minutes the call light was on). At 11:06 AM, the surveyor observed a housekeeper enter room [ROOM NUMBER] to answer the call bell and the call light was turned off (total 7 minutes the call light was not answered).
During an interview with the surveyor on 10/19/23 at 11:21 AM, the LPN stated that staffing today consisted of 2 LPNs and 3 CNA's (census 51).
During an interview with Surveyor #3 on 10/19/23 at 11:24 AM, the unit secretary (US) stated that the resident call system console was located at the nurse's station behind a computer monitor. The US stated that the call light could be turned off from the nurse's station[at the resident call system console] but you needed to go see what the resident needed before you turned off the call light.
On 10/19/23 at 11:40 AM, Surveyor #3 observed the call light illuminated outside room [ROOM NUMBER]. At 11:50 AM, room [ROOM NUMBER]'s call light still illuminated in the hallway. Surveyor #3 observed an LPN at the medication cart with another surveyor but no other personnel in the hallway. The surveyor observed the resident call system console was not emitting a visual red light or an audible sound from the console.
At 11:51 AM, Surveyor #3 observed the RN UM sitting at the nurse's station next to the resident call system console . The surveyor asked the RN UM if there were any call lights activated and she looked at the resident call system console and noted there were no red lights emitting from the monitor and stated no. The RN UM stated that when a resident pressed the call bell, a light will go on outside the resident's room, there would be a ringing sound and a red light will light on the resident call system console.
On 10/19/23 at 11:57 AM, Surveyor #3 observed room [ROOM NUMBER] call light was still illuminated outside the resident's room. The LPN stated she was looking for the CNA who was assigned to room [ROOM NUMBER]. At that time there were 2 other CNAs in the hallway by the nurse's station, but the call light was not answered. At 12:00 PM, the LPN who was assigned to room [ROOM NUMBER] answered the call light.( call light was unanswered for 20 minutes)
On 10/19/23 at 12:02 PM, the surveyor informed the RN UM that room [ROOM NUMBER]'s call light was not answered for 20 minutes. The RN UM stated that anyone can answer a call light, such as CNA's, housekeepers, nurses, then they would get the appropriate person to assist the resident. The RN UM stated that an appropriate response time for a call light to be answered would be 2-3 minutes.
On 10/24/23 at 10:30 AM, Surveyor #3 interviewed the DON who stated that she would expect the staff to respond to a call light as soon as the call light was on and that the response time would be about 5 minutes. The DON stated that anyone could answer a call light.
A review of the facility's policy titled Nursing Services and Sufficient Staff, reviewed 09/22, revealed that the facility will supply services by sufficient numbers of each of the following personnel types on a 24 hour basis to provide nursing care to all residents in accordance with resident care plans, a. except when waived, licensed nurses: and b. other nursing personnel; including but not limited to nurse aides.
A review of the facility's policy titled Call lights: Accessibility and Timely Response, reviewed 09/22, revealed that all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.
NJAC 8:39- 4.1(a)11; 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure: a) a Medication Regimen Review (MRR) of each resident was performed at least once a month by a licensed pharmacist, and b) provide documentation that the recommendations were acted upon in a timely matter. This deficient practice was observed for 2 of 2 nursing units with a census of 101, for August 2023 and September 2023, and was evidenced by the following:
During an interview with the surveyor on 10/25/23 at 9:22 AM, the Registered Nurse Unit Manager (RN UM) stated that MRR were completed monthly, but the facility had changed pharmacy consultants and not sure how the reporting was being done at present. The process with the prior consultant pharmacy was that the Consultant Pharmacist (CP) would email all recommendations to the Director of Nursing (DON) then the DON would email them to the Unit Manager.
On 10/25/23 at 10:07 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the presence of a consultant pharmacist. The LNHA stated that she thought the pharmacy consultants stopped coming in July 2023 and it was a corporate level decision that may have been related to finances. When asked if it was important for the pharmacist to come to the facility, the LNHA stated, absolutely, it is important to have a continuum of care.
On 10/25/23 at 12:40 PM, the surveyor requested all CP recommendations for August and September 2023.
During an interview with the surveyor on 10/25/23 at 12:56 PM, the DON stated that CP would complete monthly drug reviews on each resident, complete medication passes with the nurses, review medication storage and review residents' charts. The CP recommendations would then be emailed to the DON and the facility has the responsibility to carry out the recommendations.
On 10/26/23 at 9:10 AM, the DON provided Pharmacy Recommendations and stated, this is all we have, it's not much. A review of the documents provided included a Quality Assurance Performance Improvement Program(QA PIP) for the absence of Pharmacy Consultant and no pharmacy recommendations for any residents for August 2023 and September 2023.
