Alameda Center For Rehabilitation And Healthcare

Complaint: 2587228Based on interviews, medical record review, and review of other pertinent facility documents on 12/29/2025, it was determined that the facility failed to provide documented evidence of care provided to residents (Resident #1, Resident #2, Resident #3, and Resident #7). This deficient practice occurred for 4 of 4 residents reviewed.The deficient practice was evidenced by the following:1.According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: dementia, diabetes, and muscle weakness.According to the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/4/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further revealed the resident was dependent on staff for activities of daily living (ADLs).A review of Resident #1's POC flowsheet, a form utilized for documentation of ADL care by the Certified Nursing Assistants (CNAs) for November 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift (every shift)7-3 shift on 11/1/2025, 11/4/2025, 11/5/2025, 11/6/2025, 11/8/2025, 11/11/2025, 11/12/2025, 11/14/2025, 11/17/2025, 11/19/2025, 11/22/2025, 11/24/2025, 11/25/2025, 11/26/2025, and 11/29/2025.3-11 shift on 11/15/2025, 11/22/2025, and 11/30/2025.11-7 shift on 11/11/2025 11-7, 11/22/2025, and 11/28/2025. Toileting Hygiene QShift7-3 shift on 11/1/2025, 11/4/2025, 11/5/2025, 11/6/2025, 11/8/2025, 11/11/2025, 11/12/2025, 11/14/2025, 11/17/2025, 11/19/2025, 11/22/2025, 11/24/2025, 11/25/2025, 11/26/2025, and 11/29/2025.3-11 shift on 11/15/2025, 11/22/2025, and 11/30/2025.11-7 shift on 11/11/2025, 11/22/2025, and 11/28/2025. A review of Resident #1's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for December 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift7-3 shift on 12/1/2025, 12/2/2025, 12/3/2025, 12/4/2025, 12/5/2025, 12/11/2025, 12/13/2025, 12/19/2025, 12/20/2025, 12/22/2025, 12/23/2025, 12/24/2025, 12/25/2025, 12/26/2025, 12/27/2025.11-7 shift on 12/25/2025.Toileting Hygiene QShift7-3 shift on 12/1/2025, 12/2/2025, 12/3/2025, 12/4/2025, 12/5/2025, 12/11/2025, 12/13/2025, 12/19/2025, 12/20/2025, 12/22/2025, 12/23/2025, 12/24/2025, 12/25/2025, 12/26/2025, and 12/27/2025.11-7 shift on 12/25/2025.22. According to the AR, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: dementia, anxiety, and diabetes. According to the most recent comprehensive MDS, an assessment tool dated 12/10/2025, Resident #2 had a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed the resident required supervision with ADLs. A review of Resident #2's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for November 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift:7-3 shift on 11/21/2025, 11/23/2025, 11/24/2025, 11/26/2025, and 11/29/2025.3-11 shift on 11/30/2025.11-7 shift on11/19/2025.Toileting Hygiene QShift7-3 shift on 11/21/2025, 11/23/2025, 11/24/2025, 11/26/2025, and 11/29/2025.3-11 shift on 11/30/2025.11-7 shift on 11/19/2025. A review of Resident #2's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for December 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift:7-3 shift on 12/4/2025, 12/9/2025, 12/17/2025, 12/20/2025, 12/22/2025, 12/26/2025, and 12/27/2025.3-11 shift on 12/17/2025.Toileting Hygiene QShift:7-3 shift on 12/4/2025, 12/9/2025, 12/17/2025, 12/20/2025, 12/22/2025, 12/26/2025, and 12/27/2025.3-11 shift on 12/17/2025.3. 3. According to the AR, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: muscle weakness, chronic obstructive pulmonary disease, acute kidney failure. According to the most recent comprehensive MDS, an assessment tool dated 12/18/2025, Resident #3 had a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed the resident required substantial assistance with ADLs. A review of Resident #3's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for November 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift:7-3 shift on 11/9/2025,11/15/2025, 11/19/2025, and 11/23/2025.3-11 shift on 11/8/2025, 11/9/2025, 11/22/2025, 11/23/2025, and 11/30/2025.11-7 shift on 11/18/2025 and 11/19/2025. Toileting Hygiene QShift:7-3 shift on 11/9/2025, 11/15/2025, 11/19/2025, and 11/23/2025.3-11shift on 11/8/2025, 11/9/2025, 11/22/2025, 11/23/2025, and 11/30/2025.11-7 shift on 11/18/2025 and 11/19/2025.A review of Resident #3's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for December 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift:7-3 shift on 12/6/2025, 12/7/2025, 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, and 12/28/2025. 3-11 shift on 12/6/2025, 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, and 12/28/2025. Toileting Hygiene QShift:7-3 shift on 12/6/2025, 12/7/2025, 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, and 12/28/2025.3-11 shift on 12/6/2025, 12/13/2025, 12/14/2025, 12/20/2025, 12/21/2025, and 12/28/2025.4. According to the AR, Resident #7 was admitted to the facility with diagnoses which included but were not limited to: alzheimer's, diabetes, and heart failure. The resident was discharged from the facility prior to this complaint survey.According to the most recent comprehensive MDS, an assessment tool dated 8/8//2025, Resident #7 had a BIMS score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further revealed the resident required moderate assistance with ADLs. A review of Resident #7's POC flowsheet, a form utilized for documentation of ADL care by the CNAs for August 2025 revealed missing signatures on the following dates and shifts:Personal Hygiene QShift:7-3 shift on 8/1/2025, 8/2/2025, 8/4/2025, 8/5/2025, 8/6/2025, 8/7/2025, 8/8/2025, 8/9/2025, 8/24/2025, and 8/26/2025.11-7 shift on 8/7/2025 and 8/8/2025.Toileting Hygiene QShift:7-3 shift on 8/1/2025, 8/2/2025, 8/4/2025, 8/5/2025, 8/6/2025, 8/7/2025, 8/8/2025, 8/9/2025, 8/24/2025, and 8/26/2025.11-7 shift on 8/7/2025 and 8/8/2025. On 12/29/2025 at 10:25 A.M., the surveyor interviewed CNA#1 who stated that that the CNAs were to document the care they provided in the POC for their shift. The CNA further stated that if care was documented in the POC it meant the care was completed. On 12/29/2025 at 10:30 A.M., the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/ UM) who stated that the CNAs documented care in the kiosk. She stated that she thought they only had to document ADLs once a shift. She further stated that the unit managers were responsible for making sure the documentation was completed by the end of the day shift and the supervisors were responsible on the other shifts. On 12/29/2025 at 1:20 P.M., the surveyor interviewed the Director of Nursing (DON) in the presence of the Regional DON. The DON stated that the CNAs were responsible for documenting in the POCs. She stated herself, the unit managers, and the supervisors were responsible for checking that the ADL documentation was completed every shift. The DON stated it was important that the CNAs documented ADLs, so that the care was accurately reflected in the resident's medical record. The DON further stated that the ADL documentation should not be blank for any shift. A review of the facility's policy titled Charting and Documentation with a revised date of July 2017 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. Under Policy Interpretation and Implementation,, 8. Documentation of procedures and treatments will include care-specific details, may include the following but not limited to: a. the date and time the procedure/treatment was provided.NJAC 8:39-27.1 (a)

Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 1 of 35 residents reviewed (Resident #120). This deficient practice was evidenced by the following:
On 6/30/2025 at 12:09 AM, the surveyor observed Resident #120 in the dining with a palm guard on left hand.
The surveyor reviewed the medical record for Resident #120.
A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Chronic Obstructive Pulmonary Disease and Generalized Muscle Weakness.
A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/28/25 included the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severly impaired. Section GG identified that the resident was not coded for any upper extremity contractures. A review of previous MDS assessments also revealed that the following dates did not identify Resident #120's upper extremity contracture: quarterly submitted on 3/29/24; annual submitted on 6/28/24; quarterly submitted on 9/27/24; and the quarterly submitted on 12/27/24.
A review of the Physician Order Summary Report included the following physician orders (PO):
A PO, with an order start date of 6/20/2025, to Apply (Left) Palm Protector to be work after AM care and remove at PM Care or as tolerated to prevent further contracture.
During an interview with the surveyor on 7/1/2025 at 11:40 PM AM, Actifing Director of Rehabilitation (ADOR) reviewed Resident #120's rehabilitation documentation with the surveyor. It was determined that the resident's contracture was first identified in 8/3/2024 with left hand tightness and joint immobility. When asked if this date should be considered the onset of the contracture, the ADOR confirmed.
During an interview with the surveyor on 7/2/2025 at 9:52 AM, Licensed Practical Nurse (LPN #1) said that they were familiar with Resident #120 and confirmed that the resident has been had their contracture to the left hand since their last admission.
During an interview with the surveyor on 7/2/2025 at 10:15 AM, Director of MDS (DMDS) stated that the MDS coordinators were responsible for signing off all entries as accurate. Upon review of Resident #120's 3/28/25 MDS, DMDS confirmed that contracture was not identified. When questioned if Therapy Notes were reviewed or discussed prior to a resident's MDS submission, DMDS responded that if there was documentation of the contracture then it should have been identified on the MDS.
A review of the facility provided Resident Assessment Instrument (RAI) Process Policy with Revision Dated: 1/3/2025, identified under Purpose: To ensure that the MDS for each resident is completed accurately and timely in accordance with State and Federal regulations. The following was identified under Scope: This policy and procedure applies to the Interdisciplinary Team which may include [ .] Director of Rehabilitation and nursing staff in resident care.
NJAC 8:39-33.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan to include a positioning device. This deficient practice was identified for 1 of 35 residents reviewed for resident-centered care plans (Resident #208), and was evidenced by the following:
On 06/26/2025 at 09:48 AM, the surveyor observed Resident #208 ambulating using a cane, the left arm was observed in the sling.
According to the admission Record, Resident #208 was admitted with diagnosis that included, but were not limited to, cerebral vascular accident (a stroke) and hemiplegia (weakness on one side of the body)
A review of Resident #208's Quarterly Minimum Data Set, an assessment tool dated 05/06/2025, revealed that he/she was cognitively intact.
A review of Resident #208's Care Plan with an effective date of 06/25/2025 reflected that this resident had limited physical mobility. The use of the sling was not included in the interventions.
A review of Resident #208's Care Plan with an effective date of 01/28/2025 reflected that this resident had hemiplegia/hemiparesis related to a stroke. The use of the sling was not included in the interventions.
On 07/01/25 at 09:10 AM, the Licensed Practical Nurse/ Nurse Manager LPN/NM stated the Resident #208 utilized the sling. The LPN/NM stated that the sling should be included on the resident care plan. She acknowledged that Resident #208's sling was not included in the care plan.
On 07/02/25 at 12:00 PM, the Director of Nursing acknowledged that Resident #208's care plan did not include the use of the sling.
A review of the facility provided policy titled, Care Plans, Comprehensive Person-Centered, with an original issue date of 01/03/2025, reflected 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.
