Autumn Lake Healthcare At Oceanview

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # 2649488, 2597199Based on interviews, medical record review and review of pertinent facility documents on 10/30/2025 it was determined that the facility failed to: a.) complete a thorough investigation of an injury of unknown origin by ruling out abuse and neglect; b.) ensure it reported an injury of unknown origin to the New Jersey Department of Health.This deficient practice occurred for 1 of 3 residents reviewed for accidents and injuries (Resident #1). This deficient practice is evidenced by the following:A review of the admission Record (an admission summary) reflected that Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; Dementia (poor blood flow that causes memory and thinking problems) and cerebral infarction (lack of blood and oxygen to the brain that causes damage).A review of the admission Minimum Data Set, an assessment tool dated 09/23/2025, reflected that Resident #1 had a Brief Interview for Mental Status score (BIMS) of 00 out of 15, indicating that the resident was severely cognitively impaired. A review of a facility document labeled #2127 Bruise, Date: 10/18/2025, 12:07 revealed under Notes a 10/20/2025 entry; Alert Note -- On 10/18/25 at approx 10:45am [Resident #1] was observed with swelling and discoloration to the right hand, fourth finger. [Resident #1] unable to state what happened. Prior to incident, noted documentation of [Resident #1] becoming physically aggressive with staff during care. [Resident #1] was hitting and scratching the staff. [Resident #1] has a history of resisting care and combative behaviors. Risperdal was titrated on 10/15. MD made aware of bruising and swelling. PRN Tylenol administered for pain. X-ray of right hand ordered to r/o (rule out) fracture or dislocation. POA (Power of Attorney).made aware of incident. The document further revealed under Notes a 10/25/2025 entry, In conclusion, [Resident #1] did obtain a fracture to the fourth middle phalanx on [their] right hand due to combative behavior with care that was noted previously.A review of Resident #1's Weekly Skin Evaluation - V3 with an Effective Date: 10/18/2025 12:23 revealed under 4. Integrity .Description .Right hand ringer finger bruise/swelling.A review of Resident #1's Radiology Results Report with an Examination Date: 10/19/2025 18:19 revealed under INTERPRETATION: .IMPRESSION: .Fracture at the base of the fourth middle phalanx with impaction.A review of Resident #1's Order Summary Report (OSR) with active orders as of 10/30/2025 revealed an order for ortho (orthopedic) consult with dr [NAME] dated 10/20/2025.A review of Resident #1's Progress Notes (PNs) dated 10/20/2025 at 6:25 A.M. revealed, There is a fracture at the base of the fourth middle phalanx [Doctor] notified. Awaiting return response. A PN dated 10/20/2025 at 11:20 A.M. revealed orders obtained consult dr [NAME] ortho. A PN dated 10/22/2025 at 2:26 P.M. revealed, New orders from Ortho appointment boxer splint on buddy tape may remove for hygiene.A review of Resident #1's Care Plan (CP) revealed a focus, with an initiation date of 10/19/2025, of [Resident #1] has a fracture at the base of the fourth middle phalanx with impaction d/t (due to) combative/aggressive behaviors, arthritis, osteoporosis, and narrowing of the joint.A review of a facility provided document titled REPORTABLE EVENT RECORD/REPORT dated 10/21/2025 revealed under Today's Date 10/21/2025 and under Narrative: 3) that the physician, power of attorney and the ombudsman were notified.In a 10/30/2025 interview at 10:11 A.M. Certified Nursing Assistant #1 (CNA #1) stated she provided care to Resident #1 on 10/17/25 during the 3 P.M. to 11P.M. shift, specifically around 7P.M. She further stated that she and another CNA changed Resident #1 for bed. CNA #1 stated nothing was wrong with her hand on the 17th.In a 10/30/2025 interview at 11:23 A.M., Licensed Practical Nurse #1 (LPN #1) stated that CNA #2 came to her on 10/18/2025 and reported Resident #1's finger on their right hand had a bruise. LPN #1 further stated that when she saw Resident #1's hand just the tip was bruised but as the day went on the hand became bruised.In a 10/30/2025 interview at 11:44 A.M., when questioned about the reporting of the injury of unknown origin, the Director of Nursing (DON) stated, Well [Resident #1] is combative with care. I believe it was when they were getting her dressed. Probably the 3-11 shift, mostly because at that time before bed [Resident #1] was much more aggressive. The surveyor asked if the injury of unknown origin was reported to the New Jersey Department of Health and the DON replied, No we did not report to the state because it's not necessarily unknown origin because [Resident #1] was noted in PCC (Point Click Care the electronic medical record) to be more combative at that time. We assumed it was from this changing. She further stated, For us it wasn't of unknown origin.In an 10/30/2025 interview at 3:34 P.M., with the DON and the Licensed Nursing Home Administrator (LNHA), the DON stated Resident #1 had signs and symptoms of a potential injury on 10/18/2025 and that during the investigation she did not check other residents on the same unit or assignment for injuries to rule out abuse. The DON explained she did obtain statements from the staff on 10/20/2025 but she was unsure of what shifts provided statements. The DON stated the 18th was the weekend, so on Monday when management came back to work, we had everyone write statements. The statements are talking about previous encounters in general. The DON further stated that abuse was ruled out since Resident #1 had a note of aggressive behavior from the 17th and no allegations of abuse were reported. The DON went on to say, Yes, we did a thorough and complete investigation. We don't see it as an injury of unknown origin.A review of the facility's undated policy titled Abuse, Neglect and Exploitation revealed under IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse., and under B. Possible indicators of abuse include, but are not limited to.2. Physical marks such as bruises. A further review revealed under V. Investigation of Alleged Abuse, Neglect and Exploitation, A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigation include.5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.A review of the facility's undated policy titled Reporting Abuse to State Agencies and Other Entities/Individuals revealed under Policy Interpretation and Implementation: Should a suspected violation or substantiated incident of all [sic] alleged violation of abuse.Including injuries of unknown source.Should be reported to any covered individual including the facility administrator, or his/her designee, owner operator, employee, manager, agent, or contractor will promptly notify the following persons or agencies (verbally and written) of such incident. The Department of Health, The State Ombudsman, The Resident's Representative, The Resident's Attending Physician, Others as deemed appropriate.NJAC 8:39-9.4(f)

Based on observation and interview, it was determined that the facility failed to make survey results readily accessible to residents and visitors. This deficient practice was evidenced by the following:
On 01/07/2025 at 10:30 AM, the surveyor conducted the resident council task with five (5) facility long-term residents. When asked if the residents were made aware of the location of the most recent state survey results, 5 of 5 resident responded that they were not aware of the existence of a state survey book and were not notified as to where the most recent survey results were located.
On 01/07/2025 at 11:30 AM, the surveyor went to the front reception area to look for the State Survey Result Book. The surveyor did not visualize the State survey book. The surveyor asked the receptionist where the State Survey Results Book was, she replied she was not familiar with the book. The Surveyor did observe a books behind the reception desk. The surveyor reviewed the books, and identified the unmarked State Survey Results Book.
On 01/08/2025 at 09:46 AM, the surveyor went to the Serenity Unit Nursing Station. When the surveyor asked the staff at the desk where the State Survey Result Book was, they were not able to provide the book initially. The book was eventually located on a shelf behind the nursing station, above the counter, which would be unreachable and unattainable to a resident in a wheelchair.
On 01/08/2025 at 10:19 AM, the surveyor met with Administration to discuss the Resident Council Meeting. At that time, the concerns regarding the inaccessible State Survey Results were reviewed.
N.J.A.C. 8:39-9.4 (b)

Based on observations, interviews, record review, and review of other facility documentation, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. This deficient practice was observed for 2 of 25 sampled residents, (Resident #367 and #7) .
This deficient practice was evidenced by the following:
1. On 01/05/2025 at 09:45 AM, the surveyor observed Resident #367 lying in bed. Resident #367 stated they had not seen the doctor but just saw their bills.
A review of Resident #367's hybrid (electronic and paper) medical records (MR) from December 2024 - January 2025 revealed the following:
The admission Record (AR) reflected that the resident was admitted to the facility with diagnoses that included Hemiplegia (complete paralysis of one side of the body) and Hemiparesis (partial weakness on one side of the body) following Cerebral Infarction ( blood vessel blockage in the brain) Affecting Left Non-Dominant Side, Malignant Neoplasm (abnormal growth of tissue) of the Lungs.
A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/30/24 revealed that Resident #367 had a Brief Interview for Mental Status (BIMS) score of 14 of 15 which indicated that the resident was cognitively intact.
A review of the Electronic Medical Record (EMR) revealed the Nurse Practitioner (NP) visit progress notes (PN) dated 12/6/24, 12/9/24, 12/10/24, 12/11/24, 12/12/24, and 12/16/24. A further review of the PN did not reveal any PN from the attending physician from December 2024 to January 2025.
A review of the paper medical records did not reveal any PN from the attending physician from December 2024 to January 2025.
2. On 01/05/2025 at 09:55 AM, the surveyor observed Resident #7 waiting outside their room for a medical appointment.
A review of Resident #7's hybrid medical records from November 2024 to January 2025 revealed the following:
The admission Record reflected that the resident was admitted to the facility with diagnoses that included End Stage Renal (Kidney) Disease, Cerebral Infarction (blood vessel blockage in the brain).
A review of the most recent comprehensive MDS, an assessment tool used to facilitate the management of care, dated 12/03/24 revealed that the resident had a BIMS score of 13 of 15 which indicated that the resident was cognitively intact.
A review of the EMR revealed the NP visit progress notes PN dated 12/03/24, 12/10/24, 12/12/24, 12/17/24, and 12/19/24. A further review of the PN did not reveal any PN from the attending physician from December 2024 to January 2025.
A review of the paper medical records did not include documentation of the attending physician visit from November 2024 to January 2025.
During an interview with the surveyor on 01/08/2025 at 09:30 AM, Licensed Practical Nurse (LPN #2) stated that physicians make rounds and update their notes.
During an interview with the surveyor on 01/08/2025 at 10:05 AM , Licensed Practical Nurse/Unit Manager (LPN/UM #2) stated that after the physicians see the patients, they will document and flag the paper charts. LPN/ UM #2 further stated that the doctors (MD #1 and MD#2) have access to the electronic medical record.
During an interview with the surveyors on 01/08/2025 at 02:00 PM, the Director of Nursing (DON) stated that all physicians have access to the electronic medical record. The DON further said that some physicians did handwritten notes which should have been scanned and uploaded to EMR or placed in the residents' paper charts.
A review of the facility provided policy titled Physician Visits and Physician Delegation revised in October 2022, included under Policy Explanation and Compliance Guidelines section: 2. The Physician should: a. See resident within 30 days of initial admission to the facility. d. Date, write and sign a progress note for each visit.
NJAC 8:39-23.2 (b)

Based on interview and review of pertinent facility records it was determined that the facility failed to follow through on recommendations made by the consultant pharmacist (CP) during their monthly medication regimen review (MRR) in a consistent and timely manner. This deficient practice was observed for 1 of 5 residents (Resident #55) and was evidenced by the following:
On 01/07/2025 at 08:48 AM Resident #55 was observed lying in bed awake and alert. Resident #55 was pleasant and cooperative and answered surveyor questions. No maladaptive behaviors were observed, and Resident #55 did not appear to be in any distress. Resident #55 was observed to be confused at times.
According to the admission record, Resident #55 was admitted to the facility with the following but not limited to diagnoses: Alzheimer's disease early onset, dementia, anxiety disorder, major depressive disorder, and atherosclerotic heart disease.
A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 11/14/2024, revealed that Resident #55 had a Brief Interview for Mental Status score of 6/15 which indicated severe cognitive impairment.
On 01/07/2025 at 01:19 PM, the surveyor reviewed the past 6 months of consultant pharmacist (CP) therapeutic suggestions for Resident #55 during the monthly medication regimen review process. The CP made the following recommendation on 11/20/2024: PRN (as needed) medications that have not been used for over 60 days are recommended to be discontinued. Please consider discontinuing Diphenhydramine (an antihistamine). On 11/21/2024 the facility responded to the CP's therapeutic suggestion and indicated that the Diphenhydramine had been discontinued by writing D/c'd (discontinued) on the therapeutic suggestion sheet. However, when the surveyor reviewed the 11/1/2024-11/30/2024 Medication Administration Record (MAR) for Resident #55 to ensure that the medication had been discontinued by the facility, the MAR revealed that the order for Diphenhydramine was discontinued on 01/07/2025 at 0919 (9:19 AM). This was done approximately 45 days after recommendation and the same day the reports were made available to the survey team.
On 01/08/25 at 02:31 PM the surveyor conducted an interview with the facility Director of Nursing (DON). The surveyor asked the DON what the facility process was for responding to the CP's therapeutic suggestions once received by the facility and the DON told the surveyor that recommendations are addressed by unit managers, and they are completed prior to the next CP visit. I spot check them or I'll address something if I am notified. I do not regularly review them for accuracy or completion. The surveyor then asked the DON to provide the surveyor with the last date that the CP visited the facility for the monthly medication regimen review. The DON told the surveyor that the last visit to the facility by the CP was 12/23/2024.
A review of a facility policy titled Pharmacy Services-Role of the Consultant Pharmacist revealed the following under Policy Interpretation and Implementation:
Providing the facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review. The facility will review the reports before the next subsequent review is available.
NJAC 8:39-29.3(a)(1)

Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to ensure that specific target behaviors exhibited were documented as well as the non-pharmacological interventions attempted prior to the administration of an antianxiety medication. This deficient practice was identified for 1 of 1 resident reviewed for Psych (psychotropic)/Opioid side effects, (Resident # 45) and was evidenced by the following:
On 01/05/2025 at 09:52 AM, the surveyor observed Resident #45 in the unit activity room sitting in his/her wheelchair (w/c) at the table. Resident appeared lethargic, leaning forward in the w/c, and appeared to have difficulty staying awake.
A review of the EMR on 01/06/2025 at 01:00 PM, revealed the following:
According to the admission Record, Resident #45 was admitted to the facility with diagnoses including but not limited to: cognitive communication disorder, Alzheimer's disease late onset.
A review of the most recent Minimum Data Set (MDS) an assessment tool used to facilitate care dated 12/05/2024, revealed Resident #45 had a Brief Interview for Mental Status score of 10/15, indicating moderately impaired cognition. A further review indicated that the resident had wandering behavior 1 to 3 days and is taking an Antianxiety medication.
A review of the Order Summary Report with Active orders as of 12/01/2024 and 01/01/2025, revealed a physician order for Lorazepam (medication used to commonly treat anxiety) Oral Tablet 0.5 MG (milligrams) Give 0.5 mg by mouth every 6 hours as needed for agitation for 14 Days.
A review of the EMAR (Electronic Medication Administration Record) progress notes from 12/22/2024 through 1/5/2025 as follows:
Resident #45 received Lorazepam 52 times from 12/22/24 thru 1/5/25. There was no documentation in the EMAR progress notes for 23 of the 52 times of behaviors that Resident #45 exhibited and any non-pharmacological interventions that were attempted prior to administering the medication. Resident #45 received the medication on the following dates: 12/22/2024, 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/27/2024, 12/28/2024, 12/29/2024, 12/30/2024, 12/31/2024, 01/01/2025, 01/02/2025, 01/03/2025, 01/04/2025, and 01/05/2025.
A review of the care plan for Resident #45 revealed a Focus are of [resident name] has a behavior problem related to interfering with roommate care, pulling on the blinds to look out the window .can become agitated when redirected (hitting staff, verbally abusive towards staff) with Date Initiated: 02/09/2022. Under the Goal section resident will have fewer episodes of interfering with roommates' care. Interventions include but are not limited to: Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, monitor behavior episodes, and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.