During an interview with the surveyor on 10/26/23 at 10:07 AM, the DON stated that she started at the facility on 10/06/23. The DON stated that the facility did not have a CP for the month of August 2023. A new CP started in September, but the reports were sent to the previous DON, and she could not access the reports. The DON confirmed that the MRR was not completed for August 2023 and could not provide any CP recommendations for September 2023.
During an interview with the surveyor on 10/26/23 at 10:52 AM, the LNHA stated that the previous CP terminated their contract with the facility in July 2023. The surveyor requested a copy of the termination letter but it was not provided.
During an interview with the surveyor, in the presence of the survey team, on 10/26/23 at 11:24 AM, the LNHA stated that the role of the CP was to come to the facility, review residents mediations and charts, check the nursing units, complete random medication passes with the nurses for competencies and then email the recommendations to the DON who would then send to the unit managers to take action on it with the doctors. The LNHA stated it was important for MRR to be completed monthly because there could be drug interactions, polypharmacy, allergies, drug side effects and behavior monitoring needed for certain medications. When asked what was implemented when there was an absence of CP services, the LNHA stated they implemented a QAPI.
During an interview with the surveyor on 10/26/23 at 11:52 AM, the Medical Director stated that she was aware of the interruption of service from the pharmacy consultant.
During a telephone interview with the surveyor on 12/26/23 at 12:53 PM, the CP (from the new consultant corporation) stated that they started in September 2023. She stated she only reviewed residents on one unit and her medication recommendations were then emailed to the DON. She further stated that the facility could access the recommendations through a portal.
The facility was unable to provide any further documentation that a MRR was completed for August 2023 and September 2023.
A review of the facility's policy titled, Addressing Medication Regimen Review Irregularities, dated 11/2017, revealed that the medication regimen of each resident must be reviewed by a licensed pharmacist at least once a month (or more frequently, as indicated by the resident's condition). The policy is to provide a MRR for each resident in order to identify irregularities and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event.
NJAC 8:39-29.3 (a)

Based on observation, interview, and review of facility documents it was determined that the facility failed to properly label and date medications in 2 of 4 medication carts inspected. The deficient practice was evidenced by the following:
1. On 10/19/23 at 11:00 AM, the surveyor inspected the low side of the Noble Unit medication cart on the 2nd floor with the Licensed Practical Nurse (LPN#1) who was assigned to the cart. Inside of the medication cart the surveyor observed following:
-1 bottle of Nitroglycerin tablet (medication used to treat angina) with an expiration date of 07/23
-1 multi dose vial of insulin opened but not dated, a pack of Oxycodone 5/325 milligrams( mg) (medication to treat pain) with an expiration date of 09/23
-5 multi dose vials of Insulin that had an open date and no expiration date
-1 multi doses vial of Aspart Insulin opened 09/07/23 last used 10/19/23.
2. The surveyor inspected the medication storage room on the Noble Unit with LPN #1. Inside the locked medication refrigerator was the following:
-1 multi doses vial of PPD (Purified Protein Derivative) vaccine opened but not dated
An inspection of the medication cabinets revealed 3 bottles of Vitamin E with an expiration date of 09/23.
At that time, the surveyor interviewed LPN #1. The LPN #1 stated the Pharmacy Consultant and the Unit Manager were responsible to check all medication rooms for expired medications and/or removing medications from active inventory if indicated from the medication room. The LPN added that the nurses were responsible for checking the medications inside the medication carts prior to administration. She could not comment on why expired medications were inside the medication cart.
3. On 10/19/23 at 11:15 AM, the surveyor inspected the second medication cart on the Noble unit with LPN #2 which revealed the following:
-5 Flexpen insulin with the open date only.
-1 Lantus Flexpen dated on the box 09/14, pen not dated. The manufacturer specification on the box, reviewed with the LPN, directed to discard the insulin after 28 days.
During an interview with LPN #2, he stated that insulin could be used for 30-60 days.
The surveyor interviewed both nurses on the medication carts, no explanation was offered as to why the multi-dose vials of Insulin were not labeled with the open date and the expiration date.
On 10/20/23 at 11:30 AM the surveyor interviewed the Unit Manager regarding the the facility's process to date insulin. The UM stated that the process was to date with the date the insulin was opened only. However the Clinical Director stated upon interview on 10/20/23 that all insulin vials and Flexpens should be dated with an open and expiration date.
On 10/23/23 at 11:30 AM, the surveyor reviewed the facility's policy and procedure which was titled Medication Storage with a review date of 09/22, Under Policy Explanation and Compliance Guidelines Interpretation and Implementation
#5. Unused medications, The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, expired and outdated medications. These medications are destroyed in accordance with the facility policy.
The facility provided the policy labeled 7.0 Insulin Pen Labeling and Packaging
with the following instructions:
Insulin pens are placed in a resealed bag with the following/labels/stickers
Prescription label in accordance with the labeling regulations.