NJAC 8:39-11.2

Complaint # NJ00172928
Based on observation, interview, and record review, it was determined that the facility failed to follow acceptable standards of clinical practice with following physician orders for the application of a treatment. This deficient practice was identified for 1 of 38 residents (Residents #378) reviewed for professional standards, and was evidenced by the following:
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
A review of the admission Record for Resident #378 reflected that the resident was admitted to the facility with diagnoses which included but not limited to diabetes mellitus (a disease in which the body has trouble controlling blood sugar) and aftercare following surgical amputation.
A review of the 04/05/2024 Order Summary Report for Resident #378 reflected physician orders (PO) for the following wound treatments: 04/05/2024 cleanse right leg and right foot 3rd, 4th and 5th toe amputation with normal saline solution, paint with betadine (antiseptic), cover gauze, wrap with kling (gauze dressing) as needed, and 4/5/24 Cleanse right leg and right foot 3rd, 4th and 5th toe amputation with nss, paint with betadine, cover gauze, wrap with kling every day shift.
A review of the April 2024 Medication Administration Record (MAR) reflected the PO dated 04/05/2024 for the wound treatments. The start date for the wound treatments were 04/09/2024 not 04/05/2024 as ordered.
On 07/02/2025 at 10:38 AM, the surveyor interviewed the Director of Nursing (DON) and the Regional Director of Nursing (RDON) regarding the missing wound treatments. The DON said that the clinical staff identified on 04/09/2024 in a clinical meeting that the treatments were not transcribed onto the MAR as ordered by the physician on 04/05/2024. The DON acknowledged that the physician orders for the application of the wound treatment was missed.
The surveyor reviewed the facility's Wound Care policy reviewed and updated 12/20/24 which reflected 1. Verify that there is a physician's order for this procedure.
The surveyor reviewed the facility's Physician Orders policy reviewed 01/03/2025 which reflected 5. All orders must be entered in the electronic health record by the nurse or therapist accepting or transcribing the order.
NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to obtain a Physician's Order (PO) for an orthotic device for 1 of 2 residents (Resident#208) reviewed for positioning and mobility.
On 06/26/2025 at 09:48 AM, the surveyor observed Resident #208 ambulating using a cane, the left arm was observed in the sling (an orthotic device).
According to the admission Record, Resident #208 was admitted with diagnosis that included, but were not limited to, cerebral vascular accident (a stroke) and hemiplegia (weakness on one side of the body)
A review of Resident #208's Quarterly Minimum Data Set, an assessment tool dated 05/06/2025, revealed that he/she was cognitively intact.
Review of the Order Summary Report with active orders as of 06/30/2025 did not reveal an order for Resident #208's sling.
On 07/01/2025 at 09:10 AM, the Licensed Practical Nurse/ Nurse Manager LPN/NM stated the Resident #208 utilized a sling. The LPN/NM stated that there should be a physician order for the use of the sling.
On 07/02/2025 at 12:00 PM, the Director of Nursing acknowledged that Resident #208's physician orders did not include the use of the sling.
Review of the facility provided policies did not speak to requiring a physician order for use of orthotic devices.
NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice specifically by A.) leaving a nasal cannula out of a bag, exposed to air and B.) not having a physician's order for oxygen administration. The deficient practice was identified for 2 of 4 (Residents # 22, 215) residents reviewed for Respiratory Care.
The deficient practice was evidenced by the following:
On 06/26/2025 at 10:23 AM during the initial tour, the surveyor observed Resident # 215 in their room. At that time, the surveyor observed a nasal cannula (tube that delivers oxygen through the nares) wrapped and resting on top of an oxygen concentrator. The nasal cannula was not in a bag and it was exposed to air. At that time, Resident # 215 said he/she wears the nasal cannula only at night.
On 6/27/2025 at 9:11 AM while in Resident # 215's room, the surveyor observed the nasal cannula left on top of the concentrator not in a bag, exposed to air.
On 6/30/2025 at 9:57 AM while in Resident # 215's room, the surveyor observed the nasal cannula left on top of the concentrator not in a bag.
On 7/02/2025 at 12:00 PM during an interview with the surveyor, the Director of Nursing stated, It should be bagged when the surveyor asked how should a nasal cannula be stored.
A review of the physician's orders located in the Electronic Medical Record (EMR) revealed Resident # 215 had an order for, O2 [oxygen] continuously at 2 liters per minute via nasal cannula at bed time.
A review of Resident # 215's Care Plan located in the Electronic Medical Record revealed, [Resident # 215] has oxygen therapy r/t [relate to] ineffective gas exchange.
On 06/30/2025 at 11:19 AM, during an interview with the surveyor, the Infection Preventionist replied, Any tubing not being used has to be in a plastic bag. She further said, Don't want it touching every surface.
A review of the facility policy titled, Oxygen Administration dated 1/3/2025 did not reveal how to store oxygen tubing when not in use.
N.J.A.C. § 8:39-27.1
B) On 06/26/25 10:14 AM, during the initial tour, the surveyor observed an oxygen sign on Resident #22's door and saw the resident with a nasal cannula on her/his face.
On 06/30/2025 at 11:34 AM, the surveyor observed Resident # 22 in their room. At that time, the surveyor observed a nasal cannula in use by the resident. During the interview, Resident # 22 stated he/she wears the nasal cannula with 2 Liters of oxygen, as needed, since admission to the facility.
On 07/01/25 08:49 Licensed Practical Nurse (LPN) # 1 on the 6th floor, during an interview with the surveyor stated residents with oxygen would require physician orders and identified that the order should contain the reason for the order, the length of time (continuous vs PRN), how much, and any monitoring parameters, as well as how the oxygen would be delivered.
On 7/02/2025 at 09:38 AM during an interview with the surveyor, the Unit Manager (UM) of 6th floor confirmed there was not a physician order for Resident #22's oxygen while checking the EMR. The UM stated that Resident #22 should have an order for the oxygen administration.
On 7/02/2025 at 09:57 AM during an interview with the surveyor, the DON stated, Residents with oxygen should have orders on their chart.
A review of the physician's orders located in the EMR revealed Resident # 22 did not have a physician order for oxygen administration.
A review of Resident # 22's CP located in the EMR revealed, [Resident # 22] has oxygen therapy r/t Respiratory illness.
A review of the facility policy titled; Oxygen Administration dated 1/3/2025 under Purpose reveals: The purpose of this procedure is to provide guidelines for safe oxygen administration. Under Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration.
N.J.A.C. § 8:39-27.1

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer medication in accordance with prescriber orders, specifically administering an intravenous antibiotic outside of the prescribed time of administration. The deficient practice was identified for 1 of 1 resident (Resident # 328) reviewed for Antibiotics.
The deficient practice was evidenced by the following:
A review of Resident # 328's physician's orders located in the Electronic Medical Record (EMR) revealed an orders for daptomycin intravenous solution reconstituted 500mg (milligram) and ceftaroline fosamil intravenous solution reconstituted 600 mg (Both antibiotics, medications used to treat infections)
A review of Resident # 328's Care Plan located in the EMR revealed a focus that the resident is on IV (intravenous) medications related to bacteremia (bacterial infection of the blood).
A review of the Medication Audit Report located in the EMR revealed the following administrations for daptomycin intravenous solution outside of the scheduled administration time:
06/22/2025 scheduled for 9:00 AM; was administered at 10:47 AM
06/23/2025 scheduled for 9:00 AM; was administered at 10:29 AM
06/28/2025 scheduled for 9:00 AM; was administered at 10:24 AM
A review of the Medication Audit Report located in the EMR revealed the following administrations for ceftaroline fosamil intravenous solution outside of the scheduled administration time:
06/20/2025 scheduled for 10:00 PM; was administered at 11:18 PM
06/29/2025 scheduled for 2:00 PM; was administered at 3:14 PM
06/30/2025 scheduled for 2:00 PM; was administered at 3:11 PM
On 06/27/2025 at 10:52 AM during an interview with the surveyor, Licensed Practical Nurse/Unit Manager (LPN/UM) # 1 said, From my training, it would be one hour before and one hour after. when the surveyor asked what is your expectation on how late medications can be given before or beyond their scheduled time. Secondly, she said, If its after the hour, contact the medical doctor. after the surveyor asked should an IV antibiotic be given an hour past its administration time. Thirdly, she said, It could degrade the effectiveness of the medication. after the surveyor asked why is it important to give antibiotics at their scheduled time. Lastly, the LPN/UM # 1 concluded by saying Prioritize the time management and prioritize was should be given first. after the surveyor asked if there is a reason medication such as IV antibiotics would be given past their administration time.
On 07/02/2025 at 12:00 PM during an interview with the surveyor, the Director of Nursing (DON) replied, An hour after when the surveyor asked when would a medication be considered late. The DON replied, They should inform the primary care provider. when asked what should the nurse do if mediations are being administered late. Lastly, she replied, To ensure the therapeutic level when asked why would it be important to hang an IV antibiotic within the scheduled time.
A review of the facility policy Administering Medications dated 1/3/2025 revealed but not limited to the following, 4. Medications are administered in accordance with prescriber orders, including any required time frame. and 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication
N.J.A.C. § 8:39-27.1 (a)

Based on observations, interview, and review of facility policy, it was determined that the facility failed to appropriately dispose of medication in accordance with currently accepted professional principles. The deficient practice was identified for 1 of 5 nurses observed during the Medication Administration task.
The deficient practice was evidenced by the following:
On 07/01/2025 at 8:57 AM during medication pass on the second floor, Licensed Practical Nurse (LPN) # 1 poured one tablet of aspirin 81 milligrams (mg) and one tablet of clopidogrel 75mg (blood thinner medication). As LPN # 1 continued, the cup of tablets spilled and the tablets came to rest on top of the medication cart. At that time, LPN # 1 picked up the tablets with her gloved hand, turned the glove inside-out and threw it in the trash can.
After LPN # 1 completed the medication administration, the surveyor asked LPN # 1 how should she dispose of medications that are not being administered. She replied, They have a jug for it in the cart. At that time, LPN # 1 showed the surveyor the bottle of Drug-Buster (solution used to dissolve medications) in the bottom drawer of the medication cart. At that time, LPN # 1 said, Oh my God, I threw it out in the trash!
On 07/02/2025 at 12:00 PM during an interview with the surveyor, the Director of Nursing replied, Drug buster in the cart. when the surveyor asked how should medications be disposed of if they are spilled. The Director of Nursing replied, Because no one can take the medication. after the surveyor asked why is it important to dispose of the drugs in the drug buster.
A review of the facility policy titled Storage of Medications revealed, 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
N.J.A.C. § 8:39-29.7

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness.
This deficient practice was evidenced by the following:
On 06/30/2025 at 10:48 AM, the surveyor inspected the pantry refrigerator on Unit 4 in the presence of the Licensed Practical Nurse and Unit Manager #2 (LPN/UM #2) and observed the following: a 14-ounce container of sour cream with an expiration date of 03/19/2025, and a quart of half and half with an expiration date of 06/20/2025. Additionally, six containers of food brought in from outside the facility were found without any labels or dates. A plastic bag containing an unidentified whitish edible substance lacked both a label and a use-by date, and a 15-ounce open plastic container of soup was found without an open date or use-by date.
On 06/30/2025 at 10:50 AM, On 06/30/2025 at 10:48 AM, during an interview with the surveyor, the LPN/UM #2 said that expired food should not be stored in the refrigerator and that any food brought in from outside the facility should be properly labeled and dated according to the facility policy.