During an interview with the surveyor on 01/08/2025 at 10:31 AM, Licensed Practical Nurse (LPN #3) was asked what the facility policy was for a resident who is prescribed a PRN (as needed) psychotropic medication (drugs that affect a person's mental state). LPN #3 replied psychiatry sees the resident and makes recommendations. We get family and physician approval. There is behavior charting for 14 days for adverse side effects or targeted behaviors. When asked where is this documented, LPN #3 stated in the EMR under progress notes. LPN #3 confirmed that Absolutely it is expected to document non-pharmacological interventions prior to administration and the final effect of the medication.
During an interview with the surveyor on 01/08/2025 at 10:36 AM, Licensed Practical Nurse/Unit Manager (LPN/UM #1) was asked what the facility policy was for a resident is who is prescribed a PRN psychotropic medication. LPN/UM #1 replied that prn antianxiety medications are 14 days only, and after that we reach out for new order from the physician. LPN/UM #1 went on to say for PRN we notify family and get consent prior to administering. The nurse prior to administration goes through nonpharmacological interventions such as walks, snacks and conversation. If that is ineffective, they administer the medication and document effective or not effective. LPN/UM #1 said the expectation is to document behaviors, non-pharmacological interventions attempted, and administer medication and document effect post administration.
During an interview with the surveyor on 01/08/2025 at 01:59 PM, the Director of Nursing (DON) was asked what the facility policy was for a resident who is prescribed a PRN psychotropic medication. The DON said it depends on the order. If the patient requests, or if they exhibit signs/symptoms of agitation we would give the medication. The nurses document on EMAR and there should be a section to note effective and go back and check. The DON confirmed yes, there should be documentation of any non-pharmacological interventions used and this would be in the EMAR progress notes. The DON also said yes, there should be documentation of signs and symptoms exhibited by the resident prior to administering the medication.
On 01/08/2025 at 01:13 PM, a review of a facility policy titled Use of Psychotropic Medication with a reviewed date of October 2024, revealed under Policy Explanation and Compliance Guidelines section: 4. The indications for use of any psychotropic drug will be documented in the medical record. b. For psychotropic drugs that are initiated after admission into the facility, documentation shall include the specific condition as diagnosed by the physician. ii non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation.
NJAC 27.1(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:
On 01/05/2025 from 08:54 to 9:38 AM,, the surveyor, accompanied by the Assistant Food Service Director (AFSD), observed the following in the kitchen:
1. Upon entry to the kitchen the surveyor observed three (3) staff actively working on the breakfast tray line. 3 of 3 female staff did not have hairnets and their hair was exposed while actively working with food. One (1) staff had lengthy hair in a ponytail, a second staff had lengthy hair in a bun style with a head band around their forehead and the third staff also had lengthy hair pulled back and in a hair tie. On interview the AFSD told the surveyor, Yes, we should have hair nets. I'm sorry.
2. Observation of the Walk-In refrigerator temperature log revealed that no temperatures were recorded for the following: 1/2/2025 PM, 1/3/2025 AM, 1/4/2025 AM and 1/5/2025 AM. According to the AFSD the morning and evening cook were responsible for recording refrigeration temps.
3. Observation of the prep table/sink adjacent to the walk-in refrigerator revealed what appeared to wilted lettuce and an unidentified white substance on the tile floor. In addition, several plastic portion control cups were observed under the table. When interviewed the AFSD agreed that the area had not been cleaned from the previous day.
4.In the dry storage area on a middle shelf of a multi-tiered storage rack a previously opened bag of dry pasta had no open or use by dates. On interview the AFSD agreed that previously opened food products required an open and use by date.
5. On an upper shelf of the walk-in refrigerator a Styrofoam take out style container contained a large baked potato. The container had no dates. In addition, a deep 1/4 pan contained baked beans and was covered with plastic wrap. The pan had no dates. A second deep 1/4 pan covered with clear plastic wrap contained red grapes, pieces of pineapple and pieces of honey dew melon. The pan had no dates. On a middle shelf an opened cardboard box contained iceberg lettuce heads. Visual inspection of the lettuce revealed that several heads of lettuce were brown and slimy on appearance. When interviewed the AFSD told the surveyor that all food products should be dated. The AFSD told the surveyor that she would throw them out and proceeded to remove the undated foods from the walk-in.
6. Prior to entering the walk-in freezer the surveyor observed the walk-in freezer temperature log attached to the door. The temperature log did not have internal freezer temperatures recorded for the following dates: 1/2/2025 PM, 1/3/2025 AM, 1/4/2025 AM, and 1/5/2025 AM. When interviewed the AFSD told the surveyor that the AM and PM cooks were responsible for recording the refrigerator and freezer temperatures.
A review of a facility policy titled Food Storage: Cold Foods, [company name] Policy 019, revised 2/2023, revealed under Procedures:
4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded.
5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
A review of a facility policy titled Staff Attire, [company name] Policy 024, revised 10/2023, revealed under Procedures:
1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.
A review of a facility policy titled Food Storage: Dry Goods, [company name] Policy 018, revised 2/2023, revealed under Procedures:
6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate.
N.J.A.C. 8:39-17.2 (g)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris and failed to have a cover over the opening of 3 of 3 garbage containers/dumpsters. This deficient practice was evidenced by the following:
On 01/05/2025 at approximately 9:30 AM, the surveyor, accompanied by the Assistant Food Service Director (AFSD), observed four (4) yard dumpsters that were designated for garbage in the facility parking lot. According to the AFSD three of the dumpsters were designated for garbage and one dumpster was designated for recyclables. 3 of 3 dumpsters designated for garbage had the contents of bagged trash exposed due to the dumpster lids not being fully closed. Each dumpster had two (2) plastic lids to cover the garbage dumpster. Dumpster #1 had 2 of 2 plastic lids in the open position which exposed the bagged garbage. Dumpster #2 had 1 of 2 lids opened exposing bagged garbage and dumpster #3 had 1 of 2 lids opened exposing bagged garbage. On interview the AFSD told the surveyor that the garbage area was a shared responsibility between the kitchen staff and environmental staff, and they were responsible for the maintenance of the area. In addition to the exposed contents of the dumpsters the area surrounding the garbage dumpsters was observed to have garbage on the ground. The garbage included plastic cups, disposable gloves, plastic bags, plastic milk crates and other unidentified debris.
On 01/09/2025 at 10:47 AM, during a meeting with facility administration the Licensed Nursing Home Administrator agreed that garbage dumpsters must be covered at all times.
A reviewed of a facility policy titled Dispose of Garbage and Refuse, [company name] Policy 030, dated 8/2017, revealed the following under Policy Statement: All garbage and refuse will be collected and disposed of in a safe and efficient manner. In addition, the following was revealed under Procedures: 1. The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster is maintained in a manner free of rubbish or other debris.
NJAC 8:39-19.3(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical records, and other facility documentation, it was determined that the facility failed to follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 4 of 6 staff (2 Housekeepers, 2 Certified Nursing Assistants) to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy.
This deficient practice was evidenced by the following:
Reference: Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; after contact with blood, body fluids, or contaminated surfaces; immediately after glove removal.
CDC recommendations for Hand Hygiene: Updated February 27, 2024:
https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html#cdc_clinical_safety_best_practices_recomm-recommendations
1. On 01/07/2025 at 09:16 AM, the surveyor observed the housekeeping staff (HSK #1) transfer bags of soiled linens wearing gloves from the subacute rehab (SAR) unit soiled linen room to a rolling covered linen cart. HSK #1 removed their gloves but did not wash nor sanitized their hands after removing the gloves. HSK #1 pushed the cart in the hallway until it reached the laundry soiled linen room.
On 01/07/2025 at 12:35 PM, the surveyor observed Certified Nursing Assistant (CNA #2) in room [ROOM NUMBER] exit the bathroom with wet paper towels in her hand. CNA #2 proceed to touch the cover of a foot-operated trash can with bare hands to discard the wet paper towels. CNA #2 did not wash nor sanitized hands after touching the trash can cover.
On 01/08/2025 at 12:03 PM, the surveyor observed CNA #1 pickup soiled linens from the floor and place them in a plastic bag without wearing gloves. He then placed the bag into a bin in the soiled linen room. CNA #1 returned to the resident room and picked up a soiled pink blanket and walked in the hallway carrying the pink blanket unbagged. CNA #1 then opened the soiled linen door and threw the blanket into a bin. CNA #1 did not wash nor sanitized their hands after discarding the spoiled blanket. CNA #1 then went to the clean linen cart, obtained clean linen then proceeded to put the clean linen on the mattress in the resident's room.
2. On 01/07/2025 at 09:20 AM, the surveyor observed HSK #1 sort soiled linens in the laundry soiled linen room wearing only gloves. Another housekeeping staff #2 (HSK #2) put on gloves, opened the soiled linen plastic bags, and sorted dirty linens. Neither HSK staff wore any other PPE.
On 01/07/2025 at 10:23 AM, the surveyor observed two yellow reusable gowns hanging from a wall in the laundry washing area next to the soiled linen room. When surveyor asked HSK #2 when they should use the reusable gowns, HSK #2 stated we have these things and I guess we are supposed to wear them. that they were supposed to wear them but have never used them.
On 01/08/25 at 01:05 PM, the surveyor interviewed the Housekeeping District Manager (HDM). The HDM stated that there were reusable yellow gowns in the sorting area to wear while sorting dirty laundry as well as gloves.
During an interview with the surveyor on 01/08/2025 at 01:05 PM, the Housekeeping District Manager (HDM) was asked who collects the soiled linens. The HDM stated that porters collect soiled linens and should be wearing gloves when transferring soiled linen bags to the rolling cart. HDM further stated that after transferring bags to the cart, porters should remove their gloves and wash their hands if soiled, if not soiled they need to use sanitizer to sanitize their hands. At that time, the HDM stated that there were reusable yellow gowns in the sorting area to wear while sorting dirty laundry as well as gloves.
A review of the facility policy titled Hand Hygiene updated in April 2024, under Policy Explanation and Compliance Guidelines revealed: 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, .after touching a patient or the patient's immediate environment; after contact with blood, body fluids or contaminated surfaces; immediately before putting on gloves and after glove removal.
A review of facility policy titled Laundry Operation with a revised date of 06/2016, under section Transferring Soiled Linen included but was not limited to; Statement . all soiled linen must be covered during transportation and while being stored on unit or floors.
A review of facility policy titled Laundry Operation with a revised date of 06/2016, under section Sorting Soiled Linen included but was not limited to; 2. As soiled linens are sorted out into the proper wash classifications, employees must wear the proper protective equipment (PPE), which includes gloves and a protective apron.
NJAC 8:39-19.4 (a)(1); 21.1 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and review of other facility documentation, it was determined that the facility failed to contain nebulizer/respiratory equipment (a machine used to administer medication in the form of a mist inhaled into the lungs) delivery systems in protective coverings for 4 of 4 residents (Resident #26, #42, #55 and #368) reviewed for respiratory care. This deficient practice was evidenced by the following:
1. On 01/05/2025 at 10:28 AM, Surveyor #1 observed a nebulizer machine on top of Resident #55's dresser. The nebulizer machine was not currently in use. The nebulizer mask was lying on top of the dresser with the interior of the mask facing upwards. The mask was not covered while not in use and was exposed to contamination. The nebulizer tubing was dated but not able to determine exact date except 24. The surveyor asked Resident #55 if he/she had used the nebulizer and Resident #55 responded that he/she had not used the machine.
On 01/07/2025 at 08:46 AM, Resident #55 was observed lying in bed, awake and alert. Resident #55 was pleasant and cooperative. No nebulizer machine was observed in the residents room on this observation Resident #55 was the only occupant of room.
According to the admission record, Resident #55 was admitted to the facility with the following but not limited to diagnoses: Alzheimer's disease early onset, dementia, anxiety disorder, major depressive disorder and atherosclerotic heart disease.
A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 11/14/2024, revealed that Resident #55 had a Brief Interview for Mental Status (BIMS) score of 6,which indicated severe cognitive impairment. According to Section O of the MDS, Resident #55 did not receive oxygen therapy.
On 01/07/2025 at 10:57 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #55 as follows:
A review of the 12/1/2024-12/31/2024 Medication Administration Record (MAR) revealed that Resident #55 received Ipratropium-Albuterol Solution 0.5-2.5(3) MG/3ML (milligrams/milliliter) 1 vial inhale orally every 6 hours as needed for chest congestion on 12/3/2024 at 05:36. According to the MAR no other treatments were provided following the administration on 12/3/2024. According to the MAR the order was discontinued on 1/5/2025 at 1500, which indicated that the order was discontinued after the survey team left the faciity on 1/5/2025. The order was actively in place during the observation of the nebulizer machine/mask on the initial tour/observation on 1/5/2025 at 10:28 AM as described above.
A review of Resident #55's comprehensive care plan did not reveal a care plan for the use of respiratory equipment, specifically a nebulizer.
On 01/08/2025 at 09:03 AM, a review of the EMR revealed a progress note dated 12/2/2024, Resident has occasional n/p (non productive) cough. Received new order for duoneb as prn (as needed) as RX (prescription) for cough and congestion. Course Rhonchi (low-pitched, coarse lung sounds that are often described as snoring or gurgling) heard in bilateral upper lobes.
During an interview with the surveyor on 01/08/2025 at 10:21 AM, Licensed Practical Nurse/ Unit Manager (LPN/UM #1) was asked what the facility practice was for respiratory equipment when not in use. LPN/UM#1 responded that the mask and O2 (oxygen) tubing when not in use are to be placed in a plastic bag. The oxygen tubing is to be changed every Sunday on 11-7 shift. The surveyor then asked LPN/UM #1 why is was important to protect respiratory equipment when not in use and LPN/UM #1 responded, It's an infection control practice to ensure resident safety.
On 01/08/2025 at 02:17 PM during a meeting with the facility administration including the Licensed Nursing Home Administrator, Director of Nursing (DON), Regional Director of Nursing, and Infection Preventionist the surveyor asked what the facility practice was for respiratory equipment when not in use. The DON told the surveyors that the nebulizer mask should be bagged when not in use and tubing was to be dated weekly. The DON further explained that nebulizer masks are to bagged when not in use and the reason was It is important for infection prevention.
2. On 01/06/2025 at 11:28 AM, during the initial tour of the facility, Surveyor #2 observed Resident # 26 in bed. At that time, Resident # 26 was wearing a nasal cannula (tube used to deliver oxygen through the nostrils). Upon further observation, the surveyor was unable to determine if the oxygen tubing was dated however, Surveyor #2 also observed a nebulizer face mask (mask used to deliver aerosolized medications) on top the nightstand attached to the nebulizer machine by the elastic band of the face mask. The face mask was not inside a container or bag exposing it to air.
On 01/06/2025 at 12:48 PM, the surveyor reviewed Resident # 26's Electronic Medical Record (EMR) as follows:
A review of Resident # 26's EMR revealed he/she had a diagnosis of but not limited to Multiple Sclerosis and Pneumonia.
A review RFesident #26's most recent MDS dated [DATE], under Section O, did not indicate that Resident #26 received oxygen therapy.
Under Orders section of EMR Resident #26 had a physician order for Ipratropium-Albuterol Solution Nebulization Solution, 3 milliliters to inhale orally via nebulizer every 4 hours as need for shortness of breath.
According to the Medication Administration Record (MAR) for the month of January 2025, it was revealed that Resident #26 received Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML on 01/3/2025 at 05:15 PM, 01/04/2025 at 07:30 AM , and 01/05/2025 at 08:00AM.
A review of Resident #26's Comprehensive Care Plan did not address the use or care of respiratory equipment, specifically a nebulizer.