Refrigerate until opened
Keep Insulin in bag sticker.
A yellow Date/Expiration sticker.
None of the Insulin observed on both medication carts had a yellow sticker for identifying the expiration date.
On 10/20/23 at 11:00 AM, the surveyor interviewed the DON who stated that the nurses were responsible for discarding expired items found in all storage rooms.
NJAC 8:39-29.4 (b)2

Based on observation and interview, it was determined that the facility failed to ensure that the meals were served at a palatable temperature for 2 of 2 Residents reviewed for food (Resident #23 & Resident #87). The deficient practice was evidenced by the following:
On 10/18/23 11:29 AM, the surveyor observed Resident #87 awake and alert sitting in bed. The surveyor asked about the food at the facility and Resident #87 stated the food is horrible and it is cold.
On 10/18/23 at 11:40 AM, the surveyor observed Resident #23 awake and alert sitting in wheelchair inside the resident's room. When asked about the meals, Resident #23 stated the food *****, the food is always cold.
On 10/20/23 at 8:27 AM, the surveyor observed the meal cart brought to the second floor by the dietary staff.
On 10/20/23 at 8:32 AM, the second to last tray was delivered and the requested the last tray which belonged to Resident #23 and proceeded to check the temperatures of the food items in the presence of the Registered Nurse.
The meal tray was labeled Regular diet and contained scrambled eggs which were 122 degrees Farenheight (F), a hard cooked egg which was 132 F, and 8 ounces of milk which was 53 F.
At 10/20/23 at 8:50 AM, the surveyor interviewed the Food Service Director in the kitchen. The surveyor asked the FSD what the temperatures should be for the meals that are served to the residents. The FSD stated our standards are 165 F or better, and stated there is no temperature on the floor that the food should be, as long as it leaves the kitchen at 165 F it is palatable and stated it can be reheated. When asked about a food temperature policy the FSD stated they don't have one.
10/20/23 at 8:55 AM, the surveyor asked the FSD to show the surveyor the kitchen food temperatures for the cooked items. The FSD looked at the kitchen food temperature log, and the surveyor also observed that the scrambled eggs and hard cooked egg were not listed.
On 10/20/23 at 8:56 AM, the FSD went to the cook who made the breakfast and took the temperature log to the cook to ask him what the temp was for the scrambled egg. The FSD then stated to the cook you didn't put it down, and when the cook wanted to document the temperatures at that time, the FSD stated it is too late to put it down. The FSD stated to the surveyor that he forgot to put the egg down and they should be 145 or better '(not the 165 F that the FSD previously stated). The FSD stated he didn't write it down and it did not exist.
NJAC 8:39- 17.4(a)2

Based on observation and interview it was determined that the facility failed to ensure that garbage was regularly removed from the facility in a manner to prevent the potential spread of infection and vermin infestation. The deficient practice was evidenced by the following:
On 10/18/23 at 8:53 AM, during the initial approach from the parking area/rear of the building, the surveyor observed a large pile of garbage bags that covered approximately one- half of the loading dock. The garbage bags were piled up against the back wall of the loading dock and adjacent to a chain link fence cage that appeared to have oxygen cylinders inside with a sign affixed Danger, No Smoking, No Open Flames to the outside of the cage and above a pile of the garbage bags. The garbage bags that were piled up against the back wall obstructed a sign Notice all cardboard needs to be . making it unreadable in it's entirety. There was a large compacter type dumpster below the loading dock, and an uncovered cardboard type dumpster next to it. There was also debris strewn about next to the compacter dumpster and cardboard type dumpster which included papers, wood, etc.
On 10/18/23 at 11:11 AM, the surveyor observed the loading dock of the building and observed two trucks for a [junk removal service] and two men were loading the garbage bags into the [junk removal service trucks]. At that time, in the presence of the Food Service Director (FSD), the surveyor asked one of the workers if the facility contracted with them for garbage removal and he responded no, only for today, then asked the FSD who was going to continue to remove the garbage and he stated, that is above my pay grade.
On 10/25/23 at 9:48 AM, the surveyor interviewed the LNHA regarding if she had been made aware of the garbage not being picked up. The LNHA stated there was daily stand up meetings for clinical and one for operations. When asked about the garbage piling up, the LNHA stated they [garbage company] were not paid timely, and she had followed up with the facility corporate office and confirmed to the surveyor that she observed that the garbage had been piled up. The LNHA confirmed that there was a delay in rectifying the garbage situation, and stated she had not been made aware of the garbage piling up until a day or so before the surveyor brought it to her attention. The surveyor asked the LNHA if leaving the garbage piled up outside was okay and the LNHA stated, no, it was not okay, that the facility was in a wooded area and you cannot chance it.