On 07/02/2025 at 10:11 AM, during an interview with the surveyor, the Dietary Director said that nursing was responsible for maintaining pantry cleanliness, ensuring all food items are not expired, and verifying that outside food is properly labeled and dated.
On 07/02/2025 at 12:00 PM, during an interview with the surveyor, the Director of Nursing said that food brought in from outside the facility should be labeled and dated and discarded after three days.
A review of the undated facility policy, titled, Food and Nutrition Services, Subject: Foods Brought by Family or Visitor revealed, Perishable prepared foods will be checked by the designee housekeeper/nurse and discarded after 3 days of storage. Perishable manufactured foods stored in the manufacturer packaging will be discarded as per the best by or use by date. If no date, follow facility refrigerated storage guidelines of disposing items after 3 days of storage.
A review of the undated facility policy titled, Labeling and Dating System Protocol, revealed, Follow manufactures expiration date on all un-opened or opened product. All fresh and frozen foods must be dated with the date it was received into the kitchen, unless purveyor shipping label on it. Make sure to not date over or cover the manufacturer's expiration date on the product. Day 1 is the first day of labeling.
N.J.A.C 8:39-17.2 (g)

Based on observation, interview, and pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 3 of 5 unit pantries (Units 2, 3, and 4).
This deficient practice was evidenced by the following:
On 06/30/2025 at 10:32 AM, the surveyor inspected the Unit 3 pantry in the presence of the Licensed Practical Nurse and Unit Manager #1 (LPN/UM #1) and observed the following: white debris was present inside of the microwave, a cabinet drawer panel was not intact and slid back and forth, and an aluminum pan containing white debris was found inside the cabinet.
On 06/30/2025 at 10:48 AM, the surveyor inspected the Unit 4 pantry in the presence of the Licensed Practical Nurse and Unit Manager #2 (LPN/UM #2) and observed the following: light brown debris on the wall next to the refrigerator.
On 07/02/2025 at 10:34 AM, the surveyor inspected the Unit 2 pantry in the presence of the Licensed Practical Nurse and Unit Manager #3 (LPN/UM #3) and observed the following: light brown, powdery debris on the wall vent; black, sticky residue on the wall next to the refrigerator; and a loose white rack. Brown, dry debris was also found inside the cabinets.
On 06/30/2025 at 10:35 AM, during an interview with the surveyor, the LPN/UM #1 said that the microwave should be clean, the drawer should not be damaged, and dirty items such as the aluminum pan should not be stored in the cabinet. She noted that housekeeping is responsible for cleaning the pantry daily.
06/30/2025 at 10:50 AM, during an interview with the surveyor, the LPN/UM #2 said that housekeeping is responsible for cleaning the pantry.
07/02/2025 at 10:15 AM, during an interview with the surveyor, the LPN/UM #3 said that the debris should not be present on the vents, walls or inside the cabinets, and that the loose white rack should be properly secured.
07/02/2025 at 10:34 AM, during an interview with the surveyor, the Maintenance and Housekeeping Director, said that housekeeping is responsible for cleaning the unit pantry areas, while nursing staff are responsible for maintaining edible items inside the refrigerators and cabinets. Maintenance handles repairs: however, nursing staff must report broken items through the electronic maintenance system. Maintenance checks the system daily, and every request entered triggers an immediate notification to maintenance. The system categorizes repairs as critical, high, medium, or low priority, and requests are addressed based on parts availability and severity, with critical issues handled promptly.
A review of the facility's dated policy 01/2025, titled, Safe and Homelike Environment, revealed, Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.
N.J.A.C. 8:39-31.3(a)

Based on interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to order an as needed (PRN) psychotropic medication for a 14-day period for 1 of 5 residents (Resident #125) reviewed for unnecessary medications.
This deficient practice was evidenced by the following:
During lunch observation on 12/12/23 at 1:04 PM, the surveyor observed resident #125 leave the dining room, asking staff if he/she could leave the room. The 2nd floor unit clerk directed the resident to his/her room.
According to the admission Record, Resident#125's was admitted to the facility with diagnoses that included but were not limited to: anxiety disorder (an intense, excessive, and persistent worry and fear about everyday situations) and unspecified Dementia, unspecified severity, with other behavior disturbances.
The Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/22/23, indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 3 out of 15 which indicated that the resident had severe cognitive impairment. Further review of the MDS, revealed the resident was receiving antianxiety and antipsychotic medications.
A review of the Electronic Medical Record (EMR) revealed a physician order (PO) dated 4/6/23 at 1600 (4:00 PM) for Alprazolam (Xanax, a medication given for anxiety) Tablet 1 MG (milligram), give 1 tablet by mouth every 8 hours as needed [PRN] for anxiety. Further review of the physician orders revealed an order dated 12/1/23 at 21:43, Alprazolam Tablet 1 MG, Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days.
A review of the April medication administration record (MARs) revealed the medication was administered as follows: 4/6/23 at 17:02, 4/7/23 at 1714, 4/21/23 at 1808, 4/26/23 at 1650, 4/28/23 at 1703, and 4/30/23 at 1851.
A review of the May MARs revealed the medication was administered as follows: 5/21/23 at 10:32 AM.
A review of the June MARs revealed the medication was not administered.
A review of the July MARs revealed the medication was administered on 7/31/23 at 17:17.
A review of the August MARs revealed the medication was administered as follows: 8/12/23 at 1259, 8/15/23 at 2059, 8/22/23 at 1726, 8/23/23 at 1815, 8/25/23 at 1622, and 8/31/23 at 1721.
A review of the September MARs revealed the medication was administered as follows: 9/1/23 at 1714, 9/5/23 at 1810, 9/7/23 at 1726, 9/8/23 at 1715, 9/13/23 at 1623, 9/14/23 at 1658, 9/16/23 at 1749, 9/18/23 at 1832, 9/19/23 at 1948, 9/21/23 at 0002, 9/25/23 at 1426, and 9/30/23 at 1531.
A review of the October MARs revealed the medication was administered as follows: 10/2/23 at 1327 and 2233, 10/7/23 at 0910, 10/11/23 at 1728, 10/17/23 at 1640, 10/23/23 at 1659, 10/24/23 at 1612, 10/27/23 at 1405, 10/28/23 at 1144, and 10/29/23 at 1529.
A review of the November MARs revealed the medication was administered as follows:11/3/23 at 1543, 11/4/23 at 0810, 11/5/23 at 1705, 11/7/23 at 1729, 11/8/23 at 2018, 11/9/23 at 1616, 11/10/23 at 1729, 11/13/23 at 1826, 11/15/23 at 1716, 11/18/23 at 1753, 11/21/23 at 0812, 11/22/23 at 1337, 11/24/23 at 1652, 11/25/23 at 1830, 11/29/23 at 1622.
A review of the December MARs revealed the medication was administered on 12/1/23 at 0500.
On 12/19/23 at 9:41 AM, the surveyor interviewed the Director of Nursing (DON), who stated that prn Antipsychotics should only be written for 14 days so that it can be reviewed as to what causes the behaviors.
On 12/19/23 at 9:50 AM, in the presence of the surveyor, the DON reviewed the EMR and confirmed that the original PO for Xanax 1 mg by PO (by mouth) q (every) 8 hours as needed for anxiety was from 4/6/23. She also confirmed that there was not a duration of 14 days. The DON stated that there should be a duration so the resident could be re-evaluated to see if the medication was effective or if the medication should be titrated, increased or decreased.
On 12/19/23 at 10:40 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) of the 2nd floor, who stated that the expectation of staff was to try and distract residents and to try non-pharmaceutical interventions before using medications to address behaviors. She then stated that the purpose was to monitor behaviors and how often the behavior occurs to see they needed something (medication) standing.
On 12/19/23 at 1:54 PM, during a telephone interview, the pharmacist consultant supervisor stated that the reason that Xanax prn should have a 14-day duration was the new regulation to make sure safe alternates are used before Antipsychotics and antianxiety medications are used.
On 12/20/23 at 4:02 PM, in the presence of the survey team, the above findings were presented to the Licensed Nursing Home Administrator and the DON.
No additional information was provided.
A review of the facility's policy Antipsychotropic Use revised March 2023 revealed Procedure: 3. Any PRN psychotropic medication, excluding Antipsychotics, will be limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she will document their rational in the resident's medical record and indicate the duration for the PRN order. 4. Any PRN antipsychotic medication will be limited to 14 days. If the attending physician or prescribing practitioner wishes to write a new order for PRN antipsychotic, he/she will evaluate the resident to determine if the new order for antipsychotic is appropriate.
N.J.A.C 8:39-29.3 (d)

Based on observation and interview, it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. This deficient practice was evidenced by the following:
On 12/12/23 at 11:00 AM, the surveyor met with facility [NAME] President of Operations, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing and the Infection Preventionist for an entrance conference meeting. The facility was licensed for 250 beds and the facility census was 227 (the number of residents who currently resided at the facility).
On 12/12/23 at 12:18 PM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). The surveyor observed two pallets of water in the basement. The FSD stated that it was enough water for 250 residents for three days. The FSD could not speak to the exact quantity that was there and stated he would get back to the surveyor with an exact count.
On 12/20/23 at 9:51 AM, the surveyor conducted a follow up kitchen tour with the FSD in the presence of a second surveyor. The surveyor observed four pallets of water stored in the basement hallway which equaled 864 gallons (216 gallons per pallet). One pallet of water had a best if used by date of May 21, 2022. The FSD acknowledged that the water should have been used before that date. In addition, he acknowledged that he ordered water after surveyor inquiry. The FSD stated I got two pallets of water delivered on Monday and pointed to the pallets of water stored to the left.
On 12/20/23 at 12:28 PM, the FSD acknowledged that he placed an order for water by phone, after surveyor inquiry, on 12/12/23 and received the water on 12/13/23 (an invoice was provided).
On 12/20/23 at 1:40 PM, the surveyor interviewed the FSD who stated that the facility was required to maintain emergency water in the amount of one (1) gallon per resident per day for three (3) days. He stated he would use the number of licensed beds (250) to calculate the maximum amount needed. He further stated that the administrator was ultimately responsible for emergency food and water but it's my responsibility to order the emergency supplies and get them.
On 12/20/23 at 4:02 PM, the LNHA acknowledged the concern regarding the emergency water in the presence of the survey team.
Review of an undated facility policy Dining Services: Instructions for Implementing Menu to be Used in the Event of a Disaster or Emergency, included that the facility should maintain an adequate supply . of emergency water: one (1) gallon drinking water per day per every resident and staff member on duty.
Review of the facility policy Disaster Planning - Emergency Water Plan revised April 2023, included In the event of a loss of utilities, water may be unavailable, or if available, it may be contaminated and in need of purification. In either case, the facility will need to have an adequate supply of water on hand . Recognizing that suppliers may be unable to deliver immediately, a three-day supply of water is recommended.
It also included that A minimum of three (3) day supply of water should be available. The quantity of water that is needed can be determined by the following calculations: Drinking water 2 quarts (0.5 gallon) per person per day and All-purpose water 1 gallon per person per day. It further included, Rotate or discard water according to the manufacturers expiration date on the container.