3. During the initial tour on 01/05/2025 at 09:26 AM, Surveyor #3 observed a BiPAP (Bi-Level Positive Airway Pressure) face mask (a mask that is connected to a BiPAP machine which delivers pressurized air to help with breathing) on the windowsill of Resident #42's room. It was unbagged with the interior part exposed to the air. Resident #42 pointed to their BiPAP machine on the side table to their right. Another unbagged BiPAP face mask was lying beside the BiPAP machine with the interior part exposed to the air and contamination The resident stated that they used the machine every night.
On 01/07/2025 at 08:30 AM, Surveyor #3 observed a BiPAP face mask in the same position as observed on the initial tour, unbagged and on the windowsill. An additional unbagged BiPAP face mask was located on the side table to the with the interior exposed to air and contamination.
On 01/08/25 at 09:55 AM, Surveyor #3 observed the unbagged BiPAP masks located on the windowsill and on the side table to the right. Surveyor #5 showed LPN #2 the masks and they stated that the masks should have been bagged. LPN #2 proceeded to bag the BiPAP face masks.
According to the admission Record, Resident #42 was admitted to the facility with diagnoses including but not limited to: Surgical Aftercare following surgery on the Respiratory System (the group of organs in the body that enables breathing), Obstructive Sleep Apnea (a sleep disorder in which breathing stops), Respiratory Failure and Malignant Neoplasm (abnormal growth of tissue) of the Left Lung.
A review of the most recent MDS, dated [DATE] reflected a BIMS score of 15 out of 15, which indicated that the resident was cognitively intact. Section O of the MDS did not reflect that Resident #42 received BiPAP therapy.
A review of the active Physician's Orders (PO) did not reflect an order for BiPAP machine use until 01/08/2025, when an order to apply BiPAP at night with settings at 10/5 and remove in AM was initiated. A further review of the PO revealed a previous order for BiPAP machine use initiated on 9/3/2024 and was discontinued on 10/3/2024.
4. During the initial tour on 01/05/2025 at 10:02 AM, Surveyor #3 observed Resident #368 in bed with continuous oxygen (O2) at 2 liters per minute (lpm) via nasal cannula (NC). The oxygen tubing was observed to be unlabeled and undated.
According to the admission Record , Resident #368 was admitted to the facility with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (a lung disease that makes breathing difficult), Systemic Inflammatory Response Syndrome, and Pleural Effusion (too much fluid buildup in the space between the lungs and chest wall).
A review of the most recent comprehensive MDS dated [DATE], reflected a BIMS score of 13 out of 15 which indicated that the resident was cognitively intact.
A review of the active Physician's Orders reflected an order with an initiated date of 1/5/2025 for continuous supplemental O2 therapy at 2 lpm via NC. The PO also included another order for changing the O2 tubing every night shift every Sunday was initiated on 1/7/2025.
A review of the Baseline Care Plan initiated on 1/4/2025 reflected oxygen therapy at 3 lpm via NC.
On 01/08/2025 at 02:20 PM, the survey team met with the facility administration including the Director of Nursing (DON). The DON stated that the facility protocol would have the nasal cannula and tubing bagged when not in use and dated. The DON stated that there should be an order for it. DON further stated that the same goes for nebulizers and BiPAP machine use.
A review of a facility policy titled Oxygen Administration updated in October 2024, included under Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. 5.d. If applicable, change nebulizer tubing and delivery devices every 72 hours or per facility policy and as needed .e. Keep delivery devices covered in plastic bag when not in use.
The facility was unable to provide a policy addressing the use of Nebulizer equipment.
NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 01/05/2025 at 9:30 AM, during the initial tour of the Serenity unit, Surveyor #2 observed the PTAC unit in room [ROOM NUMBER], the right side was damaged and peeling dry wall down the entire right side. On the left side of the PTAC unit was pool noodle type material affixed to it and damage to the wall beside it. The closet was missing a drawer for A-side bed and their wardrobe had a stain on the right side.
On 01/07/2025 at 10:00 AM, Surveyor #2 observed the hallway floor on Serenity had dark colored stains and where the baseboard and floor meet were dark marks along the entire length of the baseboard in both hallways.
On 01/08/2025, Surveyor # 2 observed the following on the Serenity Unit:
12:01 PM, the wall in the small common area observed had peeling wallpaper by the rainbow.
12:02 PM, the baseboard was peeling off by janitor door.
12:03 PM, observed the wallboard on the support column had holes and was peeling paint. There were also chipped tiles on the wall outside room [ROOM NUMBER].
12:05 PM, observed the door frames of multiple rooms had chipped paint and rust looking areas exposed.
12:06 PM, observed chipped floor tiles outside room [ROOM NUMBER].
12:10 PM, observed the radiator cover in room [ROOM NUMBER] was chipped and peeling paint.
12:11 PM, observed in room [ROOM NUMBER] the toilet grab bars in bathroom had a green and white colored substance on it.
12:12 PM, observed missing wall tiles in the hall across from room [ROOM NUMBER] by the fire extinguisher cabinet.
12:15 PM, observed the wall between the nurse's station and the emergency eye wash station the door had peeling paint and dark marks.
12:16 PM, observed the door frame to nurse's station had peeling paint.
12:17 PM, observed uneven, cracked floors upon entering and exiting the unit.
On 1/9/25 at 10:28 AM, Surveyor #3 observed on the following on B wing :
10:28 AM, outside room [ROOM NUMBER] the paint was peeling in patches exposing the previous paint beneath.
10:32 AM, paint was chipped outside room [ROOM NUMBER] on the corner of the wall.
10:33 AM, mismatched chipped paint outside room [ROOM NUMBER].
10:34 AM, the baseboard edging around the nurse's station was chipped and scuffed.
10:36 AM, observed in the smoking patio cigarette butts disposed of on the ground and not in the smoking materials receptacle.
10:37 AM, observed the switch plate on wall in B wing dayroom, was cracked and broken.
10:39 AM, observed the ledge in the B wing dayroom was chipped and lifting.
10:47 AM, observed the doorway to the B wing dayroom had chipped paint at the door jam.
10:47 AM, observed the endcap for the railing across from B wing nurse's station was missing.
10:51 AM, observed the baseboard was missing and the wall was damaged on right side of nurse's station near the Unit Manager' office.
10:52 AM, observed the ceiling tile was stained outside B wing dayroom in the ocean hall,
On 01/08/2025 at 12:53 PM, surveyor #2 interviewed the District Manager for the Housekeeping/laundry department who stated there was no current director of housekeeping at the facility at this time. When asked what the process was for cleaning rooms was the Manager stated the process for cleaning the units in morning was, they would pull the trash from the resident's rooms, when the food trucks arrived the housekeeping staff would move to the common areas to clean. The housekeepers would sweep, wipe horizontal surfaces with disinfectant, and mop the floors. In the bathrooms all surfaces were disinfected including the toilet and the floor was mopped.
The porter was responsible for removing soiled linens and trash then dust and mop the floors using the auto scrubber machine daily. Unit inspections and individual room carbolizations were done monthly. If something is found to be in need of repair then staff were to verbally notify the Director of Maintenance (DOM). Cleaning of corners and edges was a scheduled monthly task.
On 01/09/2025 at 10:05 AM, surveyor #2 interviewed the DOM who stated the facility conducted environmental rounds and would look for things in the room that needed attention. When asked if there was a schedule or a checklist to follow when performing rounds and the DOM stated, Can't say we have schedule of rounds or checklist.
A review of the facility's undated Resident Room Cleaning policy revealed . All resident rooms are to be cleaned daily . the process of 7 steps of cleaning and disinfecting resident rooms . empty trash, .using EPA approved solutions disinfect all horizontal surfaces . clean walls, wipe down all vertical surfaces .clean and disinfect the bathroom . dust mop . all corners and along all baseboards must be dust mopped to prevent buildup . damp mop .
NJAC 8:39-31.4(a)
Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain the resident environment, equipment, and living areas in a safe, sanitary and homelike manner. This deficient practice was idenfied on 2 of 3 units, (Serenity and B Wing) and was evidenced by the following:
On 01/05/2025 at 10:44 AM, Resident # 3 approached Surveyor # 1 and stated that he/she wanted Surveyor #1 to go to his/her room (#126) to observe a concern. Resident #3 stated that he/she reported mold to the Maintenance Department many times yet it remains present in his/her room and that he/she is concerned that it is affecting his/her health. Resident #3 directed Surveyor #1 to the area of the packaged terminal air conditioner unit (PTAC) under the window. Resident #3 pointed out an area in the corner to the left side of the PTAC and around 2 pipes protruding from the floor.
Surveyor #1 observed the area to the left of the PTAC unit covered with a board, Surveyor #1 moved the board from the wall and observed scattered dark blackish stains in and around the corners of the wall and floor and in clustered groups. There were also dark shiny substances observed on the pipes.
Resident #3 stated that the Maintenance Department did spray the area once, but the substance remains and that he/she was told that they did all they could. Resident #3 was not satisfied with the outcome.
On 01/09/25 at 09:59 AM during an interview with Surveyor # 1, the Director of Maintenance (DOM), stated that he was aware of the issue of mold and that there are other resident rooms affected by this. The DOM stated that they have been treating these areas however to rectify, the pipes from the old units need to be removed. The DOM stated that a plumber has been out to give an estimate and that they are waiting on approval to contract for repair.

Based on observation, interview, record review, and review of pertinent facility documents it was discovered that the facility failed to a.) follow professional standards of practice specifically by not changing nebulizer (device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) tubing weekly and as needed, and b).failed to maintain respiratory equipment in a sanitary manner and follow their policy and procedure for respiratory equipment care. The deficient practice was identified for 2 of 3 residents (Resident #20 and #90) investigated for Respiratory Care.
The deficient practice was evidenced by the following:
a.) On 01/03/2024 at 10:36 AM during the initial tour, Surveyor # 1 observed Resident # 20 in his/her room. At that time, Surveyor # 1 observed a nebulizer set on top of a cardboard box adjacent to the resident's bed. The nebulizer had a tube connected to it and at the other end was a bagged face mask. The tube had tape attached to it that revealed the hand written date of 12/25.
On 01/05/2024 at 09:22 AM, Surveyor # 1 observed Resident # 20 in his/her room. At that time, Surveyor # 1 observed the nebulizer set on top of a cardboard box adjacent to the resident's bed. The nebulizer had a tube connected to it and at the other end was a bagged face mask. Again, the tube had tape attached to it that revealed the hand written date of 12/25. At that time, Resident # 20 said he/she does receive nebulizer treatments and that the last time was the night before.
A review of Resident # 20's Quarterly Minimum Data Set (MDS; and assessment tool) dated 12/18/2023, revealed under section I that Resident # 20 had a diagnosis of but not limited to Asthma (a condition in which your airways narrow and swell and may produce extra mucus).
A review of Resident # 20's Order Summary located in the EMR revealed a physician's order for Ipratropium-Albuterol (medicine used to prevent and treat symptoms such as wheezing and shortness of breath) Inhalation Solution 0.5-2.5 (3) Milligram (Mg) /3 Milliliter (mL). According to the order, the Ipratropium-Albuterol was to be administered through oral inhalation every four hours as needed. The order became active in the EMR on 12/13/2023.
A review of Resident # 20's December Medication Administration Record (MAR) located in the EMR revealed that the Ipratropium-Albuterol was administered at least four times since December 25th, 2023.
On 01/05/2024 at 11:35 AM, during an interview with Surveyor # 1, Licensed Practical Nurse (LPN) #1 said nebulizer tubing is changed once a week, every Sunday during the 11 PM-7 AM shift.
On 01/09/2024 at 12:37 PM during an interview with Surveyor # 1, the Director of Nursing (DON) replied, Weekly when asked how often nebulizer tubing is changed. The DON replied, No when asked should tubing remain on the nebulizer past seven days.
A review of the undated facility policy titled, Nebulizer Therapy revealed under subsection, Care of Equipment to, 8. Change nebulizer tubing weekly and as needed.
b.) During the initial tour of the facility on 1/3/2023 at 11:30 AM, Surveyor #2 observed Resident #90 in his/her room sitting on the bed. Surveyor #2 observed the nebulizer machine with attached face mask and tubing on Resident #90's nightstand. The nebulizer tubing and face mask were not in use and exposed to air and contamination.
On 1/4/2024 at 10:22 AM, Surveyor #2 observed Resident #90 sitting on his/her bed reading a magazine. The nebulizer machine tubing and face mask were not in use and exposed to the air and contamination.
According to the admission Record, Resident #90 was admitted to the facility with the following but not limited to diagnoses: Pneumonia (inflammation and fluid in the lungs that causes infection), Hypertension (high blood pressure), Anemia (lack of red blood cells to carry oxygen to the body's tissue), and Cardiomyopathy (enlargement of the heart).
According to the 11/26/2023 Comprehensive Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, Resident #90 had a Brief Interview for Mental Status Score of 15, indicating they were cognitively intact. Section I of the MDS revealed Resident #90 had an active diagnosis of pneumonia, anemia, Asthma, Chronic Obstructive Pulmonary disease (COPD - chronic inflammatory lung disease), or Chronic Lung Disease. According to section J of the MDS Resident #90 had shortness of breath or trouble breathing when lying flat.
A review of Resident #90's Physician Order Summary Report (POS) located in the electronic medical record (EMR) revealed a physician's order dated 12/12/23 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML. 3 ml inhale orally every 8 hours as needed for SOB (shortness of breath).
A review of Resident #90's December 2023 Medication Administration Record (MAR) revealed Ipratropium Albuterol Inhalation was administered on the following dates: 12/16/23, 12/17/23, 12/21/23- 12/24/23, 12/26/23, 12/27/23, 12/29/23, 12/20/23.
A review of Resident #90's January 2024 MAR revealed that the Albuterol Inhalation Solution was administered on 1/2, 1/4, 1/5, 1/6, and 1/8/2024.
On 1/8/2024 at 9:48 AM, Resident #90 was in the bedroom sitting on the bed. Resident #90's nebulizer machine was located on the nightstand and the face mask was observed in a plastic zip lock type bag. The tubing was dated 1/8. Resident #90 told the surveyor, I have been using my nebulizer for treatments twice a day.
Surveyor #2 reviewed a physician's order located in the EMR dated 1/8/2024 to change nebulizer tubing weekly on Sundays, 11-7 shift.
On 1/8/2024 at 11:03 AM Surveyor #2 interviewed Licensed Practical Nurse (LPN #2). LPN #2 stated, Nebulizer tubing is changed and labeled every Sunday. It gets placed in a bag and is labeled as well. It gets changed every 7 days. The surveyor then asked LPN#2 what happens when the nebulizer is not in use. LPN #2 replied, When the nebulizer is not in use, the mask should be stored in the bag.
On 1/9/2024 at 12:38 PM the surveyor conducted an interview with the facility Director of Nursing (DON). The surveyor asked what the policy and procedure is for storing the nebulizer mask when not in use. The DON stated, The mask should be protected when not in use. It should be placed in a bag.
The surveyor reviewed an undated facility policy titled, Nebulizer Therapy. The following was revealed under the heading, Care of Equipment:
7. Once completely dry, store the nebulizer cup and mouthpiece in a secure bag.
8. Change nebulizer tubing weekly and as needed.
N.J.A.C 8:39-27.1 (a)

2. On 01/03/2024 at 09:47 AM, during initial tour of the Serenity Unit, Surveyor #2 observed a common bathroom and shower utilities located by the Activity Room. Surveyor #2 then observed a towel on top of the toilet. The towel had a brown stain on it. The toilet had brown stains inside. Surveyor #2 observed paper towels and toilet paper wrappers on the floor. A vinyl baseboard near the toilet was partially detached from the wall exposing the dry wall.