NJAC 8:39-31.4 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review it was determined that the facility failed to ensure that a process was in place for explaining the arbitration agreement to a resident prior to having the resident sign the agreement. This deficient practice occurred for 1 of 2 residents reviewed for arbitration agreements (Resident #16) and was evidenced by the following:
On [DATE] at 12:19 PM, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that the facility utilized arbitration agreements which were part of the admission agreement and would provide a list of residents who have signed the agreement. The LNHA stated the admission Diretor was responsible for having the residents sign the agreements.
On [DATE] at 11:30 AM, the surveyor received the list of facility arbitration agreements which include resident #16. A reviewed of Resident #16's electronic medical record (EMR) revealed Resident #16 entered into the Arbitatrion Agreement (AA) by signing the Arbitration Agreement on [DATE]. The AA revealed 1. Arbitation Agreement. Any and all claims or controversies between Patien, the Patient Representative and Facility that arise out of the Patient's stay at the Facility, with the exception of eviction proceedings, and including but not limited to, violations of any right granted by law, including statutory resident's right, or by th Aedmission Agreement, breach of contract, fraud or misrepresentation, negligence, gross negligence, malpractice or any other claim based on any alleged departure from accepted standards of medical or health care or safety, whether sounding in tort resulting in personal injury, or in contract, shall be submitted to binding arbitration, which shall be the sole means by which said claims or controversies shall be resolved. Additionally, the agreement revealed This binding Arbitration Agreement constitutes a binding legal agreement between the parties. The patient and/or the patient representative have read and understand this arbitration agreement and understand that by signing this arbitration agreement each has waived his/her rights to a trial before a judge and/or a jury and voluntarily consent to all of the terms of this section.
On [DATE] at 10:56 AM, the surveyor interviewed Resident #16 in the resident's room. The surveyor asked Resident #16 if the resident recalled being asked to enter into an arbitration agreement and if recalled signing such an agreement. The surveyor stated to Resident #16 regarding being informed that by signing the AA, the resident gives up their rights to having a trial by jury per the AA. Resident #16 stated that he/she signed what needed to be signed for the admission agreement and did not recall signing away any rights to litigation. Resident #16 stated when he/she was asked to sign the admission agreement, there was nothing specified about signing an AA. Resident #16 stated that she has no recall of anyone explaining such an agreement. The surveyor asked Resident #16 if he/she would have signed such a document if it had been explained and Resident #16 stated, probably not, and that he/she did not know about it. Resident #16 stated the admission Director is the one that had him/her sign the AA.
On [DATE] at 12:14 PM, the surveyor conducted an interview with Admisison Director (AD). The surveyor asked the AD what her role entailed and she stated that she has would come weekly and have residents sign consents for care. The surveyor asked about AA and the AD stated it is in the admission agreements. The surveyor asked the AD if she documented any discussion she may have had with any residents. The AD stated that she did not go into the resident's charts, and kept no formal files or documents to track when she met with any residents. The surveyor asked what was told to the residents regarding signing the AA. The AD stated that she would briefly educate the resident and tell them this is if something happens, it would go through arbitration instead, and tell them that it is from lawyer to lawyer, and not a court thing.
On [DATE] at 12:20 PM, the surveyor asked the AD if she had met with Resident #16 and explained the AA. The AD stated Resident #16 already signed one and that she briefly went over it with the resident because the AD thought it had been done already been reviewed with Resident #16. The AD stated that the person from the company had asked that she have Resident #16 sign the AA. The surveyor asked the AD if someone had proivided her with documented education on the AA and the AD stated, no, nothing was documented. The AD stated she would go visit residents and verbally explain the AA to them, and then had the residents sign the AA. The AD provdied the surveyor with a copy of the AA and stated, they [the residents] should all have that.
NJAC 8:39- 13.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. ) On 10/23/23 at11:15 AM the surveyor observed the following during the wound treatment for Resident #14:
The Licensed Practical Nurse (LPN) disinfected the bedside table and set up the clean field in the hallway. The LPN then gathered her treatment supplies and placed them on the overbed table. The LPN turned the faucet on, wet her hands, applied soap, rubbed her hands together, then rinsed under the running water, turned off the faucet, dried her hands with the paper towel for 15 seconds. Then the LPN donned clean gloves, assisted the CNAs to reposition the Resident to his/her right side. The LPN then continued to perform the treatment by cleansing the sacral wound with saline, using the same gloves then LPN #1 dried the area with clean gauze, used a pair of scissors that were not disinfected to cut the Calcium Alginate. The LPN then packed the wound and left 2-3 inches of the Calcium Alginate hung on the resident's skin. The Surveyor then observed LPN #1 with the same gloves on, proceeded to take a clean bordered gauze dressing to secure the dressing on the resident's sacral area.