Review of a letter from a vendor regarding emergency water supply dated 11/1/23, included that In the event of an emergency, [name redacted] will have water available to purchase for your facility not in excess of our supply.
NJAC 8:39-31.6 (n)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. According to the admission Record, Resident #27 was admitted to the facility with diagnoses that included but were not limited to; Type 2 Diabetes Mellitus without complications (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and Chronic Obstructive Pulmonary Disease, unspecified (a progressive lung disease characterized by long-term respiratory symptoms and airflow limitation).
Review of Resident #27's Order Summary Report revealed an order for Isolation precautions-COVID+ every shift dated 12/17/23 and Maintain droplet and contact precautions every shift dated 12/17/23.
On 12/20/23 11:25 AM, the surveyors toured the 4th floor. The surveyors observed a white pedal garbage can (a touchless trash can that you open by stepping on the pedal with your foot to open the lid), with blue gowns overflowing from under the lid, to the right of the door frame of room [ROOM NUMBER]. Signage for droplet precautions was noted at the door.
On 12/20/23 at 11:37 AM, the surveyors interviewed the 4th floor Unit Manager (UM) who acknowledged that the gowns were overflowing and should not be because the gowns were contaminated and should be contained inside the garbage can. She further stated that the garbage can should be inside the room and not outside of it to prevent the spread of infection.
On 12/20/23 at 12:30 PM, the surveyors observed a Certified Nursing Aide (CNA) wearing an N95 mask, donn (put on) a blue gown and gloves, and bring a lunch tray into room [ROOM NUMBER]. The CNA did not put on eye protection before she entered the room. The CNA was observed exiting the room wearing only the N95. The surveyors interviewed the CNA, who acknowledged, that she should have worn eye protection and that she should have changed her N95 during the doffing (removing) process. She stated I was only bringing in the tray. The surveyors observed the blue PPE bin that had face shields, surgical masks and N95 masks readily available.
On 12/20/23 at 3:48 PM, the LNHA and the DON were made aware of the above findings.
On 12/21/23 at 9:40 AM, the surveyor interviewed the ADON/ IP related to the above observation. She stated that the PPE garbage can should have been inside the room right by the door so staff can doff their PPE inside the room. She stated that this was to contain the contaminated materials to prevent the spread of infection. The ADON/ IP further stated that the CNA should have applied a face shield or goggles before entering room [ROOM NUMBER] and she should have removed the N95 prior to exiting the room. She then stated that once outside the room, staff should apply an Alcohol-Based Hand Rub and then apply a new N95.
A review of the facility's policy, Hand Hygiene revised April 2023, revealed Policy Explanation and Compliance Guidelines: 1. Hand Hygiene: a. during the delivery of patient care services, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surface.
A review of the facility's policy, Nutritional Services, review 8/9/2023, revealed Policy: All residents will be treated with dignity and respect at all times. A respectful, positive dining experience is essential to the residents' quality of life and helps to identify resident's needs and improve their overall nutritional status. Residents will be properly groomed and their needs attended to during the meal service.
A review of the facility's policy Infection Prevention and control Program/Outbreak Response Plan revised April 2023 revealed Adhere to Standard and Transmission-based Precautions including use of a facemask, gown, gloves, and eye protection for confirmed and suspected COVID-19 case(s).Limit only essential personnel to enter the room with appropriate PPE and respiratory protection. PPE includes: Gloves, Gown, Respiratory Protection: facemask, eye protection that covers both the front and side of the face.
A review of the facility's policy, Transmission-Based (isolation) Precautions, revised 4/2023, revealed Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Definitions: Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. 10. Droplet Precautions- f. Based upon the pathogen or clinical syndrome, if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn.
NJAC 8:39-19.4 (m)(n)
REPEAT DEFICIENCY
Based on observations, interviews, and review of facility documentation, it was determined that the facility failed to a.) ensure visitors follow appropriate infection control practices and perform hand hygiene as indicated during dining observation for 1 of 5 units (2th-floor dining room), b.) appropriately discard soiled personal protective equipment (PPE) to prevent the potential spread of COVID-19 (a contagious disease caused by the virus SARS-CoV-2), c.) apply eye protection prior to entering a COVID-19 room and d:) change an N95 mask (a particulate-filtering facepiece respirator) upon exiting a COVID-19 room. This was observed on 1 of 5 units (4th-floor) during lunch pass.
This deficient practice was evidenced as follows:
1. On 12/12/23 at 12:37 PM, the surveyor observed lunch in the dining room on the 2nd floor. The Licensed Practical Nurse/Unit Manager (LPN/UM) reviewed the lunch tickets, verified the residents diets, and filled the tray orders. Staff was observed distributing the trays.
On 12/12/23 at 12:40 PM, the surveyor observed a woman, who the LPN/UM later identified as a family member/visitor (FM/V). The FM/V was observed encouraging Resident #217 to eat by putting the fork in the resident's hand and then walked over to Resident #233, touch their coffee cup and move their lunch tray out of the way. The FN/V then went back to Resident #217 and encouraged the resident to eat another fork full of food. The FN/V then went to resident #125 and removed their plate. The FN/V picked up a plastic lid from the ground and threw it away. The FN/V then went back to Resident #233, she placed her hand on the arm of the resident and then picked up and gave the resident their coffee mug. The FM/V did not perform hand hygiene during the above observations.
On 12/12/23 at 12:43 PM, the surveyor attempted to interview the woman, but she stated, No English.
On 12/12/23 at 12:46 PM, the LPN/UM identified the women as a FM/V. She stated she shouldn't be touching people or their trays and she should sanitize her hands in between if she does. She then stated, she (FM/V) encourages them (residents) to eat. The LPN/UM called the Assistant Director of Nursing/ Infection Preventionist (ADON/IP) who speaks Spanish to come speak to the FM/V.
On 12/12/23 at 12:56 PM, the ADON/ IP spoke with FM/V to inform her that she cannot touch or assist the other residents. The ADON/IP stated that hands should be washed before handling food and after serving it. She then stated that family members should not be assisting other residents.
On 12/12/23 at 3:16 PM, during an interview with the Director of Nursing (DON), she stated that hand hygiene should be performed between residents because you could infect others by touching one resident and then another. She stated she spoke with the family of the resident and informed them that the visitor was not listening to the facility and that this was the second time they spoke to the FM/V.
On 12/20/23 at 4:02 PM, in the presence of the survey team, the License Nursing Home Administrator (LNHA) and the DON were made aware of the above findings.
No additional information was provided to the surveyor.

**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 kitchen sanitation in a manner intended to prevent the spread of food borne illness. This deficient practice was evidenced by the following:
On 12/12/23 from 9:26 AM to 11:25 AM, the surveyor conducted a tour of the main kitchen in the presence the Food Service Director (FSD) and observed the following:
At 10:11 AM, the surveyor observed a dish machine temperature log which was filled out for the afternoon (for lunch time). The FSD stated, They signed this early, I don't know why.
At 10:24 AM, the surveyor observed orzo pasta wrapped in clear plastic with a use by date of 12/3. This was stored on a metal rack in the dry storeroom. The FSD stated, It's Orzo, maybe ten pounds and stated, I am not sure why they put it there and he removed it from the storage room. The surveyor observed an opened five pounds (lbs) container of Honey with no open date. The FSD stated, it should be good for seven days.
At 11:00 AM, the surveyor observed several opened food items with no opened date or labels in the walk-in refrigerator as follows:
-Seven hardboiled eggs in an opened clear package, with no opened date.
-An opened one-pint container of Mayonnaise, with no opened date.
-A 64 ounce (oz) opened gallon of Apple Juice, with no opened date.
-An opened bag of shredded Mozzarella cheese wrapped in the original packet, with no opened date. The FSD stated, I am gonna throw it out. Majority of the food is good for seven days once its open.
-An opened eight oz container of sour cream dated 10/28, the FSD stated, It's probably (the date) when it came it and It's probably somebody's personal sour cream.
-One 17 oz bottle of unopened black raspberry juice and one 17 oz bottle of unopened cranberry lime juice. The FSD stated, It's somebody's personal juice because I don't order that.
-Two and a half lbs. opened [name redacted] Greek yogurt, without a lid, covered with clear plastic wrap and dated 11/26.
-Half four-inch pan with a half of a tomato wrapped in plastic wrap, not dated. The FSD stated, I told them so many times to date things, but they don't listen.
-One gallon opened chunky Bleu cheese dressing, with no opened date.
-An opened one gallon of regular milk, with no opened date. The FSD stated, It was probably opened today.
At 11:25 AM, the surveyor conducted a tour of the Indian kitchen prep room with the FSD and Indian [NAME] (IC) # 1 and observed the following:
-In the first white closet, there was a brownish yellow flaked snack stored in a small plastic container. The FSD stated, it's personal food and should not be there. IC#1 identified them as corn flake snacks.
-In the black closet there was an opened five lbs. container of Cumin powder in it's original clear plastic bag packaging, with no opened date. The surveyor observed an unwrapped black immersion blender stored directly on the floor in the closet. IC #1 stated, its clean because its not used. The FSD explained to IC#1 that the blender can not just sit on the floor unwrapped, once it is used, it should be cleaned and a bag placed over it.
-On top of the white reach in freezer there was a jacket in a large clear plastic bag . IC #1 stated, it belongs to another staff. The FSD stated, The jacket should not be in the kitchen, it should be in the locker.
-There was a pan on the top of the black closet. The FSD identified it as a six-inch third pan that contained four boxes of of hashbrown potatoes (4.2 oz) with a best date of 9/23.
-In a double door cabinet, under the prep table, there was an opened 32 oz bottle of lime juice, with no opened date.
-On the bottom shelf of a double door cabinet there were two pairs of eyeglasses next to the lentil containers. IC #1 stated, they belong to IC #2 and the FSD stated, They (the glasses) shouldn't be there.
-In the left top cabinet, there was an unidentified brown colored powder stored in a plastic container which had the name of a different manufactured item [name redacted]. The container had no label and no opened date. IC #1 stated, It's amchoor powder (a spice made from dried green mangoes).
-In the left top cabinet there was a closed clear plastic container with two small packets wrapped in plastic, IC#1 identified the packets as an opened four lbs packet of pearl tapioca, with no opened date and an opened four lbs packet of [NAME] seeds (a type of rice/[NAME]), with no opened date.
-A green cutting board that had multiple scratches/gouges and black, brown marks on it.
-In the single door white refrigerator was an opened four lbs container of [name redacted] natural dahi (whole milk yogurt), with no opened date. On the outside of the refrigerator, the surveyor observed the Freezer Temperature Log sheet and the Refrigerator Temperature Log sheet for [DATE].
Review of the Indian kitchen preparation room's log labelled Freezer Temperature log for December 2023 revealed that the temperatures were documented for the refrigerator temperatures and not the freezer temperatures from December 2 to 12th. The IC#1 stated that staff filled out the log incorrectly.
Review of the Indian kitchen preparation room's Refrigerator Temperature log for December 2023 revealed the temperatures were not filled in for the AM or PM for December 2,3,4,5,6,7,8,9,10,11, and 12. The FSD stated, I do not check temp logs in the Indian kitchen prep room as often as I should be. He then stated that the temperature log sheets should be checked daily, and I didn't.