On 01/08/2024 at 09:03 AM, Surveyor #2 observed the same common bathroom and shower area. Surveyor #2 then observed a towel on top of the toilet. The towel had a brown stain on it. The toilet had brown stains inside. Surveyor #2 observed paper towels, toilet paper wrappers, and surgical mask on the floor. A vinyl baseboard near the toilet was partially detached from the wall exposing the dry wall. At that time, the Activity Director followed Surveyor #2 to the common bathroom and shower area and stated that the area was actively utilized by residents, and that he/she would call someone to clean it.
N.J.A.C. 8:39-31.4(a)
Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain services necessary to maintain a sanitary, orderly, and comfortable interior. The deficient practice was identified for 3 of 3 shower rooms and 1 out of 5 residents investigated (Resident #9) under the Environmental Task.
The deficient practice was evidenced by the following:
On 01/04/2024 at 10:09 AM, Surveyor # 1 observed Resident # 9 in his/her room. At that time, Resident # 9 said housekeeping doesn't clean his/her room every day, and that there was mold around the bottom of the toilet. At that time, Surveyor # 1 observed a crumbled paper towel on Resident # 9's floor next to the bed. Surveyor # 1 observed a detached floor baseboard exposing drywall. At that time, Surveyor # 1 then observed Resident # 9's bathroom. Surveyor # 1 observed the trash can. The trash can did not have a trash bag in it. Lastly, Surveyor #1 observed a black substance around the caulk on the bottom of the toilet.
On 01/08/2024 at 09:41 AM, Surveyor # 1 observed Resident # 9's bathroom. At that time, the bathroom was observed with paper towels on the floor, a yellow stain on the wall behind the sink, and brown stains on the toilet and seat.
On 01/05/2024 at 12:14 PM, Surveyor # 1 observed the shower room on B wing. At that time, Surveyor # 1 observed bath towels on the floor. Surveyor # 1 then observed the shower stalls. At that time, Surveyor # 1 observed a plunger in a bucket, geriatric recliner chair, a pillow, a detached wooden door, a picture frame and a mechanical lift. At that time, Surveyor #1 observed the whirlpool tube. Inside the whirlpool tub, Surveyor # 1 observed discolored stains, a beige strap, and a blue tube.
On the same date and time outside the shower stall, Surveyor # 1 observed what appeared to be a wrapper from a feminine product on the top of a table. In another shower stall, Surveyor # 1 observed the top pump of a soap dispenser along with a bag of liquid soap on the top of a storage bin. Surveyor # 1 also observed water stains on two ceiling tiles. Lastly, Surveyor # 1 observed a broken electrical outlet plate on the wall.
On 01/05/2024 at 12:24 PM, Surveyor # 1 observed the shower room on the subacute unit. At that time, Surveyor # 1 observed a tied, clear plastic bag that revealed what appeared to be clothing inside. Surveyor # 1 also observed an unpackaged incontinence brief on top of a storage bin in the shower stall.
On 01/08/2024 at 9:44 AM, Surveyor # 1 again observed the B wing shower room. At that time, Surveyor # 1 observed the top pump of a soap dispenser on a table outside the shower. Surveyor # 1 observed paper towels on the floor in the bathroom area of the shower room. Lastly, Surveyor # 1 observed a geriatric recliner chair, a pillow, and several unpackaged incontinence briefs.
On 01/08/2024 at 12:33 PM, Surveyor # 1 observed the water fountain near the physical therapy gym. At that time, Surveyor # 1 observed a discolored stain and unidentified residual matter from spout to drain.
On 01/08/2024 at 11:38 AM, during interview with Surveyor # 1, Housekeeper (HK) # 1 said the resident rooms were cleaned once a day and as needed. At that time, HK # 1 replied, sweeping, dusting, changing toilet papers and soaps, wipe down tables, AC [air conditioning] vents . when asked by Surveyor # 1 what room cleaning entails. He also mentioned bathrooms are done last. Secondly, HK # 1 said the shower rooms were cleaned daily at the beginning of the day. Lastly, HK # 1 replied, Cleaning floors, picking everything off the floor, cleaning door knobs, sanitizing walls, changing soaps, bagging and removing linens . when asked by Surveyor # 1 what shower room cleaning entails.
On 01/08/2024 at 12:16 PM, during interview with Surveyor # 1, the Director of Environmental Services (DES) said the resident rooms were cleaned daily on day shift daily. He replied cleaning the bathrooms, surfaces, and walls when asked by Surveyor # 1 what cleaning a resident's room entailed. He concluded by saying that dust mop and wet mop were used on floors.
On the same date and time during the same interview with Surveyor # 1, the DES confirmed shower rooms are cleaned daily. At that time, The DES stated It should not look like that when Surveyor # 1 made him aware of their observations.
A review of an undated facility policy titled SHOWER ROOM CLEANING POLICY revealed under subsection titled, PROCDURES that, B. Follow 7-Step Method: 1. Pull trash. Wipe can and if necessary, replace liner. 2. Fill Dispensers. Soap, paper, and etc. 3. Dust Mop. Pick up trash, use a dust mop before using water in the room.
A review of an undated facility policy titled, Environmental Services Guidelines revealed under section, Routine cleaning of horizontal surfaces that All horizontal surfaces such as tabletops, window ledges, bedside stands, counter, sinks, tubs, shower floors, etc. will be cleaned daily with an acceptable hospital-grade disinfectant/germicide . Also, the policy revealed under section Trash that All trash collection containers will be lined with plastic bags to prevent leakage into the primary container and for the protection of the housekeeping staff during collection and transfer.

Based on interview, record review, and review of pertinent facility documents, 1). it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical and nursing needs specifically by failing to include focuses and interventions for a respiratory diagnosis and 2). failing to implement Care Plan interventions for fall prevention. The deficient practice was identified for 2 of 3 residents (Resident # 20 and # 90) investigated for Respiratory and 1 of 2 residents (Resident # 46) investigated for Falls. The deficient practice is evidenced as follows:
1a). On 01/03/2024 at 10:36 AM during the initial tour of the facility, Surveyor # 1 observed Resident # 20 in his/her room. At that time, Surveyor # 1 observed a nebulizer (device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) adjacent to the resident's bed.
On 01/05/2024 at 09:22 AM, Surveyor # 1 observed Resident # 20 in his/her room. At that time, Surveyor # 1 observed the nebulizer set on top of a cardboard box adjacent to the resident's bed. At that time, Resident # 20 said he/she does receive nebulizer treatments and that the last time was the night before. Further, he/she said that he/she had pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid) weeks ago.
A review of Resident # 20's Quarterly Minimum Data Set (MDS; and assessment tool) dated 12/18/2023, revealed under section I that Resident # 20 had a diagnosis of but not limited to Asthma (a condition in which your airways narrow and swell and may produce extra mucus).
A review of the list of facility residents who smoke cigarettes revealed that Resident # 20 was a smoker.
A review of the Electronic Medical Record (EMR) revealed that Resident # 20 had a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease (a group of diseases that cause airflow blockage and breathing-related problems).
A review of Resident # 20's Order Summary located in the EMR revealed a physician's order for Ipratropium-Albuterol (medicine used to prevent and treat symptoms such as wheezing and shortness of breath) Inhalation Solution 0.5-2.5 (3) Milligram (Mg) /3 Milliliter (mL). According to the order, the Ipratropium-Albuterol was to be administered through oral inhalation every four hours as needed. The order became active in the EMR on 12/13/2023.
A review of Resident # 20's Care Plan located in the EMR revealed a focus that he/she is a smoker that was revised on 09/26/2023. The interventions did not include any information regarding Resident # 20's respiratory status, respiratory medications and/or diagnoses. In it's entirety at that time, the Care Plan did not include any focuses or interventions regarding Resident # 20's respiratory status, respiratory medications and/or diagnoses.
A review of Resident # 20's progress notes located in the EMR revealed that on 12/13/2023, he/she had a deep cough and unclear lung sounds. At that time, the Physician started Resident # 20 on Ceftin 250milligrams (an antibiotic). A chest X-RAY was also ordered at that time that later revealed a, small right base infiltrate (a substance denser than air that is in the lungs).
On 01/09/2024 at 12:37 PM during an interview with the surveyor, the Regional Director of Nursing stated, If they have a diagnosis of COPD [Chronic Obstructive Pulmonary Disease] and Asthma they should have a focus. During the same interview, the Director of Nursing replied, In a timely manner. We review them quarterly. when the surveyor asked when a care plan should be implemented.
A review of the undated facility policy titled, Care Plans, Comprehensive Person-Centered revealed under number, 7. The comprehensive, person-centered care plan:, b. described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .
8:39-11.2 (e)2
3. On 01/04/2024 at 12:39 PM, Surveyor #3 observed Resident #46 in the Activity Room on Serenity Unit. Resident #46 was in his/her chair. Surveyor #3 did not observe an audible device (a device that detects position changes) being used for this resident.
On 01/05/2024 at 09:15 AM, Surveyor #3 observed Resident #46 in the Activity Room on Serenity Unit. Resident #46 was sitting in his/her chair. Surveyor #3 did not observe an audible device being used for this resident.
On 01/05/2024 at 09:28 AM, Surveyor # 3, in the presence of the Activity Director, checked Resident # 46's chair and did not observe any audible device. At that time, the Activity Director stated, Oh yeah, there should be one [audible device]. It's usually right here [pointing at the back of the chair]. Let me double check. The Activity Director checked the chair one more time and stated, It's not there, but it should.
A review of admission Record found in the Electronic Medical Record (EMR) revealed that Resident #46 had diagnoses, including but not limited to acquired absence of left leg below knee, dementia (an impaired ability to remember, think, or make decisions) need for assistance with personal care, bipolar disorder (an illness that causes unusual shifts in mood, energy, and concentration), and psychosis (a condition characterized by a loss of contact with reality).
A review of Resident #46's Quarterly Minimum Data Set (MDS; an assessment tool) dated 11/14/2023 revealed that the resident had a Brief Interview for Mental Status (BIMS; a screening tool) score of 10/15 indicating moderate cognitive impairment. Further, the MDS revealed that Resident #46 had a previous history of falls and used bed and chair audible device on daily basis.
A review of Physician's Orders found in the EMR revealed an order dated 04/16/2023 for electronic chair alarm check placement and function every shift for fall prevention.
A review of Resident #46's Care Plan (CP) initiated on 08/21/2029 and revised on 10/30/2023 revealed Focus: [Resident's name] is at risk for falls r/t [related to] gait and balance problems, BKA [below knee amputation], psychoactive drug use, h/o [history of] falls. Furthermore, the same CP revealed an intervention of electronic chair alarm check placement and function initiated on 02/12/2023.
A review of the Treatment Administration Record (TAR) found in the EMR for December of 2023 and January of 2024 indicated that the chair audible device was being checked for placement and functionality every shift.
A review of Quarterly AUTM Fall Risk Evaluation dated 11/25/2023 revealed that Resident #46 scored 17.0 which indicated high risk for falls.
On 01/08/2024 at 09:20 AM, during an interview with surveyor #3, a Certified Nurse Aide (CNA #1) stated, Yes, [he/she] has both when asked if Resident #46 was using chair or bed alarms. Furthermore, CNA #1 stated, Yes, if [he/she] is in bed, we put the bed alarm for [him/her]; and when he/she is out of bed, he/she should have the chair alarm when asked by Surveyor #3 if Resident #46 should use the alarm at all times. During the same interview, CNA #1 also said that it was important to use audible device for Resident #46 because it prevented him/her from falling and related injuries.
On 01/08/2024 at 10:45 AM, during an interview with Surveyor #3, a Licensed Practical Nurse/Unit Manager (LPN/UM #1) said that interventions such as an audible device required a physician's order and had to be added to the CP. Furthermore, LPN/UM #1 said that it was expected of nurses and CNAs to apply audible devices. LPN/UM #1 stated, So they don't fall. It gives us a chance to get to them before they fall when asked by Surveyor #3 why it was important to apply functional audible device as per physician's order and care plan.
On 01/09/2024 at 12:37 PM, during an interview with Surveyor #3, the Director of Nursing (DON) and Regional Director of Nursing stated, Yes when asked if care planned interventions such as an audible chair device should be implemented in practice by appropriate staff. Furthermore, the DON said that nurses and CNAs were responsible for application of audible chair devices, and that Resident #46 should have had the device applied while out of bed in his/her chair. Lastly, the DON stated, It was intervention because of his/her history of falls, to prevent him/her from any falls and injuries related to a potential fall. It allows us to respond to the resident before they fall when asked by Surveyor #3 about the importance of audible chair device application for Resident #46.
A review of facility provided undated policy titled, Care Plans, Comprehensive Person-Centered revealed under number four that Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including right to . receive the services and/or items included in the plan of care.
A review of facility provided undated policy titled, Resident Alarms revealed under the subsection titled, Monitoring and modification that b. When alarms are utilized, additional monitoring shall be provided, including but not limited to i) verifying alarms are used in accordance with the resident's care plan.
N.J.A.C. 8:39-27.1(a)
1b). During the initial tour of the facility on 1/3/2023 at 11:30 AM, Surveyor #2 observed Resident #90 in his/her room sitting on the bed. Surveyor #2 observed a nebulizer machine an with attached face mask and tubing on Resident #90's nightstand. The nebulizer tubing and face mask were not in use and exposed to air and contamination.
On 1/4/2024 at 10:22 AM, Surveyor #2 observed Resident #90 sitting on his/her bed reading a magazine. The nebulizer machine, tubing, and face mask were not in use and exposed to air and contamination. Resident #90 stated, I am on isolation precautions because my roommate tested positive for Covid. I have tested negative once but will be tested again today.
According to the admission Record, Resident #90 was admitted to the facility with the following but not limited to diagnoses: Pneumonia (inflammation and fluid in the lungs that causes infection), Hypertension (high blood pressure), Anemia (lack of red blood cells to carry oxygen to the body's tissue), and Cardiomyopathy (enlargement of the heart).
According to the 11/26/2023 Comprehensive Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, Resident #90 had a Brief Interview for Mental Status Score of 15, indicating they were cognitively intact. Section I of the MDS revealed Resident #90 had an active diagnosis of pneumonia, anemia, asthma, Chronic Obstructive Pulmonary disease (COPD - chronic inflammatory lung disease), or Chronic Lung Disease. According to section J of the MDS Resident #90 had shortness of breath or trouble breathing when lying flat.
A review of the Physician Order Summary Report (POS) located in the electronic medical record (EMR) revealed a physician's order dated 12/12/23 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML. 3 ml inhale orally every 8 hours as needed for SOB (shortness of breath).
A review of Resident #90's December 2023 Medication Administration Record (MAR) revealed Ipratropium Albuterol Inhalation was administered on the following dates: 12/16/23, 12/17/23, 12/21/23- 12/24/23, 12/26/23, 12/27/23, 12/29/23, and 12/20/23.
A review of Resident #90's January 2024 MAR revealed that the Albuterol Inhalation Solution was administered on 1/2, 1/4, 1/5, 1/6, and 1/8/2024.
A review of Resident #90's Care Plan date initiated 12/5/2023, revised on 12/5/2023, revealed that there were not any focus, goals or interventions for respiratory diagnoses or respiratory medications.
A review of Resident #90's Care Plan located in the EMR, initiated on 1/3/2024, revised on 1/3/2024, revealed a focus on Isolation for exposure to Covid-19 times 7 days. Interventions included contact/droplet precautions, infection will resolve with no complications, wear a mask during care, monitor for dehydration, poor appetite, respiratory assessment, and vital signs (temp) every shift.