Resident #14 had 2 other wounds, one to the right buttock and a new wound which was discovered on the left buttock during the treatment. The LPN went to the sink washed her hands and returned to care for the wound to the right buttock. The LPN don gloves, cleansed the wound with Normal Saline, pat the wound dry, then used the same gloves hands to reach for the Silvadene ointment that was to be applied to the wound per the Physician's order. The LPN opened the Silvadene jar and noted that the jar was emptied. The LPN then proceeded to apply a protective skin barrier to the wound. The LPN did not measure the new wound. She cleansed the wound with Normal Saline solution and applied the protective skin barrier to the new wound.
A review of the indication noted on the skin barrier cream, indicated the following, for external use. Do not used on deep or puncture wounds.
The LPN gathered all the dirty/used supplies and threw them in the garbage, then she performed hand washing under running water for 5.62 seconds. The LPN then returned the pair of scissors inside the treatment cart without first being disinfected.
The surveyor conducted an interview with LPN #1 on 10/23/23 at 12:17 P.M., she stated that hand washing should have been performed for at least 15 to 20 seconds, that gloves should have been changed after contact with soiled surfaces, then wash hands, don (put on) new gloves, then proceed with wound care.
On 10/23/23 at 1:15 PM, The above concerns were discussed with the Director of Nursing and the Regional Clinical Nurse. The surveyor also requested the wound care competency for the LPN.
On 10/24/23 at 10:15 AM, the facility provided the competency evaluation and the protocol for wound care. The protocol did not include how to pack a wound. The Clinical nurse informed the surveyor that she observed the LPN on 10/24/23, and she was not deemed competent to care for the wound.
The surveyor interviewed the DON about her expectations, she added that the nurse should have done a wet to dry saline dressing, measured the wound and called the physician.
A review of the facility's Wound Treatment Management dated 11/2012 last revised 09/2023 indicated under Policy explanation:
1. Wound treatment will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.
2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders.
NJAC 8:39-19.4(a)
Based on observation, interview, record review and review of facility documents, it was determined that the facility failed to follow facility policy to limit the spread of potential infection by ensuring: a.) hand hygiene at the lunch meal service, b.) hand hygiene and clean procedure during the care of a feeding tube dressing, c.) the demonstration of a hemodialysis access assessment, and d.) the Clean Dressing Change Policy was followed for 1 of 1 resident (Resident #14) observed during a wound care treatment observation. This deficient practice was identified for 3 residents (Resident #358, #90, and #14) on 2 of 2 nursing units and was evidenced by the following:
a.) On 10/19/23 at 11:48 AM, Surveyor #1 observed the [NAME] unit staff passed out the lunch meal trays. A Certified Nursing Assistant (CNA) #1 was observed not performing hand hygiene prior to, or after delivery of meal trays as follows:
11:50 AM, into room [ROOM NUMBER].
11:51 AM, into room [ROOM NUMBER] and another tray into room [ROOM NUMBER].
11:53 AM, another tray into room [ROOM NUMBER] and into room [ROOM NUMBER].
12:01 PM, another tray into room [ROOM NUMBER].
12:03 PM, a tray into room [ROOM NUMBER].
12:04 PM, a tray into room [ROOM NUMBER].
12:05 PM, prior to moving the lunch tray cart.
On 10/19/23 at 12:13 PM, during an interview with Surveyor #1, CNA #1 stated the process for the meal delivery was to check the meal tickets, clean the resident's hands, and help set the resident's meal up. When asked about performing hand hygiene, CNA #1 stated yeah ok, I should have cleaned hands.
On 10/19/23 at 12:34 PM, during an interview with Surveyor #1, the Director of Nursing (DON) stated the process to deliver the meal trays was to assist the residents with hand hygiene, check the meal ticket, staff performs hand hygiene, deliver the meal tray, set up any resident who needs help, and staff performed hand hygiene again. The DON stated the staff needs to perform hand hygiene because of infection control and currently the facility was in an outbreak of COVID-19.
b.) On 10/20/23 at 6:58 AM, Surveyor #1 observed a Licensed Practical Nurse (LPN) #1 during care of Resident #358's feeding tube. Surveyor #1's observations included but were not limited to the following: LPN #1 had donned (put on) gloves without first performing hand hygiene and removed the dressing surrounding the feeding tube insertion. LPN #1 next used the same soiled gloves to pick up clean gauze, open the clean solution bottle, pour the solution on the gauze, and clean the exposed tubing feed insertion site. LPN #1 doffed (removed) her gloves, did not perform hand hygiene, picked up a new dressing, reached into a pouch she was wearing and obtained a marker and scissors, dated the dressing, and used the scissors to cut the dressing to fit the site. LPN #1 completed flushing the residents feeding tube procedure, and during an interview at that time, LPN #1 stated that she should have performed hand hygiene in between changing her gloves and going from dirty to clean supplies.