At 12:30 PM, in the main kitchen, the surveyor observed a metal rack with four shelves next to the pillar. The third shelf contained dry spices and other cooking ingredients. The surveyor identified the following:
-An opened one gallon container of red hot sauce, with no opened date.
-An opened 12 fluid (fl) oz glass bottle of red cooking wine, with no opened date.
-An opened 12 fl oz glass bottle of white cooking wine, with no opened date.
-Two 32 oz opened bottles of gravy mix, with no opened date.
Review of the undated facility policy Record of Refrigeration Temperatures included a daily temperature record is to be kept of refrigerated items. It further included, the refrigerator temperatures must be 41 degree or below.
Review of the undated facility policy Food Storage included all products shall be dated upon receipt or when they are prepared. It also included the following:
- Label and date all storage containers as follows:
1. The received date should already be on it.
2. Date opened.
3. Date the item expires.
Review of the undated facility job description for Director of Food Services included the following:
- Perform administrative duties such as completing necessary forms, reports, evaluations, studies, etc., to assure control of equipment and supplies.
- Inspect food storage rooms, utility/janitorial closets, etc., for upkeep and supply control.
- Maintain a reference library of written material, laws, diet manuals, etc., necessary for complying with current standards and regulations and that will provide assistance in maintaining quality food service.
- Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility.
- Monitor dietary service personnel to assure that they are following established safety regulations in the use of equipment and supplies.
- Ensure that all food storage rooms, preparation areas, etc., are maintained in a clean, safe, and sanitary manner.
- Make weekly inspections of all dietary functions to assure that quality control measures are continually maintained.
NJAC 8:39-17.2 (g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of hot foods served to the residents. This deficient practice was identified for two (2) of six (6) residents interviewed during the Resident Council meeting and confirmed during the lunchtime meal service on 12/20/23 for 1 of 5 nursing units tested for food temperatures by two surveyors and was evidenced by the following:
On 12/14/23 at 11:00 AM, the surveyor met with six (6) residents for council meeting. Two out of six residents stated that food temperatures varied depending upon if they ate in the dining room or in their rooms; if they ate in their rooms, the food was cold. One of the two residents further stated that this was a recurrent complaint at resident council meetings.
On 12/20/23 at 11:11 AM, the Registered Dietitian (RD) surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the survey team.
On 12/20/23 at 11:35 AM, the surveyor interviewed the evening cook in the presence of a second surveyor. He was setting up a five well steam table for lunch service on the fourth floor. He stated that it was working properly and that it warms up quick.
On 12/20/23 at 11:57 AM, the surveyor observed kitchen staff deliver hot food in a food warmer to the unit pantry.
On 12/20/23 at 12:50 PM, the surveyor observed the last tray delivered to the residents. At that same time the evening cook joined the dietary aide who was plating food from the steam table in the fourth-floor unit pantry. The surveyor took the temperatures of the following items in the presence of both food service staff and a second surveyor:
Beef cubes teriyaki style: 122 degrees F
Mixed vegetables: 117 degrees F
Lo Mein noodles: 126 degrees F
Sausage: 110 degrees F
Puree beef: 123 degrees F
Puree vegetables: 113 degrees F
Mashed potatoes: 116 degrees F
On 12/20/23 at 12:52 PM, the surveyor interviewed the two food service staff members in the presence of a second surveyor. The evening cook stated that beef should have been at 140-145 degrees F at which time the dietary aide agreed.
On 12/20/23 at 1:20 PM, the surveyor interviewed the Food Service Director (FSD) in the presence of the survey team. He stated that food temperatures were checked before transport to the unit via warmer about five to ten minutes prior to service. The FSD further stated that to his knowledge all the steam tables were working properly. He stated, their process should maintain food temperatures, food should stay hot. He also stated that he had not done test trays and had not taken food temperatures on that unit. In addition, the FSD stated that there have been issues about food being cold discussed in resident council meetings. He stated that the facility did not have plate warmers and that hot food temperatures should be held at 165 degrees F.
Review of an undated facility policy Dining Services Food Temperatures, indicated that acceptable serving temperatures for the following items were:
Meat, entrees > 140 degrees F, but preferably 160-175 degrees F
Potatoes, pasta > 140 degrees F, but preferably 160-175 degrees F
Vegetables > 140 degrees F, but preferably 160-175 degrees F
The policy also included to heat hot plates.
NJAC 8:39-17.2(g), 17.4(e)

**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 (a). properly label, store and dispose of medications in three (3) of seven (7) medication carts and in two (2) of three (3) medication storage room inspected, and b). failed to secure one (1) of three (3) narcotic lock boxes in 1 of 3 medication refrigerators inspected.
This deficient practice was evidenced by the following:
(a). On [DATE] at 10:20 AM, the surveyor inspected the 6th floor medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed a bottle of blood glucose test strips that was opened and had no opened date. The surveyor also observed a Basaglar insulin pen that was opened and dated but the resident's name on the vial did not match the resident's name that was on the medication bag that held the insulin pen.
At that time, the surveyor interviewed LPN#1, who stated that an opened bottle of blood glucose strips should have been dated. LPN#1 further stated that the Basaglar insulin pen should have been stored in a bag that contained the same resident's name as was on the insulin pen. She also stated that prior to administering any insulin via a vial or pen that she will always assure that the resident's name on the product matched the resident who was receiving the insulin.
On [DATE] at 10:40 AM, the surveyor inspected the 6th floor medication room refrigerator in the presence of LPN#1. The surveyor observed four bottles of Lorazepam (medication for anxiety) 2 mg (milligrams)/ml (milliliters) multi-dose injectable vials. The surveyor observed one vial of the Lorazepam 2mg/ml that was opened and not dated.
At that time, the surveyor interviewed LPN#1 who stated that a vial of multi-dose Lorazepam should have been dated once opened. She also stated that the resident was no longer on the medication and that the medication should have been removed from active medication stock.
On [DATE] at 10:45 AM, the surveyor inspected the 5th floor medication cart #2 in the presence of LPN#2. The surveyor observed an opened and undated vial of Lantus insulin.
On [DATE] at 10:50 AM, the surveyor inspected the 5th floor medication room in the presence of LPN#2. The surveyor observed a bottle of Vitamin B-12 house stock that had an expiration date of 6/2023.
At that time, the surveyor interviewed LPN#2 who stated that an opened vial of Lantus should have been dated and that an expired bottle of Vitamin B-12 should have been removed from active medication stock.
On [DATE] at 11:15 AM, the surveyor inspected the 2nd floor medication cart #3 in the presence of LPN#3. The surveyor observed an opened and undated bottle of blood glucose test strips.
At that time, the surveyor interviewed LPN #3 who stated that once a bottle of blood glucose test strips was opened that it should have been dated.
A review of the Manufacturer's Specifications for the following medications revealed the following:
1. Blood glucose test strips once opened have an expiration date of 180-days.
2. Lorazepam 2mg/ml multi-dose injectable vial once opened have an expiration date of 28-days.
3. Lantus insulin vial once opened have opened have an expiration date of 28-days.
b). On [DATE] at 10:40 AM, the surveyor inspected the 6th floor medication room refrigerator in the presence of LPN#1. The surveyor observed a locked narcotic refrigerator that contained a narcotic lock box that was not affixed to the refrigerator. The surveyor was able to pull the whole shelf with the narcotic box out of the refrigerator. The narcotic box contained 4 Lorazepam multi-dose injectable vials.
At that time, the surveyor interviewed LPN#1 who acknowledge that the narcotic box inside the medication should have been affixed to the refrigerator.
On [DATE] at 3:30 PM, the surveyor discussed the above concerns with the administrative team which included the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) and the Infection Preventionist. There was no additional information provided.
A review of the facility's policy for Medication Administration that was dated [DATE] and provided by the DON that included the following:
G. Prior to Medication Administration:
3. Check expiration date on medication label.
A review of the facility's policy for Storage of Controlled Medications that was dated [DATE] and provided by the DON included the following:
2. Schedule II through V medications and other medications subject to abuse or diversion are stored in either in a permanently affixed, double locked compartments separate from all other medications or in accordance with state regulations.
3. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator and/or in accordance with state regulations and facility policy.
10. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed in accordance with facility policy and state regulations. Accountability records for discontinued controlled substances are maintained with the unused supply until it is destroyed or disposed of, and then stored for five years or as required by applicable law or regulation.
NJAC: 8:39-29.4 (a) (h) (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 12/18/2023 at 9:26 AM, the surveyor interviewed Resident #119, who stated that he/she used half side rails for repositioning in bed as well as an assist to get out of bed due to left side weakness.
A review of the AR revealed the resident had diagnoses which included but were not limited to: a fracture of the left femur (hip), hemiplegia (paralysis of one side of the body) and hemiparesis following cerebrovascular disease affecting the right dominant side and lack of coordination.
Review of the quarterly MDS dated [DATE], revealed the resident had BIMS score of 14 out of 15, which indicated that Resident #119 had an intact cognition. The MDS also coded section P0100 as the resident with a physical restraint with a bed rail used less than daily.
Review of the Order Summary Report reflected a physician's order dated 1/18/23 for Half side rail to left side as enabler to increase independence in bed mobility when in bed, and Half side rail to right side as enabler to increase independence in bed mobility when in bed.
On 12/14/23 at 2:30 PM, the surveyor interviewed the MDS Coordinator in the presence of the survey team. She reviewed the residents quarterly MDS dated [DATE] in the electronic medical record and acknowledged that she coded the resident as having side rail restraint's and that was a coding error.
On 12/18/23 at 9:45 AM, the surveyor interviewed the Licensed Practical Nurse (LPN/UM) who stated that the side rails for Resident #119 were not restraints and were enablers for bed mobility.
Review of the Consent for Siderail Use, dated 8/13/22, reflected that right and left half siderails were indicated as a mobility aid and for security as per resident preference. This document was signed and dated by the resident and the LPN/UM.
Review of the Job Description MDS Coordinator revealed Job Summary:The MDS Nurse is to assess the residents' physical and mental function and document data on the Minimum Data Set forms completely and accurately.
Under Duties and Responsibilities:
1. Interview residents, residents' representatives and others for information related to the minimum data set assessment.
2. Examine residents to collect information related to the minimum data set assessment.
3. Review medical records and records related to residents' health status to collect information related to the minimum data set assessment.
4. Enter data onto the computer program for minimum data set assessments.
5. Assume accountability and responsibility for accuracy of minimum data set (MDS) assessment information.
Review of the facility's policy titled Resident Assessment Instrument (RAI) Process which was revised 04/2023, revealed Purpose: To ensure that the Minimum Data Sets (MDS) for each resident is completed accurately and timely in accordance with State and Federal regulations. To ensure that each resident is assessed for specific needs in order to attain or maintain the resident's highest practicable well-being.
NJAC 8:39-11.1
Based on observations, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 2 of 38 residents (resident #178 and #119) reviewed for accurately coding the MDS.