Surveyor #2 reviewed the progress notes (PN) located in the electronic medical record (EMR). According to a PN dated 1/6/2024, Resident #90 complained of cough and congestion. The physician orders reveled that Resident #90 was started on Azithromycin, Mucinex and Prednisone for 5 days for an Upper Respiratory Infection (URI).
On 1/8/2024 at 11:10 AM, Surveyor #2 interviewed Licensed Practical Nurse Unit Manager (LPN/UM #2). The surveyor asked LPN/UM #2 what is the facility care plan process. LPN/UM#2 stated, The baseline care plan is completed by the unit manager within 48hrs of admission. The comprehensive care plan is done by MDS Coordinator. Some areas that should be included are diet, wounds, code status, smoking, certain medications, and peg tubes. The surveyor then asked should there be a care plan for respiratory diagnoses. LPN/UM #2 stated, Yes, if the resident has oxygen or nebulizer treatments there should be a care plan for it. The surveyor then asked if Resident #90 had any respiratory issues/diagnoses. LPN/UM #2 stated, Resident #90 was admitted with a diagnosis of congestive heart failure but isn't on oxygen. I do see an order for a nebulizer treatment every 8 hours as needed. They should have a care plan for the nebulizer treatment. It should have been added to the care plan by either the Unit Manager or the MDS Coordinator.
On 1/8/2024 at 11:33 AM, Surveyor #2 conducted an interview with the MDS Coordinator. The MDS Coordinator stated, The baseline care plan is completed by the unit manager upon admission. I complete all the initial care plans for the subacute unit. If a resident is admitted with a respiratory diagnosis, then I will add a care plan for respiratory, such as oxygen. The MDS coordinator further explained, If a nebulizer treatment or oxygen is ordered after the initial care plan is created by me then the Unit Manager is responsible for adding it to the care plan. The surveyor then asked if nebulizer treatments should be included in the resident's care plan. The MDS Coordinator stated, Yes, they should be.
On 1/9/2024 at 12:37 PM during an interview with the surveyors, the Regional Director of Nursing stated, If they have a diagnosis of COPD and or asthma, they should have a focus on the care plan. There is not a specific care plan for the use of a nebulizer. If we do a review of the care plan, we can add it. The surveyor then asked when a care plan should be implemented. The Director of Nursing replied, In a timely manner. We don't have a specific date or time frame. We review them quarterly.
The surveyor reviewed the facility policy titled Care Planning - Interdisciplinary Team, undated. The following was revealed under the heading, Policy Interpretation and Implementation:
1. Resident care plans are developed according to the timeframes and criteria established by 483.21.
The surveyor reviewed the facility policy titled Care Plans, Comprehensive Person-Centered, undated. The following was revealed under the heading, Policy Interpretation and Implementation:
12. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change.
N.J.A.C. 8:39-11.2 (e)2

Based on observation, interview, record review and review of other pertinent facility records, it was determined that the facility failed to accurately implement a physician prescribed fluid restriction order for 1 of 1 resident (Resident #91) on 1 of 3 units (subacute) reviewed for dialysis. This deficient practice was evidenced by the following:
On 01/04/2024 at 09:40 AM the surveyor observed Resident #91 observed in their room after completion of their breakfast meal. Resident #91 was lying in bed. When asked by the surveyor how their appetite was Resident #91 responded, Not good. Resident #91 suspected he/she had lost weight.
According to the admission record, Resident #91 was admitted to the facility with the following but not limited to diagnoses: Encephalopathy (a disease in which the brain is affected by some agent or condition, such as viral infection or toxins in the blood), end stage renal disease, acquired absence of kidney, and moderate protein-calorie malnutrition.
According to the Resident Assessment Instrument/Minimum Data Set (MDS), an assessment tool, dated 12/26/2023, Resident #91 had a Brief Interview for Mental Status score of 12 out of 15, indicating moderate cognitive impairment. Section GG of the MDS revealed that Resident #91 was an independent eater and required either partial/moderate or substantial/maximal assistance with most other activities of daily living. Section I indicated an active diagnosis of end-stage renal disease. In addition, Section K revealed Resident #91 received a therapeutic diet and Section O of the MDS revealed Resident #91 received hemodialysis on admission and while a resident at the facility.
Review of the Order Summary Report with active orders as of: 12/31/2023, revealed Resident #91 had the following physician order:
Fluid Restriction 960 ml (milliliters) daily 640 ml daily for dietary, 320 ml daily for nursing (106 ml each shift) every shift for ESRD (end stage renal disease) on dialysis. Order Date: 12/27/2023 Start Date: 12/27/2023.
Review of the 12/1/2023-12/31/2023 and 1/1/2024-1/31/2024 Medication Administration Record (MAR) revealed that Resident #91 had documentation of receiving nursing fluid restriction of 106 ml per shift of fluid from 12/27/2023 evening shift up to and including 1/9/2024 day shift.
A review of Resident #91's comprehensive care plan revealed a care plan focus of Hemodialysis r/t (related to) renal failure Date Initiated: 12/05/2023 and Revision Date: 12/05/2023. The following Intervention(s) were observed: Fluid restriction 960 ml daily 640 ml daily for dietary, 320 ml daily for nursing (106 ml each shift). Date Initiated 12/29/2023.
On 01/04/2024 at 12:56 PM the surveyor observed Resident #91 at the lunch meal served in their room. After gaining permission, the surveyor reviewed Resident #91's lunch meal ticket. The meal ticket indicated that Resident #91 was to receive a Renal diet for the lunch meal on 1/4/2024. Resident #91 received 1 C (cup) Buttered Cheeses Ravioli, 1/2 C Garlic [NAME] Beans, Dinner Roll, Margarine x 1, and Chilled Peaches 1/2 C, and 6 oz (ounces) of hot coffee. Resident #81 consumed 100% ravioli, 100% garlic green beans, 100% dinner roll, and 0% peaches (didn't like, too chopped up.) Resident #91 stated, I ate good because I got raviolis today. Further review of Resident #91's meal ticket did not reflect any fluid restriction for the lunch meal or that Resident #91 in fact had a fluid restriction.
On 01/05/2024 at 12:45 PM the surveyor reviewed the week 2 Friday lunch menu. The menu revealed the following: Lemon dill tilapia filet or rotisserie chicken thigh, broccoli florets or green peas, roasted red skin potatoes or seasoned rice, dinner roll/bread/margarine, and pineapple tidbits. The surveyor then observed Resident #91's lunch tray. The tray consisted of tilapia, seasoned rice, dinner roll and pineapple tidbits. Resident #91 received 4oz milk and 6oz coffee on their lunch tray (300ml). Review of Resident #91's lunch meal ticket on the tray did not indicate that Resident #91 was on a fluid restriction.
On 01/09/2024 at 11:22 AM during a review of the electronic medical record (EMR) the surveyor observed that Resident #91 had the following progress note:
12/27/2023 14:22
General Nurse Note
Note Text: New orders received from dialysis to discontinue ferrous sulfate as resident gets IV venofer at dialysis. Continue taking right arm dressings off following dialysis in the morning on Tues, Thurs, Sat. Resident to start 32 oz daily fluid restriction. and to take 2 tablets of sevelamer Carbonate 800 mg to equal 1,600 mg, with the first bite of every meal, 7 days a week. MD Dr. [NAME] aware
On 01/09/2024 at 11:34 AM the surveyor conducted an interview with the facility Food Service Director (FSD) and District Manager (DM) of food service. The surveyor asked the FSD how she is notified when a resident is placed on a fluid restriction. The FSD responded, Nursing brings a diet requisition to me alerting that a resident is on a fluid restriction. The surveyor asked the FSD if she currently had any residents in the facility on a fluid restriction. The FSD said, I don't think I do have anybody on a fluid restriction at this time. The (DM) replied, According to meal tracker (a computer system used to keep track of resident diet prescriptions and generate meal plan tickets) I do not have any resident on a fluid restriction at this time. The surveyor then asked the FSD if she currently had Resident #91 on a fluid restriction for dietary. The FSD stated, I do not have that Resident #91 is on a fluid restriction. I will have to pull my requisitions from the month of December. The FSD then told the surveyor, I checked my requisitions from the month of December, and I have no requisition form to indicate that Resident #91 was on a fluid restriction.
On 01/09/2024 at 12:30 PM the DM provided the surveyor with copies of Resident #91's meal plan tickets for the breakfast, lunch, and dinner meals from 12/27/2023 up to and including 01/08/2024. The meal tickets did not indicate that Resident #91 was on a fluid restriction of 640 ml from dietary.
On 01/09/2024 at11:46 AM the surveyor conducted an interview with Licensed Practical Nurse (LPN #3) and LPN (#4) who were assigned to Resident #91's unit. The surveyor asked the LPN's the process for implementing the physician ordered fluid restriction for Resident #91. The LPN's replied, We have a certain amount of fluid from nursing and from dietary, which is 640 ml from dietary daily and 320ml or 106 ml per shift from nursing. Dietary gets notified via a diet requisition form from nursing that is sent to the kitchen. Nursing is responsible for notifying dietary of any changes in diet and fluid changes via the use of the diet requisition form. LPN #4 then stated that dialysis recommended the fluid restriction the fluid restriction be implemented for Resident #91. LPN #4 then provided the surveyor with a copy of Resident #91's Diet Requisition Form, dated 12/27/2023. The form indicated that Resident #91 was on a fluid restriction with a dietary total of 640 ml and a nursing total of 320 (106 q shift (every)). LPN #4 then told the surveyor, The only way dietary would be aware of a resident being on a fluid restriction is if nursing issues the kitchen a requisition to notify foodservice of a diet change.
The surveyor reviewed the facility provided policy titled Fluid Restriction, reviewed, and updated - May 2021. The following was revealed under the heading Policy Statement: It is the policy of this facility to provide fluid restriction as ordered by the physician. In addition, the policy revealed the following under the heading Policy Interpretation and Implementation:
The Nursing Department will notify the Dietary Department of the fluid restriction order.
The fluids will be distributed over breakfast, lunch and dinner meals and documented on the tray card.
Supervision at tray line will assure accuracy of fluid restriction by the dietary department.
N.J.A.C. 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 handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:
On 01/03/2024 from 9:34 to 10:12 AM, the surveyors, accompanied by the Food Service Director (FSD) observed the following in the kitchen:
1. The meat slicer on a stainless steel counter was observed to be cleaned/sanitized and covered while not in use. The FSD confirmed that the meat slicer was cleaned, sanitized, and not in use. Further observation of the underside of the slicing wheel/ blade revealed brown unidentified food debris on the bottom of the blade guard. The FSD stated, The meat slicer needs to be re-cleaned. FSD then directed a staff member to clean the meat slicer.
2. In the walk-in freezer a container of breakfast gravy was observed on a middle shelf. The label read, Prepared 11/22. Use by date 12/22. The FSD stated, It was dated incorrectly, and it should be good for 90 days.
3. On an upper shelf a previously opened package of frozen bacon was wrapped in clear plastic wrap had no dates. The FSD stated, We are throwing it away because there is no date.
4. The outside walk-in freezer had unidentified debris littered on the floor. There was a plastic curtain from the door entrance lying on the floor. The FSD stated, I cleaned the floors 2 months ago. We have a cleaning schedule for it, but I ran out of the cleaner.
On 01/05/2024 from 10:35 to 10:53 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN #5) observed the following in the Serenity pantry:
1. On the second shelf of the refrigerator a red cup with pudding inside had no dates.
2. An unidentified Wawa paper wrapped item was on the bottom shelf of the pantry refrigerator. The item had no name or date on it to identify who it belonged to and when it was placed in the refrigerator. LPN #5 stated, Residents leftovers should be labeled with their name and the date. I will toss the items that do not have a name or date on them.
On 01/05/2024 from10:38 to10:50 AM the surveyor, accompanied by LPN #6, made the following observations on the B-Wing Pantry:
1. A Brazi Bites Bacon, Egg, & Cheddar sandwich in the freezer had a manufacturer's Best By: 10/04/2023. On the inside door of the refrigerator a quart container of Vanilla Spice Flavored Egg Nog had a manufacturer's Best By date of [DATE]. In the unlocked bottom drawer of the refrigerator, a take-out style container with a clear plastic lid contained unidentified food. The container had no name and no date. On interview LPN#5 told the surveyor, Everybody is responsible for monitoring the refrigerator. I'm going to throw these in the trash bin.
On 01/09/24 from 10:04 AM to 10:38 AM the surveyors accompanied by the FSD observed the following in the kitchen:
1. The wall adjacent to the designated handwashing sink in the break down room/area, which is located next to the ice machines external scoop holder had an unidentified yellow substance/splash stain down the wall. There was unidentifiable black debris, an old mouse trap, and butter and creamer containers littering the floor near a floor drain. The FSD agreed that the break down area needed to be cleaned. The FSD stated, This area is on the current cleaning schedule, and it should be deep cleaned once a week. It should be wiped down daily and any visible debris should be swept up. The District Food Service Manager swept and mopped the area and scrubbed the wall area in the presence of the surveyors.
According to the cleaning schedule provided to the surveyors from the FSD the PM [NAME] 2 is responsible to sweep and mop the walk-in cooler and freezers on Tuesdays.
A review of the kitchen cleaning schedule for the week ending 12/23/23 provided to the surveyors from the FSD revealed that they cleaned the break down area from the hand sink to the cooler was completed on 12/23/23 and initialed off by staff.
The surveyor reviewed the facility policy titled Food Storage: Cold Foods, HCSG Policy 019, revised 2/2023. The following was revealed under the heading Procedures:
5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
The surveyor reviewed the facility policy titled Equipment, HCSG Policy 027, revised 9/2017. The following was revealed under the heading Procedures:
1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.
3. All food contact equipment will be cleaned and sanitized after every use.
The surveyor reviewed the facility policy titled Foods Brought in by Family/Visitors, undated. The following was revealed under the heading Policy Interpretation and Implementation:
Perishable foods must be stored in re-usable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date.
The nursing staff will discard perishable foods on or before the use by date.
N.J.A.C. 18:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # 166936
Based on interviews, medical records review, and review of other pertinent facility documentation on 12/11/2023, it was determined that the facility failed to follow standards of clinical practice for notification of the physician in a timely frame for laboratory results of a resident (Resident #2) that was received. The facility also failed to follow its policy titled Notification of Change.
This deficient practice was evidenced by the following:
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
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 admission Record (AR), Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Unspecified Fracture of Left Femur, Initial Encounter for Closed Fracture, Vascular Parkinsonism, Mild, Recurrent Major Depressive Disorder and Unspecified Dementia, Unspecified Severity Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.
A review of the Minimum Data Set (MDS), an assessment tool dated 11/3/2023, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15, indicated the Resident was cognitively intact.
Review of the Order Summary report (OSR)Active Orders as of 07/21/2023 included the following Physician's Orders (POs): Urine Specimen for UA, (Urine Analysis) C&S (Culture and Sensitivity) one time only for 1 day.
Review of Resident #2's progress notes revealed the following: On 7/26/2023 at 11:43 A.M., awaiting C&S. On 7/30/2023 at 10:04 P.M., Resident C&S came back faxed to MD (Medical Doctor) awaiting response. On 7/31/2023 at 8:45 A.M., NP (Nurse Practitioner) from MD office called this AM to review C&S results. States no treatment at this time due to number of bacteria in urine not requiring treatment. On 7/31/2023 at 2:46 P.M., Received a fax from MD office this afternoon with new orders for Keflex 500mg (antibiotic used to treat urinary tract infection) BID for 7 days, FloraQ(probiotic) daily for 14 days.