A review of the medical records revealed that Resident #358 had diagnoses which included but were not limited to; gastrostomy status and encounter for surgical aftercare following surgery on the digestive system. A review of the most recent Annual Minimum Data Set (MDS) an assessment tool, dated 08/02/23, included but was not limited to; unable to determine cognitive status as the resident was rarely/never understood. Functional Status revealed the resident was totally dependent on staff for Activities of Daily Living including tube feeding. A review of the patient-centered comprehensive Care Plan included but was not limited to; a focus area of impaired skin integrity with interventions that included keep skin clean and dry.
On 10/20/23 at 9:42 AM, the DON stated that hand hygiene should be performed between glove changing, removing the dirty dressing, and not touching clean supplies with dirty gloves. The DON further stated it was important to break the chain of infection.
A review of the facility provided, Treatment Competency dated 04/19/23, revealed that LPN #1 had been deemed competent performing treatments including but not limited to; removes gloves and washes hands; wash hands before treatment; removes soiled dressing; removes gloves and wash hands; clean and apply dressing; wears gloves: disinfect scissors.
A review of the facility provided, Preventing Spread of Infection policy, revised 09/2023, included but was not limited to; Hand Hygiene continues to be the primary means of preventing the transmission of infection. Some situations that require hand hygiene: before and after direct resident contact, before and after changing a dressing, after handling soiled dressings, after handling soiled equipment, and after removing gloves.
c.) On 10/23/2023 at 1:57 PM, Surveyor #2 observed Resident #90's assigned Licensed Practical Nurse (LPN) perform an assessment of the resident's right upper arm (RUA) arteriovenous (AV) fistula (an abnormal connection between an artery and a vein). The LPN sanitized a stethoscope and then applied gloves. The LPN did not perform hand hygiene before applying the gloves to her hands. The LPN explained to the resident that she will be checking his/her access. The LPN had resident extend his/her right arm and stated to the surveyor, You take 2 fingers to feel the bruit. The LPN applied 2 fingers on the antecubital (crook of the elbow) area of the resident's right arm and the LPN stated that she could feel the area pulsating. The LPN then placed the stethoscope to the resident's antecubital area and stated to the surveyor that she could hear the thrill. The LPN then removed and discarded her gloves, closed the resident's overhead light and thanked the resident. The LPN did not perform hand hygiene after removing and discarding her gloves or sanitize the stethoscope after performing an assessment of the resident's access site.
A review of the admission Record reflected that Resident #90 was admitted to the facility with diagnoses which included, but were not limited to, acute ischemic heart disease (sudden reduction or blockage of blood flow to the heart), end stage renal disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and anemia (a condition in which the blood doesn't have enough healthy red blood cells and leads to reduced oxygen flow to the body's organs.)
A review of the Quarterly Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care, dated 08/18/2023, revealed that Resident #90 received a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of intact cognition.
On 10/27/2023 at 10:47 AM, in the presence of the survey team, the LNHA stated that it was important for the nurses to know about the dialysis access and perform hand hygiene when checking and or assessing the access site to prevent infection of the access site.
A review of the facility provided, Hand Hygiene policy, revised 10/2023, included but was not limited to; staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection. Policy: 2. Staff will perform hand hygiene when indicated.
A review of the facility provided, Preventing Spread of Infection policy, revised 09/2023, included but was not limited to; Hand Hygiene continues to be the primary means of preventing the transmission of infection. Some situations that require hand hygiene: before and after direct resident contact, before and after changing a dressing, after handling soiled dressings, after handling soiled equipment, and after removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to maintain the resident nurse call system to operate as designed with visual and audible signals at the nursing station for 1 of 21 residents ( Resident #15) on 1 of 2 units (Noble).
This deficient practice was evidenced by the following:
On [DATE] at 10:59 AM, the surveyor observed when Resident#15's call bell was illuminated, there was no audible or visual signal emitting from the resident call system console located at the Noble Unit nurse's station. At 11:06 AM, the surveyor observed the call light outside Resident #15's room was not illuminated (turned off).
On [DATE] at 11:40 AM, the surveyor observed that the nurse call light outside Resident #15's room was illuminated. The surveyor observed the Registered Nurse Unit Manager (RN UM) sitting at the nurse's station next to the resident call system console. At that time, the surveyor interviewed the RN UM who stated that when a resident activated the call light from their room, the call light will have a ringing sound and a red light will show on the resident call system console. The RN UM confirmed that Resident #15's call light was illuminated outside Resident #15's room but there was no audible or a red light visual emitting from the residents call system console located at the nurse's station. The RN UM stated that she will put in a work order for maintenance.