This deficient practice was evidenced by the following:
1. On 12/12/2023 at 11:15 AM, the surveyor observed Resident #178, sitting in a wheelchair, in activities.
On 12/13/2023 at 1:00 PM, the surveyor observed Resident #178 in the dining room after lunch. The resident was sitting upright in the wheelchair and was awake and alert. The Resident responded verbally to the surveyor and stated that he/she was ok.
On 12/14/2023 at 12:50 PM, the surveyor observed Resident #178 in the dining room for lunch, which was already served. The resident appeared well groomed and calm.
A review of admission Record (AR) revealed that resident #178 was admitted to the facility with diagnoses that included but were not limited to: dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), and chronic kidney disease(longstanding disease of the kidneys leading to renal failure).
Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/24/23, revealed under section B 0100(Persistent, vegetative state/no discernible consciousness) was coded yes. Due to section B 0100 being coded as yes, no Brief Interview for Mental Status (BIMS) [a tool used to screen and identify cognitive conditions] was assessed.
During the observation period of the MDS (the time-period in which the resident condition or status is captured by the MDS assessment) the progress notes were reviewed and there were no notes which identified the resident as being comatose.
The progress notes titled Skilled/COVID Documentation on 11/18/23; 11/19/23; 11/20/23; 11/21/23; 11/22/23; and 11/24/23 indicated that resident was awake, alert and verbally responsive with confusion.
A review of an assessment titled, Social Service Department-Quarterly/Medicare Assessment/Discharge dated 11/24/23, revealed: Section II. Orientation/BIMS; A. ORIENTATION/COMMUNICATION: 1. Persistent vegetative state/no discernible consciousness: O.No was selected.
On 12/14/23 at 1:14 PM, the surveyor interviewed the Registered Nurse /Unit Manager (RN/UM) regarding completion and accuracy of the MDS. The RN/UM stated, I do not complete the MDS, the MDS Coordinator is responsible for completing and checking the MDS for accuracy.
On 12/14/23 at 2:30 PM, the surveyor interviewed the MDS Coordinator in the presence of the survey team, who stated, that she had been employed at the facility since 2017 and has been doing MDS since 2021 and that she was responsible for doing the MDS for the fifth floor (the floor Resident #178 resided on). This surveyor discussed the coding of the MDS assessment dated [DATE] in which the resident was coded as being comatose. She stated , Resident #178 was not in a coma and that the section B 0100 was coded in error. This surveyor asked the MDS Coordinator who was responsible for checking the assessment for accuracy and she stated the MDS Director.
This surveyor attempted to interview the MDS Director however was made aware by the Director of Nursing (DON) that she was away on vacation.
On 12/18/23 at 9:41 AM, the surveyor interviewed the DON on the accuracy and completion of the MDS. The DON stated the MDS's were completed by both the MDS Coordinator and the MDS Director. She stated that the MDS Director was responsible for checking the accuracy of the assessment.

Based on observations, interviews, and record review, it was determined that the facility failed to a.) change the oxygen tubing as directed by the Physician order and follow the facility policy, b.) develop a care plan to address the resident requiring oxygen upon readmission to the facility and c.) re-evaluate the Physician's Order for the continuous need of oxygen at 4 liters (L) via nasal cannula. This deficient practice was identified for 1 of 1 resident, Resident #63, which was reviewed for oxygen therapy.
This deficient practice was evidenced by the following:
On 12/12/ 2023 at 11:20 AM, the surveyor entered the resident's room and observed the nasal cannula tubing (a device that delivers oxygen through a tube and into your nose) connected to an oxygen concentrator (a device which provides supplemental oxygen). The surveyor observed the nasal cannula tubing was labeled with the date of 11/15/2023. At this time, Resident #63 was observed sitting in the dining room, in a wheelchair, during group activities. The resident was not wearing oxygen.
The surveyor reviewed the medical record of Resident #63.
Review of the admission Record (an admission summary) reflected that resident #63 was admitted to the facility with diagnoses which included but are not limited to: Benign Prostatic Hyperplasia (enlargement of the prostate gland), Hypertension (a condition in which the force of the blood against the artery walls is too high), and Respiratory Failure (a condition which makes it difficult to breathe on your own).
Review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 09/24/23, revealed that Resident #63 had a Brief Interview for Mental Status (a tool used to identify the cognitive condition) score of 4 out of 15, which indicated that the resident was severely cognitively impaired. In section (I) of the MDS active diseases number I6200 respiratory failure was checked and in section I8000 it was documented that the resident had acute respiratory failure unspecified with hypoxia (a condition in which you do not have enough oxygen in the tissues of your body) or hypercapnia (too much carbon dioxide in your blood). In section O of the MDS (Special Treatments, Procedures and Program) number 00100 oxygen therapy was not checked in the column under while a resident. This section indicated that resident #63 was not on oxygen during the observation period (the time period over which the resident's condition or status is captured by the MDS assessment).
A review of the November 2023 Medication Administration Record (MAR) revealed a physician order dated 7/25/23 to CHANGE OXYGEN TUBING every night shift every Tues (Tuesday). Further review revealed the order had been signed as completed on
11/7/23, 11/14/23, 11/21/23, and 11/28/23.
A review of the December 2023 MAR revealed a physician order dated 7/25/23 to CHANGE OXYGEN TUBING every night shift every Tues (Tuesday). Further review revealed the order had been signed as completed on 12/5/23; 12/12/23.
A review of the December 2023 Treatment Administration Record (TAR) revealed a physician order dated 7/25/23 for O2 continuously at 4 LPM via nasal cannula every shift. Further review revealed that ordered had been signed as completed from 12/1/2023 to 12/11/2023 for the day, Eveni (evening), and night shifts.
Review of the Weights and Vitals Summary revealed the resident's pulse ox was documented as 92% or higher on room air from 09/24/2023 until 12/12/23.
Review of the care plan revealed that there was no care plan developed or implemented for oxygen use.
On 12/18/2023 at 10:24 AM, this surveyor interviewed the Director of Nursing (DON), who stated prior to weaning a resident off continuous oxygen it should be discussed with the Physician or Nurse Practitioner, an assessment was completed for 3 or more days which included the oxygen saturation and the results were documented in the medication administration record and skilled nursing notes and discussed with the Physician or Nurse Practitioner to determine whether the order should be changed. The DON stated that respiratory equipment (nebulizer, oxygen tubing etc.) was changed on the 11-7 shift every Tuesday.
On 12/18/2023 at 10:38 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that Resident #63 did not have oxygen on because he/she kept removing it. She stated that he/she does not become short of breath with exertion without oxygen. The LPN stated that oxygen tubing was changed weekly on the 11-7 shift.
On 12/18/2023 at 10:47 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated the Resident #63 has not been wearing oxygen. She further explains that initially when it was ordered the resident would wear the oxygen but when the resident began to feel better, he/she began to remove it. The RN/UM stated that oxygen tubing was changed weekly by the 11-7 shift.
On 12/18/2023 at 11:30AM, the surveyor interviewed the Certified Nurse Assistant (CNA), who stated that Resident #63 does not wear oxygen and that the resident does not become short of breath when being assisted with activities of daily living.
On 12/19/2023 at 9:45AM, the surveyor interviewed the MDS Coordinator, who stated that Resident #63 was coded as not using oxygen during the observation period because the resident was not observed wearing oxygen during that time. Therefore, she coded Resident # 63 as not wearing oxygen.
On 12/19/2023 at 10:21 AM, during a follow-up interview with the RN/UM regarding the care plan for Resident #63's oxygen was not initiated when the resident was readmitted to the facility. She stated, I forgot to initiate the oxygen care plan. The RN/UM stated that the Interdisciplinary Care Team (IDCP) was responsible for initiating and updating the care plan.
Review of the facility's policy Oxygen Administration/Changing which was revised April 2023, revealed Policy: Oxygen administration will be carried out only with a physician's order. A licensed nurse or other staff person trained in the use of oxygen will be on duty and be responsible for the correct administration of oxygen to the resident.; Procedure: 11. Label oxygen tubing with the date and time opened. Change oxygen tubing weekly.
NJAC 8:39-27.1(a)(b)
NJAC 8:39-11.2(f)

Based on interviews and review of pertinent facility documentation, it was determined that the facility allowed 9 of 13 Non-Certified Nursing Aides (NA) to continue working as an NA after the specified 120 days from date of hire. This deficient practice was identified during NA review.
This deficient practice was evidenced by the following:
Reference: State of New Jersey Department of Health memo dated April 21, 2023 sent to Nursing Homes included the following:
Facilities are advised as follows:
I. TNAs (Temporary Nursing Assistant)
A. Individuals who are working as TNAs must pass the nurse-aide written or oral exam and the State-approved clinical skills competency exam by May 11, 2023, or the end of the federal PHE (Public Health Emergency), whichever comes first.
B. If a TNA does not pass the exams by the end of the federal PHE, the TNA may not work after May 11, 2023, unless the TNA meets the requirements of Paragraph C below.
C. In order to work beyond May 11, 2023, TNAs must, by May 11, 2023:
1. Be enrolled in a NATCEP CNA training program, and
2. Have completed the first 16 hours of training, and
3. Be working in a facility before May 11, 2023.
4. Note that the TNA only has until September 10, 2023 to complete the NATCEP (Nurse Aide Training and Competency Evaluation Program) program and pass the exams.
II. Nurse Aides
Nurse Aides (not TNAs) who are enrolled in a NATCEP program must finish training and pass the nurse-aide written or oral exam and the State approved clinical skills competency exam within the usual 120 days, pursuant to N.J.A.C. 8:39-43.1. After completing the first 16 hours of training, the nurse aide may work in a nursing home while completing the training and testing.
On 12/12/23 at 11:00 AM, during entrance conference the Licensed Nursing Home Administrator (LNHA) stated that they did not have any NAs. The LNHA was given the Nursing Staffing Reports to be completed for the two weeks of staffing prior to the recertification survey.
On 12/14/23 at 10:05 AM, the surveyor met with the LNHA to inquire about the Nursing Staff Reports that listed 13 Non-Certified Aides in training (NAs). The LNHA apologized and stated I found out after entrance conference that we (the facility) had NAs. The surveyor requested a list of the NAs along with proof of their enrollment in a Certified Nursing Aide (CNA) school.
On 12/14/23 at 11:38 AM, the LNHA provided the NA list but stated they were still in the process of updating the list. He stated that there should be a tracking process in place and they should have had the dates. HR was responsible for maintaining the records for the NAs.
On 12/18/23 at 10:45 AM, the LNHA provided the updated NA list to the surveyor.
On 12/18/23 at 12:51 PM, a review of the updated NA list provided by the facility revealed the following:
NA #1, Date of Hire (DOH): 8/14/23, 120 days from date of hire: 12/12/2023, program completion: 8/30/23.
NA #2, DOH: 8/7/2023, 120 days from date of hire: 12/5/2023, program completion: 9/6/2023.
NA #3, DOH: 8/9/2023, 120 days from date of hire: 12/7/2023, program completion: 9/6/2023.
NA #4, DOH: 8/1/2023, 120 days from date of hire: 11/29/2023, program completion: 9/6/2023.
NA #5, DOH: 8/7/2023, 120 days from date of hire: 12/5/2023, program completion: 9/6/2023.