Review of Resident #2's Laboratory results report for Comprehensive Metabolic Panel/Urinalysis with Microscopic/ Culture Urine revealed the following information: Collection date:7/24/2023 at 6:00 A.M., Received date: 7/24/2023 at 11:52 A.M., Reported date: 7/26/2023 at 12:18 P.M.,
During an interview on 12/11/2023 at 11:47 A.M., the Assistant Director of Nursing (ADON) stated it usually takes 2-3 days to obtain the completed results of UA, C&S from the laboratory. She further stated once the lab is completed, it automatically shows up in Point Click Care (PCC) under the lab section of each resident and all the nurses have access to check a resident's lab results. The ADON stated, if there was a pending C&S results, it should be captioned on the shift -to-shift report for all nurses to follow up. She further stated, it is the responsibility of the nurse caring for a resident to follow up on their lab results. She also informed the Surveyor that her expectation is for all Nurses to notify the MD once the completed UA, C&S results is received, and it should all be documented in PCC. When asked by the Surveyor if the MD was notified of Resident #2's C&S results prior to 7/30/2023, the ADON said I am not sure why the nurse didn't call the MD, I personally would call the MD for a positive C&S results.
During an interview on 12/11/2023 at 1:49 P.M., the Director of Nursing (DON) in the presence of the ADON confirmed that the reported date on Resident #2's lab results (7/26/2023) is the date the lab results were received by the facility and the MD/NP should have been notified of the lab results on 7/26/2023.
During an off-site interview on 12/12/2023 at 12:00 P.M., the NP acknowledge Resident #2 was their patient at the time. She further stated an order for antibiotic was given once the faxed C&S result was reviewed on 7/31/2023. The NP stated, the facility should have notified the MD's office of the C&S results that was received on 7/26/2023 and document.
The Surveyor attempted to reach the MD caring for Resident #2 during this period but was unable to reach the MD for an interview.
Review of the updated facility policy titled Notification of Changes revealed Under Policy Statement, The purpose of this policy is to ensure the facility promptly informs the residents, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Under Policy Interpretation 3. Circumstances that require a need to alter treatment. This may include a. new treatment. I. Onset of communicable or infectious disease (such asCovid-19)
N.J.A.C.: 8.39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT#: NJ163054
Based on interviews, medical records review, and review of other pertinent facility documentation on 7/25/2023, 7/31/2023, and 8/1/2023, it was determined that the facility failed to follow standards of clinical practice for medications and treatments administration as ordered by the Physician as being administered for 2 of 5 residents (Resident #2 and #4) reviewed for documentation. The facility also failed to follow its policy titled Charting and Documentation.
This deficient practice was evidenced by the following:
1. According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Unspecified Fracture of Left Femur, Initial Encounter for Closed Fracture, Vascular Parkinsonism, Mild, Recurrent Major Depressive Disorder and Unspecified Dementia, Unspecified Severity Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.
A review of the Minimum Data Set (MDS), an assessment tool dated 5/3/2023, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15, indicated the Resident was cognitively intact. The MDS also revealed Resident #2 needed extensive one-person physical assistance with most ADLs.
A review of the Order Summary report (OSR)Active Orders as of 12/1/2022 included the following Physician's Orders (POs):
Air mattress check placement and function Q (every) shift, dated 11/7/2022.
Zinc Oxide External Ointment 20% (Zinc Oxide Topical)). Apply to sacrum topically every shift for prevention, dated 11/2/2022.
Zinc Oxide External Paste 25% (Zinc Oxide (Topical)). Apply to B/L (Bi-lateral) buttocks topically every shift for prevention, dated 11/2/2022.
A review of the OSR for Resident #2 Active Orders as of 3/1/2023 included the following POs:
Compression stockings, mild, B/L (Bi-lateral) LE (Lower Extremity) every day and evening shift for Hypotension apply in am (a.m), off at hs (bedtime), dated 2/23/2023.
Dermagran Skin Protectant External Ointment (Aluminum Hydroxide) Apply to B/L buttocks topically every shift for prevention, dated 1/6/2023.
Offload b/l (bi-lateral) heels while in bed every shift for blanchable redness, dated 11/1/2022.
Q (Every) 2-hour toileting every shift, dated 11/10/2022.
WBAT (Weight Bearing As Tolerated) to left LE (Lower Extremity) every shift for wound healing, dated 11/16/2022.
Melatonin Oral Tablet 3MG (milligrams) (Melatonin) Give 2 tablets by mouth in the evening for insomnia 2 tab (tablets)=6mg, dated 12/7/2022.
A review of the Medication Administration Record (MAR) dated 12/1/2022 -12/31/2022 for Resident # 2 revealed the following POs were not administered because there was no documented evidence that the staff gave the medication to the Resident, as evidenced by the following:
Melatonin Oral Tablet 3MG (milligrams) (Melatonin) Give 2 tablets by mouth in the evening for insomnia 2 tabs (tablets) =6mg at 10:00 p.m. on 3/15/2023 and 3/23/2023 were blank.
A review of the Treatment Administration Record (TAR) dated 12/1/2022-12/31/2022 revealed the following POs were not administered because there was no documented evidence that the staff gave the treatment to the Resident as evidenced by the following:
Air mattress check placement and function Q shift on the Night [shift] on 12/2/2022 was blank.
Offload b/l (bi-lateral) heels while in bed every shift for blanchable redness on the Night [shift] on 12/2/2022 was blank.
Q 2-hour toileting every Night [shift] on 12/2/2022 was blank.
WBAT (Weight Bearing As Tolerated) to left LE (Lower Extremity) every shift for wound healing on the Night [shift] on 12/2/2022 was blank.
Zinc Oxide External Ointment 20% (Zinc Oxide Topical)). Apply to sacrum topically every shift for prevention on the Night [shift] on 12/2/2022 was blank.
Zinc Oxide External Paste 25% (Zinc Oxide (Topical)). Apply to B/L (Bi-lateral) buttocks topically every shift for prevention on the Night [shift] on 12/2/2022 was blank.
A review of the Treatment Administration Record (TAR) dated 3/1/2023-3/31/2023 for Resident #2 revealed the following POs were not administered because there was no documented evidence that the staff gave the treatment to the Resident as evidenced by the following:
Compression stockings, mild, B/L (Bi-lateral) LE (Lower Extremity) every day and evening shift for Hypotension apply in am (a.m), off at hs (bedtime) on the Day shift on 3/12/2023 was blank.
Dermagran Skin Protectant External Ointment (Aluminum Hydroxide) Apply to B/L buttocks topically every shift for prevention on the Day shift on 3/12/2023 was blank.
Offload b/l (bi-lateral) heels while in bed every shift for blanchable redness on the Day shift on 3/12/2023 was blank.
Q 2-hour toileting every shift on the Day shift on 3/12/2023 was blank.
WBAT to left LE every shift for wound healing on the Day shift on 3/12/2023 was blank.
At the time of the survey, the Licensed Practice Nurse (LPN) and the Registered Nurse (RN) who cared for Resident #2 in December 2022 and March 2023 were unavailable for interviews.
2. According to the AR, Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Acute Embolism and Thrombosis of Unspecified Deep Veins of the Right Lower Extremity, Difficulty Walking Not Elsewhere Classified and Aphasia Following Cerebral Infarction.
According to the MDS, an assessment tool dated 5/23/2023, Resident #4 had a BIMS score of 7/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #4 needed extensive assistance with most ADLs.
A review of Resident #4 's OSR, Active Orders as of 07/31/2023, revealed the following POs:
Bed alarm. Check function and use q (every) shift for safety precaution, dated 5/24/2022.
Check skin integrity under wander guard q shift, dated 4/12/2023.
Right-hand splint-on in AM (a.m.) and Off in PM (p.m.) every day and evening shift for prevention, dated 5/23/2022.
RLE (Right Lower Extremity) MAFO (Molded Foot Ankle Orthosis) every day and evening shift, dated 5/23/2022.
Zinc Oxide External Cream 22% (Zinc Oxide Topical)). Apply to buttocks & Groin topically every shift for preventive, dated 5/9/2023.
A review of the TAR dated 7/1/2023-7/31/2023 for Resident #4 revealed the following POs were not administered because there was no documented evidence that the staff gave the treatment to the Resident as evidenced by the following:
Bed alarm. Check function and use q shift for safety precaution on the evening [shift] on 7/24/2023 was blank.
Check the function of Wanderguard q shift. Location: right ankle. Exp: (Expiration) January 2024, every shift on the evening [shift] on 7/24/2023 was blank.
Check skin integrity under wander guard q shift on the evening [shift] on 7/24/2023 was blank.
Right-hand splint-on in AM (a.m.) and Off in PM (p.m.) every day and evening shift for
prevention on the evening [shift] on 7/24/2023 was blank.
RLE MAFO every day and evening shift on the evening [shift] on 7/24/2023 was blank.
Zinc Oxide External Cream 22% (Zinc Oxide Topical)). Apply to buttocks & Groin topically every shift for preventive on the evening [shift] on 7/24/2023 was blank.
During an interview on 7/25/2023 at 10:38 a.m., when the Surveyor asked about the blank spaces on the MAR/TAR, the Unit Manager/Licensed Practice Nurse (UM/LPN) stated [A] blank space on [the] MAR/TAR means [the medication/treatment is] not signed out and if [it is] not documented then it's not done.
During a telephone interview on 8/1/2023 at 1:13 p.m., when the Surveyor asked about the blank spaces on the TAR on 7/24/2023 on the evening shift, the Licensed Practice Nurse (LPN) who cared for Resident #4 stated, [A] blank space may have meant that I did not complete the treatment. I don't know why I wouldn't sign it [the treatment] out.
During an interview on 8/1/2023 at 1:19 p.m., when the Surveyor asked about the blank spaces on the MAR/TAR, the DON stated, I need to review the blanks on the MAR. The expectation is to complete, to document; there should not be any blanks on the MAR/TAR. There should be a reason why the medication/treatment was not given is [the] expectation. The DON continued to say, If [the] medication/treatment was done, it would show a checkmark [as] done. To me, the nurse didn't document means nothing, even though [there was] no reason given .
During a second interview on 8/1/2023 at 3:00 p.m., the DON stated, I know Nursing 101 is if [it is] not documented, [it is] not done, but I can't assume that's what happened .
A review of the updated facility policy titled Charting and Documentation revealed Under Policy Statement, All services provided to the Resident, progress toward the care plan goals, or any changes in the Resident's medical, physical, functional or psychosocial condition, shall be documented in the Resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the Resident's condition and response to care. Under Policy Interpretation and Implementation, included 1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record: .b. Medications administered; c. Treatments or services performed; . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the Resident tolerated the procedure/treatment; e. whether the Resident refused the procedure/treatment; f. notification of family, Physician or other staff, if indicated; and g. the signature and title of the individual documenting.
N.J.A.C.: 8.39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT#: NJ163054
Based on observation, interviews, review of the medical record, and other pertinent facility documentation on 7/25/2023, 7/31/2023, and 8/1/2023, it was determined that the facility failed to consistently document Activities of Daily Living (ADL) care as being provided to 1 of 5 residents (Resident #2). The facility also failed to follow its policy titled Charting and Documentation, as required by the Job Description for the Certified Nursing Assistant (CNA).
This deficient practice was evidenced by the following:
According to the admission Record (AR), Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Unspecified Fracture of Left Femur, Initial Encounter for Closed Fracture, Vascular Parkinsonism, Mild, Recurrent Major Depressive Disorder and Unspecified Dementia, Unspecified Severity Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.
A review of the Minimum Data Set (MDS), an assessment tool dated 5/3/2023, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15, indicated the Resident was cognitively intact. The MDS also revealed Resident #2 needed extensive one-person physical assistance with most ADLs.
A review of Resident#2's ADL Sheet dated 10/31/2022 through 11/30/2022 revealed the following:
A review of the ADL tasks for Incontinence, Bowel revealed blank spaces which indicated the task was not documented as being completed as follows on 7:00 a.m.-3:00 p.m. shift on 11/1/2022, 11/2/2022, 11/3/2022, 11/6/2022, 11/8/2022, 11/10/2022, 11/11/2022, 11/12/2022, 11/13/2022, 11/17/2022, 11/18/2022, 11/20/2022, 11/21/2022, 11/25/2022, 11/26/2022, 11/27/2022, 11/28/2022, 11/29/2022 and 11/30/2022; on 3:00 p.m.-11:00 p.m. shift on 11/3/2022, 11/8/2022, 11/10/2022, 11/11/2022, 11/12/2022, 11/13/2022, 11/16/2022, 11/17/2022, 11/21/2022, 11/22/2022, 11/26/2022, 11/27/2022 and 11/29/2022; on 11:00 p.m.-7:00 a.m. shift on 11/1/2022, 11/2/2022, 11/10/2022, 11/16/2022, 11/17/2022, 11/18/2022, 11/19/2022, 11/21/2022, 11/25/2022, 11/27/2022 and 11/30/2022.
A review of Resident #2's ADL for 10/31/2022 through 11/30/2022 revealed no ADL Task for Turning and Repositioning (T&R) and no documentation for T&R for the task noted on the ADL.
A review of Resident #2's Documentation Survey Report v2 (DSR), an ADL care task provided to the Resident and documented by the CNA during their assigned shift, revealed the following:
A review of the DSR form used for documentation of Intervention/Task (I/T), Bathing, dated 12/1/2022 through 12/31/2022 revealed blank spaces which indicated the task was not documented as being completed as follows: on Q (every) shift, Day (POC (plan of care)) 7:00 a.m.-3:00 p.m. on 12/1/2022, 12/3/2022, 12/7/2022, 12/8/2022, 12/10/2022, 12/13/2022 through 12/23/2022, 12/20/2022 through 12/31/2022 and on shift Evening (POC) 3:00 p.m.-11:00 p.m. on 12/2/2022, 12/5/2022, 12/7/2022, 12/10/2022, 12/12/2022 through 12/15/2022, 12/17/2022, 12/19/2022 through 12/23/2022, 12/26/2022, 12/27/2022 and 12/29/2022.
A review of the DSR form used for documentation of I/T, Bladder Continence, dated 12/1/2022 through 12/31/2022 revealed blank spaces which indicated the task was not documented as being completed as follows: on shift, Day (POC) 7:00 a.m.-3:00 p.m. on 12/1/2022, 12/3/2022, 12/7/2022, 12/8/2022, 12/10/2022, 12/13/2022 through 12/23/2022, 12/26/2022 through 12/31/2022; on shift Evening (POC) 3:00 p.m. -11:00 p.m. on 12/2/2022, 12/5/2022, 12/7/2022, 12/10/2022, 12/12/2022 through 12/15/2022, 12/17/2022, 12/19/2022 through 12/23/2022, 12/26/2022, 12/27/2022, 12/29/2022, 12/31/2022 and shift Night (POC) 11:00 p.m.-7:00 a.m. on 12/1/2022, 12/2/2022, 12/4/2022, 12/7/2022, 12/8/2022, 12/9/2022, 12/14/2022, 12/15/2022, 12/16/2022, 12/19/2022, 12/20/2022, 12/21/2022, 12/26/2022, 12/27/2022, 12/29/2022 through 12/31/2022.
A review of the DSR form for I/T, Bowel Continence, dated 12/1/2022 through 12/31/2022, revealed blank spaces, which indicated the task was not documented as being completed as follows: on Shift Day (POC) 7:00 a.m.-3:00 p.m. on 12/1/1022, 12/3/2022, 12/7/2023, 12/8/2023, 12/10/2023, 12/13/2022 through 12/23/2022, 12/26/2022 through 12/31/2022, on 3:00 p.m.-11:00 p.m. on 12/2/2022, 12/5/2022, 12/7/2022, 12/10/2022, 12/12/2022 through 12/15/2022, 12/17/2022, 12/19/2022 through 12/23/2022, 12/26/2022, 12/27/2022,12/29/2022 and 12/31/2022, on 11:00 p.m.-7:00 a.m. on 12/1/2022, 12/2/2022, 12/4/2022, 12/7/2022 through 12/9/2022, 12/14/2022 through 12/16/2022, 12/29/2022, 12/20/2022, 12/21/2022, 12/26/2022, 12/27/2022, 12/29/2022 through 12/31/2022.