On [DATE] at 10:17 AM, the surveyor observed the nurse call light outside Resident #15's room was illuminated but there was no audible or visual signal emitting from the resident call system console located at the Noble Unit nurse's station.
During an interview with the surveyor on [DATE] at 10:20 AM, the RN UM stated that she had put in a repair request to maintenance yesterday and had notified the Director of Maintenance (DM). The RN UM confirmed that that resident call system console was still not emitting a visual or audible signal when the call light was illuminated for Resident #15's room. The RN UM further stated that she will notify the DM and that when the call system is not functional, the resident would be given an manual hand bell.
On [DATE] at 9:45 AM, the surveyor observed a gold hand bell on the overbed table in Resident #15's room. Resident #15 stated the call bell is still not fixed.
A review of the medical record revealed Resident #15 was admitted to the facility with diagnosis including but not limited to: Cerebral infarction (stroke), Chronic Obstructive Pulmonary Disease, anxiety and depression.
According to the Quarterly Minimum Data Set (MDS)( an assessment tool According to the admission Record, Resident #15 was admitted to the facility with the diagnoses which included but was not limited to Acute Respiratory Failure with Hypoxia (loss of oxygen), and Chronic Obstructive Pulmonary Disease,
The admission Minimum Data Set (MDS-an assessment tool utilized to facilitate the care of a resident), dated [DATE], indicated that the resident was cognitively intact and required moderate assistance with mobility and transfers. The MDS also indicated that the resident was on oxygen.
The surveyor reviewed the [DATE] Treatment Administration Record (TAR) which reflected a physician's order for O2 at 2 L/min via nasal cannula every day shift for SOBdated [DATE], Resident #15 had a BIMS score of 15 out of 15 indicative of intact cognition. The MDS also indicated that Resident #15 required extensive assistance of 2 people for bed mobility and transfers, and supervision for locomotion in a wheelchair on the unit. and impairment of both upper and lower extremity on one side.
During an interview with the surveyor on [DATE] at 2:28 PM, the Director of Maintenance (DM) and the Maintenance Technician (MT) provided the maintenance logbook from the Noble Unit that indicated that on [DATE], maintenance urgent call bell repair needed Room [Resident #15s room] . The MT stated that on [DATE] he checked the call light and found that the switch by Resident #15's bed was broken, and the call light could only be turned off by the nurse's station. It wasn't until the next day on [DATE] that the MT was made aware that the residents call system console was not functioning and he provided the resident with a hand bell. The DM stated that the vendor was contacted and would be in on [DATE] to fix the call light for Resident #15.
A review of the facility's policy titled, Call Lights: Accessibility and Timely Response, dated 09/22, that staff will report problems with a call light or a call system immediate to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied.
NJAC 8:39-31.2(e), 31.8(c)9

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to document assessments of the resident's condition by monitoring for complications after dialysis treatments were received at a certified dialysis center for 1 of 2 residents (Resident #61) reviewed for dialysis documentation.
This deficient practice was evidenced by the following:
On 8/24/21 at 11:20 AM, the surveyor observed Resident #61 seated in a wheelchair with oxygen infusing at 3 liters/minute via nasal cannula. The resident stated they went out of the facility for dialysis treatments on Monday, Wednesday, and Friday. Resident #61 informed the surveyor that the hemodialysis access site (Arteriovenous shunt/fistula) was not assessed by the facility nurse before leaving or after returning to the facility after dialysis.
A review of the current physician's order (PO) reflected an order for hemodialysis three days a week on Monday, Wednesday and Friday; Monitor Fistula in the Right Arm for patency, prevent injury and monitor for infection, pain and bleeding and monitor shunt site by palpating for thrill (vibration) and auscultating for bruit (assess blood flow) and notify the physician and dialysis staff of absence of thrill or bruit (A bruit (a rumbling sound that you can hear) A thrill (a rumbling sensation that you can feel).
The surveyor reviewed the admission record for Resident #61 which reflected the resident was admitted to the facility on [DATE] and had diagnoses which included but was not limited to End Stage Renal Disease (ESRD), dependent on renal dialysis.
The admission Minimum Data Set (MDS), an assessment tool dated 6/23/21, reflected Resident #61 had a Brief Interview for Mental Status (BIMS) score of 15 indicating they were cognitively intact.
On 8/26/21 at 11:00 AM, the surveyor observed Resident #61 seated in a wheelchair with oxygen infusing at 3 Liters/minute via a nasal cannula. Resident #61 stated that their fistula was not assessed prior to or upon returning to the facility from dialysis.