NA #6, DOH: 8/3/2023, 120 days from date of hire: 12/1/2023, program completion: 9/6/2023.
NA #7, DOH: 8/3/2023, 120 days from date of hire: 12/1/2023, program completion: 9/6/2023.
NA #8, DOH: 7/27/2023,120 days from date of hire: 11/24/2023, program completion: 9/6/2023.
NA #9, DOH: 7/30/2023, 120 days from date of hire:11/27/2023, program completion:9/6/2023.
NA# 10, DOH AS NA: 10/5/2023, 120 days from date of hire: 2/2/2024, program completion:10/31/2023.
NA #11, DOH: 11/20/2023, 120 days from date of hire: 3/19/2023, program completion: 11/11/2023.
NA# 12, DOH: 11/20/23, 120 days from date of hire: 3/19/2024, program completion: 11/11/2023.
NA# 13, DOH: 9/19/2023, 120 days from date of hire:1/17/2024, program completion: 10/28/2023.
A review of the formal job offers letters to the above listed NAs revealed that All Certified Nursing Assistants are required to pass the state examination within 120 days of graduation from an accredited program. This is mandatory in order to continue employment with Alameda.
A review of the facility's Nursing Schedule provided daily to the survey team from 12/12/2023 to 12/19/23, revealed the NAs listed as CNA's and were scheduled to work as follows:
NA #1: night shift: 12/12, 12/13; evening & night shift:12/14; night shifts: 12/15, 12/18, 12/19.
NA#2: day shift: 12/12; evening shift: 12/15; day shift:12/18.
NA#3: evening shift: 12/12; night shifts: 12/13, 12/14; evening and night shift: 12/15; evening shift 12/16; evening & night shift: 12/17; evening shift: 12/18.
NA# 4: night shift: 12/12; day shifts: 12/13, 12/14, 12/18.
NA #5: day shifts: 12/12, 12/14, 12/15; evening shifts: 12/15, 12/16; day shifts: 12/18, 12/19.
NA# 6: evening shift: 12/13; evening & night shift: 12/14, 12/15; evening shift: 12/16; night shift:12/17; evening shifts: 12/18; evening and night shift: 12/19.
NA#7: evening shift: 12/12, 12/13; day and evening shift: 12/15; evening shifts: 12/17, 12/18.
NA# 8: evening shifts: 12/12, 12/14, 12/18, 12/19.
NA#9: day shifts: 12/12,12/13,12/14; evening shift 12/14; day and evening shift:12/15, 12/16; day shift 12/17/; day and evening shifts: 12/19.
NA# 10: day shift: 12/12, 12/13; day and evening shift: 12/15, 12/16, day shift 12/17, 12/18; night shift: 12/19.
NA# 11: evening and night shift: 12/13; day shift:12/15.
NA#12: day and evening shift: 12/13. Day shift: 12/15.
NA#13: day shift: 12/12, 12/13,12/16, 12/17; day and night shift: 12/19.
On 12/19/23 at 9:41 AM, during an interview with the Director of Nursing (DON) and the Assistant Director of Nursing/Infection Preventionist (ADON/IP), the ADON/IP stated that NAs must complete at least 16 hours of schooling to work as an NA and that they must compete the certification within 120 days from date of hire. She stated the reason was they have to learn regulations of safe practice, stay in the scope of practice, and to makes sure when in building they are providing care within guidelines.
On 12/19/23 at 10:55 AM, the LPN/UM, on the 2nd floor, provided a staffing assignment sheet to the surveyor, NA #12 was listed on the assignment sheet as a CNA. The surveyor asked the LPN/UM about NA#12, the LPN/UM stated this was the first time she was working with her and did not know anything about her.
On 12/19/23 at 11:00 AM, the surveyor interviewed NA#12, who was wearing her name badge which had her name and CNA listed below it. The surveyor asked if she was a CNA and she stated yes. The surveyor asked if she was a certified nursing aide and she stated well I completed my school and took the skills test, I will take the written part in February. She stated she started work about 3 weeks ago and they (Human Resources, HR) told me I had 120 days from my school completion date to take the test.
On 12/19/23 at 11:10 AM, during a follow up interview with DON and ADON/IP, the DON stated that the UMs would know who the NA's are and would assign them a buddy CNA to go to for help. She then stated, the UM should know the NA because they are considered to be on orientation and should be monitored.
On 12/19/23 at 11:20 AM, during an interview with the LNHA and Registered Nurse/Vice President of Clinical Services (RN/VPCS), the LNHA verified that NAs should be certified within 120 days from date of hire. He stated, he understands that tracking needs to be to done and that he started a tracking system. The LNHA confirmed at that time, that the NAs progress was not being tracked. The LNHA stated that the NAs all signed letters that they would obtain their certification within 120 days of completion of their schooling.
On 12/19/23 at 11:40 AM, during an interview with NA#9, he stated he started working in August not sure of the exact date. He stated he finished CNA school in Sept and finished up my skills test. The surveyor observed NA#9 was wearing a badge that identified him as a CNA but stated he was working as a NA training to be a CNA. He state he was informed by the facility that he has to take his test by January.
On 12/19/23 at 11:45 AM, during an interview with the surveyors, the LNHA stated that the HR Director (HRD) had been informed that NAs had to obtain certification within 120 days of completion of school. At that time, the LNHA confirmed that the certification must be obtained within 120 days from date of hire. He then confirmed again that the HRD was not tracking the NAs progress. The surveyor made the LNHA aware that 2 NAs (NA#12 and NA #9) that were currently working, were wearing name badges that listed them as CNAs. He stated that the purpose of badges with name and department was to identify staff to residents, visitors, and other staff members for their scope of practice. The LNHA stated the NA's would be taken off the schedule until they get their certification.
On 12/20/23 at 10:10 AM, during an interview with the HRD, the HRD stated that NAs must show proof of being in school, or completion of school, and that they need to complete at least 3 days of schooling before starting work at the facility. He further stated that, I believe it is 16 hours but we require them to complete 3 days. He stated he had a system in place for tracking NAs progress, but he was unable to provide the tracking to the surveyor.
On 12/20/23 at 12:10 PM, the LNHA again confirmed that the HRD did not have a tracking system for the NAs until the LNHA emailed him one.
On 12/20/23 at 4:02 PM, the LNHA and the DON were made aware of the above findings.
No additional information was provided to the survey team.
N.J.A.C. 8:39-43.10

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to physician orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 6 (six) residents (Resident #7) observed during the medication observation pass.
The deficient practice was evidenced by the following:
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
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.
On 12/18/23 at 9:10 AM, during the medication administration observation, the surveyor observed a Licensed Practical Nurse (LPN) in the room of Resident #7. The surveyor observed the LPN checking the resident's identification bracelet and informing Resident #7 that she would be administering the resident's medications. The surveyor observed the resident in their bed and just finished eating breakfast.
On 12/18/23 at 09:15 AM, the surveyor observed LPN preparing to administer (5) medications to Resident #7 which included one tablet of Benztropine 0.5 mg tablet (anti-tremor medication), one tablet of Vitamin D3 2000 tablet (supplement), two tablets Sodium Chloride 1 gram (low sodium levels), 5 ml of Valproic acid 250mg/ml (mood disorder) and one tablet of Zyprexa 5 mg tablet (mood disorder).
The surveyor observed the LPN put one tablet of Benztropine, one tablet of Vitamin D, and 2 tablets of Sodium Chloride into a medication cup for a total of 4 tablets. The surveyor then observed the LPN add 5 ml of Valproic syrup into a measuring cup. The surveyor did not observe the LPN add Zyprexa into the medication cup. The surveyor then observed the nurse pour 120 ml of water into a cup. The surveyor checked the medication cup three more times which showed 4 tablets in the cup. The surveyor then observed the LPN administered the resident their medications. After administering Resident #7's medication the surveyor observed the LPN signed off the electronic medication administration record (EMAR) which included Zyprexa 5 mg.
At that time, the surveyor interviewed the LPN who refused to acknowledge that she omitted Zyprexa.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to schizoaffective disorder (schizophrenia and mood disorder symptoms), hypo-osmolality and hyponatremia (produced by retention of water, by loss of sodium or both), and gastro-esophageal reflux disease without esophagitis (a digestive disease in which stomach acid or bile irritates the stomach but without involving inflammation of the esophagus.
A review of the Quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 11/10/23, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident was cognitively intact.
A review of the December 2023 Medication Review Report (MRR) which revealed a physician order (PO) dated 8/17/23, for Zyprexa oral tablet 5 mg, give 1 tablet by mouth in the morning for mood d/o (disorder).
A review of the December 2023 electronic Medication Administration Record (eMAR) revealed an order dated 8/17/23, for Zyprexa oral tablet 5 mg, give 1 tablet by mouth in the morning for mood d/o and scheduled for 9:00 AM, and showed on 12/18/23 that Zyprexa was documented as being administered.
On 12/20/23 at 3:30 PM, the surveyor met with the Licensed Nursing Home Administrator, Director of Nursing (DON) and the Infection Preventionist and discussed the above findings. No further information was provided.
A review of the facility's policy for Medication Administration dated 04/30/23, which was provided by the DON, revealed that they were no policy that assure that prepared medications should be double check prior to medication administration.
NJAC 8:39-11.2 (b), 29.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of facility documentation, it was determined that the facility failed to respond to pharmacy consultant recommendations in a timely manner for 2 of 5 residents (Resident # 125 and #152) reviewed for unnecessary medications.
This deficient practice was evidenced by the following:
1. During lunch observation on 12/12/23 at 1:04 PM, the surveyor observed resident #125 leaving the dining room, asking staff if he/she could leave the room. The 2nd floor unit clerk directed the resident to his/her room.
According to the admission Record (AR), Resident#125 was admitted to the facility with diagnoses that included but were not limited to: anxiety disorder (an intense, excessive, and persistent worry and fear about everyday situations) and unspecified Dementia, unspecified severity, with other behavior disturbances.
The annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/22/23, indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 3 out of 15 which indicated that the resident had severe cognitive impairment. Further review of the MDS, revealed the resident was receiving antianxiety and antipsychotic medications.
A review of the electronic Medical Record (eMR) revealed a physician order (PO) dated 4/6/23 at 1600 (4:00 PM) for Alprazolam (Xanax, a medication given for anxiety) Tablet 1 MG (milligram), give 1 tablet by mouth every 8 hours as needed (PRN) for anxiety. This order did not include a duration for the prn medication. Further review of the physician orders revealed an order dated 12/1/23 at 21:43, Alprazolam Tablet 1 MG, Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days.
On 12/18/23 at 9:30 AM, the Director of Nursing (DON) provided the Consultant Pharmacist's Medication Regiment Review (CPMR) reports, which included the Medication Regimen Review (MRR), from 4/1/23.
On 12/19/23 at 8:30 AM, a review of the CPMR for Resident #125 revealed the following:
-MRR Priority Normal: dated 4/27/23, As per Federal Regulations all prn psychoactives should be written for 14 days. Please clarify Alprazolam prn to 14 days.