A review of the DSR form for I/T, Turned and Repositioned, dated 12/1/2022 through 12/31/2022, revealed blank spaces which indicated the task was not documented as being completed as follows: on Shift Day (POC) at 7:00 a.m.-3:00 p.m. on 12/1/2022, 12/3/2022, 12/7/2022, 12/8/2022, 12/10/2022, 12/13/2022 through 12/23/2022, 12/26/2022 through 12/31/2022, on Shift Evening (POC) 3:00 p.m.-11:00 p.m. on 12/2/2022, 12/5/2022, 12/7/2022, 12/10/2022, 12/12/2022 through 12/15/2022, 12/17/2022, 12/19/2022 through 12/23/2022, 12/26/2022, 12/27/2022, 12/29/2022 and 12/31/2022 and on Shift Night (POC) 11:00 p.m.-7:00 a.m. on 12/1/2022, 12/2/2022, 12/4/2022, 12/7/2022, 12/8/2022, 12/9/2022, 12/14/2022, 12/15/2022, 12/16/2022, 12/19/2022, 12/21/2022, 12/22/20222, 12/26/2022, 12/27/2022, 12/29/2022 through 12/31/2022.
A review of the DSR form for I/T, Bathing, dated 1/1/2023 through 1/31/2023 revealed blank spaces which indicated the task was not documented as being completed as follows; Shift Day (POC) 7:00 a.m.-3:00 p.m. on 1/1/2023 through 1/7/2023, 1/9/2023, 1/10/2023, 1/14/2023, 1/16/2023, 1/17/2023, 1/23/2023 and 1/31/2023; on shift Evening (POC) 3:00 p.m,-11:00 p.m. on 1/2/2023, 1/3/2023, 1/4/2023, 1/7/2023, 1/9/2023, 1/10/2023, 1/13/2023 through 1/16/2023, 1/21/2023, 1/22/2023 and 1/23/2023.
A review of the DSR form for I/T, Bladder Continence, dated 1/1/2023 through 1/31/2023, revealed blank spaces, which indicated the task was not documented as being completed as follows; shift Day (POC) 7:00 a.m.-3:00 p.m. on 1/1/2023 through 1/7/2023, 1/9/2023, 1/10/2023, 1/14/2023, 1/16/2023, 1/17/2023, 1/23/2023 and 1/31/2023, on shift Evening (POC) 3:00 p.m.-11:00 p.m. on 1/2/2023, 1/3/2023, 1/4/2023, 1/7/2023, 1/9/2023, 1/10/2023, 1/13/2023 through 1/16/2023, 1/21/2023, 1/22/2023 and 1/23/2023 and on shift Night (POC) 11:00 p.m.-7:00 a.m. on 1/3/2023, 1/5/2023, 1/9/2023, 1/12/2023, 1/19/2023, 1/25/2023 through 1/27/2023 and 1/30/2023.
A review of the DSR form for I/T, Bowel Continence, dated 1/1/2023 through 1/31/2023 revealed blank spaces which indicated the task was not documented as being completed as follows; shift Day (POC) 7:00 a.m.-3:00 p.m. on 1/1/2023 through 1/7/2023, 1/9/2023, 1/10/2023, 1/14/2023, 1/16/2023, 1/17/2023, shift Evening (POC) 3:00 p.m.-11:00 p.m. on 1/2/2023, 1/3/2023, 1/4/2023, 1/7/2023, 1/9/2023, 1/10/2023, 1/13/2023 through 1/16/2023, 1/21/2023, 1/22/2023 and 1/23/2023, shift on Night (POC): 11:00 a.m. -7:00 p.m. on 1/3/2023, 1/5/2023, 1/9/2023, 1/12/2023, 1/15/2023, 1/16/2023, 1/19/2023, 1/25/2023, 1/26/2023, 1/27/2023 and 1/30/2023.
A review of the DSR form for I/T, T &R, dated 1/1/2023 through 1/31/2023 revealed blank spaces which indicated the task was not documented as being completed as follows; shift Day (POC) 7:00 a.m.-3:00 p.m. on 1/1/2023, 1/7/2023, 1/9/2023, 1/10/2023, 1/14/2023, 1/16/2023, 1/17/2023, 1/23/2023 and 1/31/2023, shift Evening (POC) 3:00 p.m. - 11:00 p.m. on 1/2/2023, 1/3/2023, 1/4/2023, 1/7/2023, 1/9/2023, 1/10/2023, 1/13/2023 through 1/16/2023, 1/21/2023, 1/22/2023 and 1/23/2023, on shift Night (POC) 11:00 p.m.-7:00 a.m. on 1/3/2023, 1/5/2023, 1/9/2023, 1/12/2023, 1/15/2023, 1/16/2023, 1/19/2023, 1/25/2023 1/26/2023, 1/27/2023 and 1/30/2023.
A review of the DSR form for I/T, Bathing, dated 2/1/2023 through 2/28/2023, revealed blank spaces, which indicated the task was not documented as being completed as follows: shift Day (POC) 7:00 a.m. - 3:00 p.m. on 2/8/2023 and 2/18/2023, on shift Evening (POC) 3:00 p.m.-11:00 p.m. on 2/4/2023.
A review of the DSR form for I/T, Bladder Continence, dated 2/1/2023 through 2/28/2023, revealed blank spaces, which indicated the task was not documented as being completed as follows; shift Day (POC) 7:00 a.m.-3:00 p.m. on 2/8/2023 and 2/18/2023, shift Evening (POC) 3:00 p.m.-11:00 p.m. on 2/4/2023 and shift Night (POC) 11:00 a.m. -7:00 p.m. on 2/1/2023, 2/2/2023, 2/3/2023, 2/4/2023, 2/6/2023, 2/8/2023, 2/10/2023, 2/12/2023, 2/13/2023, 2/16/2023, 2/17/2023, 2/18/2023, 2/20/2023, 2/22/2023 and 2/23/2023.
A review of the DSR form for I/T, Bowel Continence, dated 2/1/2023 through 2/28/2023 revealed blank spaces which indicated the task was not documented as being completed as follows; shift Day (POC) 7:00 a.m.-3:00 p.m. on 2/8/2023 and 2/18/2023, on shift Evening (POC) 3:00 p.m.-11:00 p.m. on 2/4/2023, on shift Night (POC) 11:00 p.m.-7:00 a.m. on 2/1/2023 through 2/4/2023, 2/6/2023, 2/8/2023, 2/10/2023, 2/12/2023, 2/13/2023, 2/16/2023, 2/17/2023, 2/18/2023, 2/20/2023, 2/22/2023 and 2/23/2023.
A review of the DSR form for I/T, T &R, dated 2/1/2023 through 2/28/2023, revealed blank spaces, which indicated the task was not documented as being completed as follows; shift Day (POC) 7:00 a.m.-3:00 p.m. on 2/8/2023 and 2/18/2023, shift Evening (POC) 3:00 p.m.-11:00 p.m. on 2/4/2023 and on shift Night (POC) 11:00 p.m.-7:00 a.m. on 2/1/2023, 2/2/2023, 2/3/2023, 2/4/2023, 2/6/2023, 2/8/2023, 2/10/2023, 2/12/2023, 2/13/2023, 2/16/2023, 2/17/2023, 2/18/2023, 2/20/2023, 2/22/2023 and 2/23/2023.
A review of the DSR form for I/T, Bathing, dated 3/1/2023 through 3/31/2023, revealed blank spaces which indicated the task was not documented as being completed as follows; shift Day (POC) 7:00 a.m.-3:00 p.m. on 3/10/2023, 3/12/2023, 3/18/2023 and 3/19/2023 and shift Evening (POC) 3:00 p.m.-11:00 p.m. on 3/1/2023, 3/8/2023, 3/13/2023 and 3/29/2023.
A review of the DSR form for I/T, Bladder Continence, dated 3/1/2023 through 3/31/2023 revealed blank spaces which indicated the task was not documented as being completed as follows; shift Day (POC) 7:00 a.m.-3:00 p.m. on 3/10/2023, 3/12/2023, 3/18/2023 and 3/20/2023 and shift Evening (POC) 3:00 p.m.-11:00 p.m. on 3/1/2023, 3/8/2023, 3/13/2023 and 3/29/2023 and shift Night (POC) 11:00 p.m.-7:00 a.m. on 3/5/2023, 3/7/2023, 3/8/2023, 3/9/2023, 3/12/2023, 3/20/2023, 3/22/2023, 3/23/2023, 3/24/2023, 3/26/2023 and 3/29/2023.
A review of the DSR form for I/T, Bowel Continence, dated 3/1/2023 through 3/31/2023 revealed blank spaces which indicated the task was not documented as being completed as follows; shift Day (POC) 7:00 a.m.-3:00 p.m. on 3/10/2023, 3/12/2023, 3/18/2023 and 3/20/2023 and shift Evening (POC) 3:00 p.m. -11:00 p.m. on 3/1/2023, 3/8/2023, 3/13/2023 and 3/29/2023 and shift Night (POC) 11:00 p.m.-7:00 a.m. on 3/5/2023, 3/7/2023, 3/8/2023, 3/9/2023, 3/12/2023, 3/20/2023, 3/22/2023, 3/23/2023, 3/24/2023 3/26/2023 and 3/29/2023.
A review of the DSR form for I/T, T &R, dated 3/1/2023 through 3/312023 revealed blank spaces which indicated the task was not documented as being completed as follows; shift Day (POC) 7:00 a.m.-3:00 p.m. on 3/10/2023, 3/12/2023, 3/18/2023 and 3/20/2023 and shift Evening (POC) 3:00 p.m.-11:00 p.m. on 3/1/2023, 3/8/2023, 3/13/2023 and 3/29/2023 and shift Night (POC) 11:00 p.m.-7:00 a.m. on 3/5/2023, 3/7/2023, 3/8/2023, 3/9/2023, 3/12/2023, 3/20/2023, 3/22/2023, 3/23/2023, 3/24/2023, 3/26/2023 and 3/29/2023.
A review of the Task Schedule (TS) for July 2023, dated 7/1/1023 through 7/31/1023, Shower schedule Tuesday and Friday 7-3 shift revealed blank spaces, which indicated the task was not documented as being completed as follows: shift on 7/14/2023 and 7/25/2023.
A review of T's for July 2023 for Bathing, dated 7/1/2023 through 7/31/2023, revealed blank spaces, which indicated the task was not documented as being completed as follows: shift 7/10/2023, 7/14/2023, 7/15/2023 and 7/24/2023.
A review of Ts for July 2023 for Bladder Continence, Bowel Continence, and T&R, dated 7/1/2023 through 7/31/2023, revealed blank spaces, which indicated the task was not documented as being completed on 7/10/2023.
During an interview on 7/25/2023 at 10:38 a.m., the Unit Manager/Licensed Practice Nurse stated, The aides turn and reposition [the residents] every 2 hours and ask [the] nurse for assistance. [The] Turn and Reposition [task] triggers on [the] aide's kiosk [plan of care].
During an interview on 8/1/2023 at 12:44 p.m., when the Surveyor showed the printout of the ADL Tasks sheet with the blank spaces, the CNA replied, I never saw the printout. I document throughout the day. It [the ADL task] should not be blank; we [the] CNAs are expected to document throughout the day. Showers are documented on the ADL sheet as showers . She continued to say, A blank space is possible [the] shower or task [was] not done or signed off .
During an interview on 8/1/2023 at 1:19 p.m., when the Surveyor asked about why the T&R ADL task does not show on the 11/2022 ADL [sheet], the Director of Nursing (DON) stated, .not sure why [the task is] not on 11/2022 tasks sheet, [I will need] to reprint.
During the same interview, when the Surveyor asked about the blank spaces on the ADL sheet, the DON stated, For a blank space on the ADL, I have to check, is unanswered, if no documentation, there's no way to know if [the] task was done .I'm not knowledgeable about the ADLs .
During a second interview on 8/1/2023 at 3:00 p.m., the DON stated, The blanks are undocumented on [the] ADL sheet, not documented [so] it was done or not done, so I don't know. I can't say with certainty if [the] ADL was done or not done. My expectation is for the ADL [sheets] to be documented .
At the time of the survey, the 10/31/2022 through 11/30/2022 ADL task sheet for T&R was not provided.
A review of the updated facility policy titled Charting and Documentation revealed Under Policy Statement, All services provided to the Resident, progress toward the care plan goals, or any changes in the Resident's medical, physical, functional or psychosocial condition, shall be documented in the Resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the Resident's condition and response to care. Under Policy Interpretation and Implementation included 1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record .c .services performed; . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 4 .Certified nursing assistants may only make entries in the Resident's medical chart as permitted by facility policy .
A review of the undated job description titled Certified Nursing Assistant revealed Under Purpose of Your Job Position The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors. Under Delegation of Authority, included As a Certified Nursing Assistant, you have delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.
N.J.A.C.: 8:39-27.1(a)
N.J.A.C.: 8:39-35.2 (g)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to have a cover over the opening of 3 of 3 garbage dumpster's and 1 of 1 recycling dumpster's. This deficient practice was evidenced by the following:
1. On 12/2/2021 at 9:41 AM the surveyor, accompanied by the cook observed 4 dumpster's outside the facility in the parking lot area. The cook told the surveyor that (3) dumpster's were designated for trash and (1) dumpster was designated for cardboard recyclables. 3 of 4 dumpster's had their doors opened and trash and cardboard were exposed. In addition, a clear plastic bag of garbage was observed to lie on the ground adjacent and in contact with a garbage dumpster. On interview the cook stated, I tried to pick that up last night, but the bag was stuck under the dumpster. Further observation of the area revealed plastic beverage cup lids, a half of a tomato, a bed mattress, plastic medication style cups, clear plastic beverage cups, (2) additional clear plastic bags filled with garbage and approximately (4) cardboard boxes on the ground surrounding the dumpster's. On interview the cook stated, Food service and housekeeping are responsible for maintaining the garbage area. Mostly my dishwashers are responsible for cleaning up.'
2. On 12/7/2021 at 7:55 AM upon arrival to the facility parking lot the surveyors observed (3) garbage dumpster's and (1) recyclable dumpster. On observation, 3 of 3 garbage dumpster's and 1 of 1 recyclable dumpster had their lids/doors open and the garbage/recyclable contents were exposed.
A review of a facility policy titled Food-Related Garbage and Refuse Disposal updated March 2021, revealed under the heading Policy Interpretation and Implementation:
Outside dumpster's provided by garbage pickup services will be kept closed and free of surround (sic) litter.
NJAC 8:39-19.3(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to keep resident areas, the outdoor exterior, and equipment clean, sanitary and in good repair for one of three units (B Unit Wing) observed for the Environmental Task.
The deficient practice was evidenced by the following:
during the initial tour of the facility on 12/2/21 at 10:13 AM, Surveyor #1 observed the following:
1. debris on the floor that appeared to be dust and food crumbs near the doorway of Resident #19's room. Surveyor #1 also observed a brown, dried substance on the mobility pole and formula pump (pump used to deliver nutritional formula to a resident).
2. heavily brown color stained ceiling tiles in the shower room.
3. cobb webs on the wall near the ceiling across from the nurses station.
4. in the hallway outside of room [ROOM NUMBER], the hand sanitizer dispenser was missing the cover.
5. lifted ceiling tiles exposing wires and pipe outside of room [ROOM NUMBER], 106, and 104.
6. inside the laundry room an accumulation of dust on the exhaust fan that was in operation.