On that same day at 11:10 AM, the surveyor requested Resident #61's Dialysis Communication Record from the Registered Nurse/Unit Manager (RN, UM). The RN/UM provided the surveyor with the Dialysis Communication Record. The surveyor reviewed the records from 6/23/21-8/25/21 and observed that the Post Dialysis section which was to be completed by the receiving facility nurse were all blank.
On 8/26/21 at 11:15 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that she didn't know she was supposed to complete the Dialysis Communication log. The LPN further stated that she always assessed Resident #61 status post dialysis and although she had not completed the post dialysis forms with Resident #61 vitals, she documented her assessments of resident #61 in the Electronic Medical Record (EMR).
On that same day, at 11:30 AM, during an interview, the RN/ UM stated that the Nurse who received the resident status post dialysis should have assessed the resident and completed the Post Dialysis section of the forms which included assessment of the graft site (vascular access for Hemodialysis), any changes in the resident's condition post dialysis, vital signs, pain assessment and intervention.
At that time, the RN/UM and LPN reviewed Resident #61's EMR and were unable to provide any documentation indicating assessments were done post dialysis. The LPN stated she thought she had documented her assessments in the EMR and further stated I guess I didn't, but I should have. The RN/UM acknowledged that she should have reviewed the Dialysis Forms to ensure they were being completed.
The surveyor reviewed the facility's Dialysis policy dated 11/2012 and revised 3/2020, which indicated It is the policy of this facility to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. A Dialysis Communication Form will be sent with the resident to dialysis. Upon return from dialysis, the charge nurse will review and take note of any recommendations.
On 8/30/21 at 10:50 AM, the surveyor discussed the above observations and concerns with the Director of Nursing who acknowledged that the LPN should complete the pre and post dialysis sections of the Dialysis Communication Record and the RN/UM should review them to ensure they are being done. No further information was provided by the facility.
NJAC 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices identified during 1 of 1 wound treatment observation for Resident # 79.
This deficient practice was evidenced by the following:
On 8/25/21 at 11:08 AM, during the initial tour, Resident #79 was observed in bed, with eyes closed.
A review of Resident #79's Face Sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to, Parkinson's Disease, Type II Diabetes Mellitus, Hypertension and Schizo-Affective Disorder.
A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate care management dated 7/15/21, indicated a Brief Interview for Mental Status scored at 15, which indicated that the resident was cognitively intact.
The surveyor reviewed the August 2021 Physician Order Summary, which reflected a Physicians' order (PO) to cleanse sacral wound with Normal Saline (NS), apply Santyl, and pack with gauze, cover with dry dressing once a day (Day Shift). The same PO was also noted on the August 2021 electronic Treatment Administration Record (TAR).
On 8/27/21 at 10:26 AM, the surveyor along with another surveyor, observed the Registered Nurse (RN) perform a wound treatment for Resident #79's. The RN was observed treating a non-facility acquired Stage 4 pressure ulcer to the sacro-coccyx area. The RN was observed assisted by the Certified Nurse Assistant (CNA) in positioning of the resident during the treatment.
The surveyor observed the RN as she introduced herself to Resident #79. The RN then proceeded to wash her hands for 20 seconds. The surveyor observed the RN clean the overbed table with Microkill Sanitizing Disposable wipes.
The surveyor observed the RN place a plastic trash bag on the side of the resident's overbed table to be used for discarding all contaminated supplies. The surveyor then observed the RN remove her gloves and wash her hands for 20 seconds.
While the CNA repositioned Resident #79 to the left side, the surveyor observed the RN put on clean gloves and pour the NS bottle onto the gauze. The surveyor observed the RN start to cleanse the sacral wound from inner to outer motion. The RN then discarded the gauze and took another clean gauze, poured the NS bottle to wet the gauze and cleansed the wound again using inner to outer motion.
The surveyor observed that during the treatment process, the RN did not remove the dirty gloves she was using to cleanse the wound prior to proceeding to get another clean gauze, apply Santyl ointment onto the gauze and then placed the gauze to the sacral wound.
The surveyor observed the RN remove her gloves after the procedure was complete, wash her hands for 20 seconds, dry her hands with a paper towel and then used the same paper towel to close the faucet. The RN stated to the surveyor that she was done rendering the wound treatment and proceeded to sign the TAR. The surveyor observed that the RN did not disinfect the overbed table after she completed the treatment, utilizing the resident's overbed table.
On 8/27/21 at 2:00 PM, the surveyor discussed the above observations with the Regional Nurse and the Administrator. The Regional nurse stated that the RN should have used a new pair of clean gloves after cleansing the wound and before proceeding to apply the ordered ointment. The Regional nurse stated that the RN should have sanitized the overbed table after the treatment was completed. The Regional nurse further stated that the RN should have discarded the paper towel she used to dry her hands and used a clean, dry, new paper towel to close the faucet.
NJAC 8-39-19.4 (a)