7. inside the hallway bathroom near the therapy gym a crack in the paper towel dispenser exposing the stored paper towels.
8. the B Unit Wing Medication Room with the Unit Manager (UM). On the counter in the room, were six, full sharps containers (rigid, plastic container that are used to store used syringes, needles, and other hazardous devices) next to two boxes of snack muffins, a container of iced tea, and multiple bottles of soda.
9. inside the B Wing Unit day room, Surveyor #1 observed two chairs with ripped upholstery on the cushions.
On 12/3/2021 at 9:40 AM, Surveyor #2 observed the following on the B Wing unit:
1. There was loose cove base molding (CBM) in areas around the nurse's station.
2. There was black discoloration on the nurse's station.
3. There was missing/peeling paint outside of room [ROOM NUMBER].
4. There was peeling paint on the left side of door trim to room [ROOM NUMBER] and 122.
5. There was brown liquid drips on the wall to the right of the bed in room [ROOM NUMBER]. There was an accumulation of dirt at the floor wall junction (FWJ) and in the corners of room [ROOM NUMBER] and 127.
6. There was peeling paint on the wall between rooms [ROOM NUMBERS] as well as between rooms [ROOM NUMBERS].
7. There was black discoloration on the walls and a piece of paint missing exposing the metal corner outside of 118.
6. There was splatters of a dried liquid substance on the wall between rooms [ROOM NUMBERS].
7. There was peeling paint on the outside wall to the left of room [ROOM NUMBER] and to the right of room [ROOM NUMBER].
8. There was peeling paint in the hallway wall between rooms [ROOM NUMBERS].
9. There was damage to the wall behind the B bed of room [ROOM NUMBER].
During an interview on 12/3/21 at 11:46 AM, with Surveyor #1, the UM stated that maintenance is responsible for removing the sharps containers. At that time, the surveyor observed that the snack muffins and drinks were removed from the counter, but the sharps containers were still present.
During an interview on 12/6/2021 at 10:16 AM, with Surveyor #2 a housekeeping employee who was on the back hall of B Wing said there are normally 3 housekeepers on the unit each day. When asked what the procedure was for cleaning the unit she said she cleans the tables, the bathroom, and the windows in the resident rooms and cleans spills on walls if something spilled. She empties the trash and mops the floors.
During a tour of the facility grounds on 12/6/21 at 11:03 AM, Surveyor #1 observed throughout the property various amounts of debris including window screens, litter, a cabinet door, therapy equipment, pallets, and a bin filled with building debris.
During an interview with Surveyor #1 on 12/6/21 at 11:46 AM, Licensed Practice Nurse #1, revealed that the snack foods and drinks observed in the Medication Room belonged to Resident #39.
During an interview with Surveyor #1 on 12/7/21 at 9:44 AM, the Director of House Keeping (DH) explained that cleaning liquid spills, such as nutritional formula should be a team effort, but housekeeping is responsible. He further explained that the exterior grounds are cleaned about once a month. The DH went on to say that he has worked at the facility for 10 months. The DH said there were 2 housekeeping employees who work 8 to 4 and 1 porter who works 6 to 2 for the B Wing unit, 5 days a week. On the weekends there is 1 housekeeper for the B Wing unit and 1 porter for the whole building and Resident rooms are cleaned daily. All high touch surfaces are cleaned, they spot check the walls and clean the bathrooms. The porter cleans the hallways and takes care of trash and linens. He/she sweeps the floors in the hallways then uses a machine to auto scrub the floor.
During and interview with Surveyor #1 on 12/7/21 at 10:06 AM, the Director of Maintenance (DM) explained that the facility is remodeling, and construction workers leave the tiles open. He further said he did not know why they left them open. The DM said he found the heavily stained ceiling tiles in the shower room. He stated, I don't know how I missed that. During the same interview and after viewing a photo of the chairs with the torn upholstery, the DM stated, That is not acceptable. 100%. During the same interview and after viewing a photo of the dust on the exhaust fan, the DM confirmed that it should have been cleaned. During the same interview, the DM revealed he has been employed at the facility for 4 months. He stated if he sees something that needs to be repaired, he repairs it. When asked about the areas in need of repair on the B wing unit he stated They are remodeling down there. They have been remodeling for 4 months at least. When asked specifically about the CBM around nurse's station, he stated he has seen it. He stated that he will look at the missing/peeling paint outside of room [ROOM NUMBER], the peeling paint on the left side of door trim to room [ROOM NUMBER] and 122, the peeling paint on the wall between rooms [ROOM NUMBERS] as well as between rooms [ROOM NUMBERS]. He further explained that he would look at the piece of paint missing exposing the metal corner outside of 118, the peeling paint on the outside wall to the left of room [ROOM NUMBER] and to the right of room [ROOM NUMBER], the peeling paint in the hallway wall between rooms [ROOM NUMBERS], and the damage to the wall behind the B bed of room [ROOM NUMBER].
During an interview with Surveyor #1 on 12/7/21 at 1:19 PM, the Director of Nursing confirmed that Resident #39's food should not have been placed next to full sharps containers. She stated, When I heard about it, I had them move it.
A review of the facility Grounds policy, with a review and update from March 2021 revealed under Policy Statement; Facility grounds shall be maintained in a safe and attractive manner. The policy further revealed under, Policy Interpretation and Implementation, The Facility shall be responsible for keeping the grounds free of litter.
A review of the facility Maintenance Services policy, with a review and update from June 2021 revealed under, Policy Interpretation and Implementation; Function of maintenance personnel included but are not limited to: Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. The policy further revealed under Policy Interpretation and Implementation that, Functions of maintenance personnel include, but are not limited: Maintaining the building in good repair and free from hazards., Maintaining the grounds, sidewalks, parking lots, etc., in good order.
A review of the facility policy 5-Step Daily Room Cleaning under 5-Step Patient Room Cleaning Procedure number 3. Spot clean walls. Walls - especially by trash cans, light switches, and door handles-will need special attention. number 4. Dust Mop, revealed, The entire floor must be dust mopped ., and All corners and along all baseboards must be dust mopped to prevent buildup . number 5. Damp Mop, revealed, Never push the mop into a corner. That will only lead to build up.
N.J.A.C. 8:39-31.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure the privacy and confidentiality of resident information on the Electronic Health Records (EMR) systems. This deficient practice was identified for 1 of 1 Licensed Practical Nurse (LPN #2) observed during medication pass and was evidenced by the following:
On 12/6/21 from 8:25 AM to 9:10 AM, the surveyor observed LPN #2 administer medications on the Serenity Unit using a computer attached to the Serenity Unit medication cart. The surveyor observed Resident # 9's medical information to include residents' picture, name, date of birth and medications, visible to unauthorized staff. On two separate occasions, prior to stepping away from the cart, the surveyor asked LPN #2 if anything had to be secured on the computer regarding HIPPA (Health Insurance Portability and Accountability Act). At that time LPN #2 stated that the computer screen had to be locked so that patient information could not be seen.
At 9:01 AM, the surveyor observed the medication cart outside of room [ROOM NUMBER]-B with the computer screen facing the hallway with Resident #9 medical information displayed on the computer screen. The surveyor noted that this information was visible to all staff and public in the hallway. The surveyor continued to observe LPN #2 enter a resident room and then move the cart from one hallway to another hallway with Resident #9's information still displayed on the computer screen. When another resident approached LPN #2 at the medication cart, the surveyor heard LPN #2 acknowledge, Oh, I forgot this was up here and closed Resident #9 medical record on the computer.
During an interview with the surveyor on 12/7/2021 at 12:15 PM, the Director of Nursing (DON) who stated, They [the nurses] should hide the screen to protect patient information. There is an option to hide the screen without logging out [identified as the lock] in eMar [electronic medication administration record].
A review of a facility policy titled Computer Terminals/Workstations/Medication Pass with a revision date of May 2021, revealed under Policy Interpretation and Implementation details, As practical/feasible, computer terminals/workstations and computer used for medication pass will be positioned or shielded so that screens are not visible to the public or to unauthorized staff [ .] A user may not leave his/her workstation or terminal or medication computer unattended unless the terminal screen is cleared and the user is logged off or a privacy screen is applied.
NJAC 8:39-4.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:
On 12/2/2021 from 9:31 AM to 11:01 AM, the surveyor, accompanied by the cook and the Food Service Director (FSD) observed the following in the kitchen:
1. Upon entry to the kitchen the cook was observed to wear a surgical type hair net. The hair net covered a bun on the top of her head, leaving all hair around the circumference of their head exposed. The surveyor questioned the cook if hair coverings were required to cover all the hair on their head. The cook responded, Ok and then proceeded to adjust their surgical type hair net to cover all of her exposed hair.
2. On a middle shelf in the walk-in freezer, a cardboard box with its lid partially opened, contained a clear plastic bag of frozen hamburger patties. The plastic bag was opened, and the hamburger patties were exposed to the air.
3. A pizza cutter was observed on an upper shelf in the snack prep area. The pizza cutter had unidentified, dried food debris on the round cutting blade. The cook removed the pizza cutter to the dirty dish area.
4. Attached to the corner of the snack prep table, a can opener was observed to have brownish/black/reddish unidentified sticky substance on the blade used to open cans and the stem of the can opener. The cook stated, That needs to go into the dish machine. The cook removed the can opener to the dish machine room.
5. The surveyor reviewed the December 2021 Dish machine and Three Compartment Sink Sanitizer Temperatures Log. The log revealed that no temperatures were recorded for the dish machine prior to the initiation of dishwashing for breakfast on December 2, 2021. The log also revealed that no sanitizer level for the three-compartment sink had been recorded prior to initiation of manual dishwashing for breakfast on December 2, 2021. When interviewed the cook stated, Temperatures and sanitizer levels should be checked and recorded prior to dishwashing, manually or machine. The dietary aide (DA) is new, he's only been here three days.
6. A DA was observed in the dish washing area. The DA was actively using the high temperature dish machine and was responsible for receiving the clean dishes and utensils from the machine and storing them to air dry. The DA was observed to wear a white bandana folded around their head, covering the forehead area. The DA's hair was exposed. When made aware, the cook instructed the DA to cover their head with a hair net.
7. On an upper shelf in the dairy box, an opened bag of shredded Mozzarella cheese was tied shut. The bag had no dates. In addition, an opened 5-pound container of sour cream had a Best If Used By Date of 11/16/21. On a middle shelf, an opened bag of parmesan cheese was wrapped in plastic wrap. The bag had no open or use by date. On interview the cook stated, They should be labeled and dated. I usually use them in a day.
8. On an upper shelf of the spice rack in dry storage, an opened container of Bay Seafood Seasoning had an opened date of 6/19/20 and a use by date of 6/19/21. An additional bottle of opened Bay Seafood Seasoning had an open date of 6/22/20 and a use by date of 6/22/21. An opened container of Ground Allspice had a rec date of 1-23-20 and a use by date of 1-23-21. An opened container of Poultry Seasoning had a date of 10-21-20 and a use by date of 10-21-21 and an opened bottle of Celery Seed had a date of 11-19-20 and a use by date of 11-19-21. On interview the FSD stated, They are expired and should have discarded.
9. On a middle shelf in the rear of the dry storage room a large metal mixing bowl and a metal colander, cleaned and sanitized, were not stored in an inverted position and were exposed to contamination on the food contact surface. On an adjacent storage shelf, a stack of 8 cleaned and sanitized dessert plates, used to serve resident meals were not stored in the inverted position and had the food contact surfaces exposed. On the same shelf 5 stacks of cleaned and sanitized monkey bowls (a small dish used for side dishes and sauces) were not stored in the inverted position and the food contact surfaces were exposed to contamination. On interview the FSD stated, I'm going to have all these recleaned. They should be covered or inverted when stored.
10. On a middle shelf in the dry storage room, an opened bag of pasta noodles had a hole in it exposing the pasta. The bag had no open or use by date. In addition, on the same shelf an opened bag of spaghetti noodles was wrapped in plastic wrap and had no open or use by dates. On interview the FSD stated, They should have been dated when opened. I'm throwing them in the trash.
11. Next to the entry door inside the dry storage room the surveyor observed a white bucket of powdered beef soup base and a bucket of chicken flavored powdered soup base. Both buckets had been previously opened. The Beef base cover did not completely cover the beef base contents, exposing it to contamination. The buckets had no open or use by dates. Both buckets were observed to have an unidentified, brown powder-like substance on their lids. On interview the FSD stated, They should be clean, dated and closed.
On 12/7/2021 from 9:16 to 9:30 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN #1) observed the following in the B-Wing pantry:
1. In the pantry freezer an opened chocolate cream pie had no name or use by date. In addition, the surveyor observed red and brown unidentified spills on the bottom of the freezer. The surveyor observed (3) Ready Care Nectar Thickened Apple Juices on the side of the refrigerator door. The apple juices had a manufacturer's use by date of 04/21/21. When interviewed LPN #1 stated, Nursing is responsible for maintaining the refrigerator in terms of monitoring use by dates and removing foods when they are expired. Housekeeping is responsible for the cleaning of the freezer and refrigerator. I'm throwing the apple juices and pie in the trash. The surveyor further questioned whether staff are to label food items with a name and use by date. LPN #1 responded, Yes, we are to label foods with name, use by date and room number.
On 12/7/2021 from 11:04 AM to 11:39 AM, the surveyor, accompanied by the Regional Food Service Director (RFSD) observed the following in the kitchen:
1. In the dairy box refrigerator, an opened container of [NAME] Sour Cream had a best by date of 29 [DATE]. The RFSD threw the sour cream in the trash.
2. On a small metal table/prep table next to the dairy box, a cleaned and sanitized meat slicer was not in use and was not covered. The meat slicer was exposed to contamination. On interview the RFSD stated, The cook just used that to cut turkey. The surveyor questioned the cook if the meat slicer had been cleaned and sanitized. The cook responded, Yeah, it's clean. I haven't used it in three days.
3. In the dry storage room a white bulk container was being used to store flour. The clear plastic lid was in the up position leaving the flour contents exposed to contamination. The RFSD stated, That should be closed when not in use. The RFSD then instructed the cook that the bulk container of flour must be closed, and the cook responded, I was just in there.
A review of an undated facility policy titled Foods Brought in by Family/Visitors revealed under the heading Policy Interpretation and Implementation:
Perishable foods must be stored in re-usable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date.
The nursing staff will discard perishable foods on or before the use by date.
The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).
A review of a facility policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, updated March 2021, revealed that Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness under the heading Policy Statement. The policy further revealed the following under the heading Policy Interpretation and Implementation: Hair nets or caps and/or beard restraints must be worn to keep hair form (sic) contacting exposed food, clean equipment, utensils and linens.
A review of a facility policy titled Refrigerators and Freezers updated March 2021, revealed under the heading Policy Interpretation and Implementation:
Information regarding acceptable storage periods for perishable foods will be kept in the supervisor's office. A condensed version will be posed (sic) by each refrigerator and freezer for reference.
All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dated (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.
Supervisors will be responsible for ensuring food items in pantry, refrigerators and freezers are not expired or past perish dates. Supervisor should contact vendors or manufacturers when expiration dates are in question or to decipher codes.
A review of a facility policy titled Sanitation updated March 2021, revealed under the heading Policy Statement:
The food service area shall be maintained in a clean and sanitary manner.
In addition, the policy revealed the following under the heading Policy Interpretation and Implementation:
All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protect form (sic) rodents, roaches, flies and other insects.
All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair.
All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.
A review of a facility policy titled Dishwashing Machine Use updated March 2021, revealed under the heading Policy Interpretation and Implementation:
The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in the facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately.
A review of a facility titled Food Preparation and Service, reviewed and updated August 2021, revealed under the heading Food Service/Distribution:
Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.
N.J.A.C. 18:39-17.2(g)