-MRR, Priority Normal: dated 5/24/23, We have noticed that the prn anxiolytic Alprazolam has been renewed after 14 days (since 4/6/23). The purpose of the 14-day rule for PRN psychoactive medications is to place our resident's on safer alternatives to prevent falls and fractures. Please have resident re-evaluated and their anxiolytic therapy and consider safer alternatives such as antidepressant that can treat general anxiety disorder, psychotherapy, and other non-interventions.
-MRR, Priority High: dated 6/22/23, 7/17/23, 8/31/23, 9/22/23, 10/19/23, and 11/17/23: We have noticed that the prn anxiolytic Alprazolam has been renewed after 14 days (since 4/6/23). The purpose of the 14-day rule for PRN psychoactive medications is to place our resident's on safer alternatives to prevent falls and fractures. Please have resident re-evaluated and their anxiolytic therapy and consider safer alternatives such as antidepressant that can treat general anxiety disorder, psychotherapy, and other non-interventions.
A review of the Psychiatry Progress Note dated 12/1/23 revealed Monitored Psych Medications: Xanax 1 mg q 8 hours prn for anxiety . Plan: 3. specify duration of Xanax prn to 14 days.
The facility failed to provide documented evidence that nursing or the physician addressed the pharmacy recommendations for Resident #125 from April 2023 to present.
On 12/19/23 at 9:41 AM, the surveyor interviewed the DON regarding the process for the pharmacy consultant recommendations. She stated that they come through email. The nurses on the floor were responsible to follow up with the physician to make sure that the pharmacist's recommendations were addressed. She also stated that the unit managers should take the lead to make sure it was done. The DON stated that prn Antipsychotics should only be written for 14 days so that it can be reviewed as to what causes the behaviors.
On 12/19/23 at 9:50 AM, in the presence of the surveyor, the DON reviewed the eMR and confirmed that the original PO for Xanax 1 mg by PO (by mouth) q (every) 8 hours as needed for anxiety was from 4/6/23. She also confirmed that there was not a duration of 14 days. The DON stated that there should be a duration so the resident could be re-evaluated to see if the medication was effective or if the medication should be titrated, increased or decreased.
On 12/19/2023 at 10:40 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) of the 2nd floor, who stated that the expectation of staff was to try and distract residents and to try non-pharmaceutical interventions before using medications to address behaviors. She then stated that the purpose was to monitor behaviors and how often the behavior occurs to see they needed something (medication) standing. She stated that the pharmacy consultant recommendations came through emails that go to every floor and we (nurses) are supposed to go through the recommendations, verify diagnoses, clarify orders with the Nurse Practitioner or physician with the pharmacist recommendations.
On 12/19/23 at 1:54 PM, during a telephone interview, the pharmacist consultant supervisor stated that the MRR's are emailed monthly to the facility, the DON, administrator, and to the unit manager. She then stated that we do not send them directly to the physicians. The facility should fax it or give to the physician. She stated that the reason that Xanax prn should have a 14-day duration was the new regulation to make sure safe alternates are used before Antipsychotics and antianxiety medications are used.
On 12/20/23 at 4:02 PM, in the presence of the survey team, the above findings were presented to the Licensed Nursing Home Administrator (LNHA) and the DON.
No additional information was provided.
2. On 12/13/23 at 12:37 PM, the surveyor observed resident #152 in the dining room for lunch. The resident was dressed and wearing a hat.
According to the AR, Resident#152's was admitted to the facility with diagnoses that included but were not limited to: schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms) and auditory hallucinations (sensory perceptions of hearing in the absence of external stimulus).
The MDS, dated [DATE], indicated that the facility assessed the resident's cognitive status using BIMS. The resident scored a 15 out of 15, which indicated that the resident was cognitively intact. Further review of the MDS, revealed the resident was receiving antidepressant and antipsychotic medications.
On 12/19/23 at 11:48, a review of the CPMR revealed the following pharmacy consultant recommendations for Resident #152 that were not addressed until 11/23/23:
MRR, Priority Normal: dated 4/27/23:
Please clarify Percocet PRN order to include degree of pain.
Please clarify ICY HOT Patch order to include leaving patch on up to 8 hours per day and remove.
MRR, Priority Normal: dated 5/24/23:
The resident is on Olanzapine. Please do the monthly quantitative behavioral summary. Include target monitoring how many times it happened in one month, non drug interventions, side effects(if any), ;last psych visit, None seen in [name redacted-EMR].
MRR, Priority Normal: dated 5/24/23, 8/31/23:
Please clarify and space Gabapentin evenly around the clock for around the clock pain coverage. Clarify to Gabapentin 300 mg q 8 hr 0600, 1400, and 2200.
MRR, Priority High dated 5/24/23, 6/22/23, 7/17/23, 8/31/23, 9/22/23:
Please clarify Percocet PRN order to include degree of pain.
Please clarify ICY HOT Patch order to include leaving patch on up to 8 hours per day and remove.
MRR, priority: Normal, dated 6/22/23:
The resident's Amitriptyline was increased on 6/16/23. Please be sure to document mood, target behaviors and side effects in the nursing notes and address quantitative monthly behavior notes.
MRR, Priority: Normal, dated 7/17/23:
Code 9 was used many times in July, there is no nursing note in the progress notes for the reason. Please review documentation with the nursing staff.
MRR, Priority: Normal, dated 7/17/2023, 8/31/23:
The resident is on Olanzapine and Amitriptyline. Please do the monthly quantitative behavioral summary. Include target behavior, how many times it happened in one month, non-drug interventions, side effects (if any), last psych visit, None seen in [name redacted-EMR].
MRR, Priority: Normal, dated 8/31/23:
Code 9 was used many times in August, there is no nursing note in the progress notes for the reason. Please review documentation with the nursing staff.
MRR, Priority: High dated 9/22/23, 10/19/23:
The resident is on Olanzapine and Amitriptyline. Please do the monthly quantitative behavioral summary. Include target behavior, how many times it happened in one month, non-drug interventions, side effects (if any), ;last psych visit, None seen in chart. None seen in [name redacted-EMR].
MRR, Priority High dated 10/19/23, 11/17/23:
Please clarify Percocet PRN order to include degree of pain.
MRR, Priority Normal, dated 10/19/23 and 11/17/23:
Resident has an order for ICY Hot Patch (Menthol) to be applied once daily for 24 hours. Please be aware, the manufacturer recommends one patch be applied for no longer than 8 hours, and to be repeated for no more than 3 times daily. Please review this order with Physician.
A review of PO revealed the following:
-3/7/23 at 19:05 (7:05 PM), Percocet Tablet 5-325 MG (oxyCODONE-Acetaminophen) *Controlled Drug* Give 2 tablet by mouth every 8 hours as needed for pain, Discontinue on 11/23/23.
-3/7/23 at 19:05, Gabapentin Oral Capsule 300 MG (Gabapentin) Give 1 capsule by mouth three times a day for neuropathic pain, facility time code: 0900-1400-2100.
-4/6/23 at 14:24 (2:24 PM), Icy Hot External Patch 5 % (Menthol (Topical Analgesic)) Apply to lower back topically every day shift for Pain-discontinued 11/23/23
-5/19/23 at 14:30 (2:30 PM), OLANZapine Oral Tablet 10 MG (Olanzapine) Give 1 tablet by mouth in the evening for schizoaffective
-6/16/23 at 13:41 (1:41 PM), Amitriptyline HCl Oral Tablet 50 MG (Amitriptyline HCl) Give 1 tablet by mouth at bedtime for depression
-10/21/23 at 15:00 (3:00 PM), Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes.
-11/23/23 at 12: 50 AM, Icy Hot External Patch 5 % (Menthol (Topical Analgesic) Apply to lower back topically every shift for Pain Remove and replace patch q shift for pain
A Review Psychiatry Progress Notes provided by facility revealed the following:
-Psychiatry notes dated 7/7/23: Plan: 3. monitor and document changes in mood and behavior notify psychiatry as indicated.
A review of the Medication Administration Record (MAR) and Treatment Administration records (TAR) reviewed form April to [DATE] did not reveal behavior monitoring or target behavior ordered or documented.
A review of the progress notes from April to October 21,2022 did not reveal documentation for behavior monitoring or target behaviors.
On 12/20/23 at 4:02 PM, in the presence of the survey team, the above findings were presented to the LNHA and the DON.
The facility failed to provide documented evidence that the physician addressed the pharmacy recommendations, behavior or target monitoring documentation for Resident #152.
On 12/21/23 at 10:11 AM, the surveyor interviewed the DON, who stated behavior monitoring would be in the progress notes. She stated she will provide the target monitoring for resident.
On 12/21/23 at 10:24 AM, the DON provided target behavior monitoring with a start date 10/21/23.
On 12/21/23 at 10:40 AM, the DON provided behavior monitoring with a start date of 10/21/23. She confirmed, at that time, that there was no behavior monitoring documentation completed prior to that date.
A review of the facility's policy, Medication Review revised April 2023 revealed: Procedure: 5. Facility should independently review each resident's medication regimen directly from the residents medical chart and with the Interdisciplinary Care Team members, resident or responsible party as needed. 6. Facility should ensure that the Facility Physicians/Prescribers are provided with copies of the MRRs. 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRRS and the Director of Nursing to act upon the recommendations contained within the MRR. For those issues that require Physician/Prescriber interventions, Facility should encourage Physician/prescriber to either (a) accept and act upon the recommendations contained within the MRR or (b) reject all or some the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected.
NJAC 8:39-29.3 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00165655
Based on observation, interview, record review, and review of other pertinent facility documentation on 7/18/23, it was determined that the facility failed to provide meals consistent with the physician's orders, the menu, and its policies titled Meal Service and Therapeutic Diet Orders, for 3 of 6 residents (Resident #1, #2, and #3) observed during meal observation.
This deficient practice was evidenced by the following:
1. On 07/18/23 at 08:30 AM, the surveyor observed Resident #2 eating breakfast in their room. The surveyor observed a yellow and tan puree on a plate, orange juice, whole milk, and coffee. No other food items were on the resident's tray, overbed table, or in the resident's hands.
At this time, the surveyor observed the resident's meal ticket (items the resident's tray was supposed to have), which indicated that the following food items should be on the resident's tray:
6 OZ [ounce]- Pureed Super Cereal (high-calorie fortified cereal)
4 OZ - Pureed Spanish Tortilla [NAME]
2 SL [slices] - Pureed Bread
4 OZ- Orange Juice
8 OZ- Whole Milk
6 OZ- Coffee
The admission Record indicated that Resident #2 was admitted to the facility on [DATE] with medical diagnoses, which included but were not limited to Muscle Wasting and Atrophy, Type 2 Diabetes Mellitus (high blood sugar), and Dementia.
The quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/04/23, indicated that the resident was rarely or never understood, so their mental status was not assessed. The MDS also indicated that the resident received a mechanically altered diet.
The Order Summary Report (OSR) (physician's orders) indicated that Resident #2 had an active physician's order (PO) dated 01/20/23 for No Conc [concentrated] Sweets/No Added Salt diet Pureed texture, Regular (None/Thin) consistency, for diet. The OSR also indicated an active PO dated 03/11/22 for Super cereal w/ [with] breakfast one time a day for w/ [with] breakfast.
2. On 07/18/23 at 08:44 AM, the surveyor observed Resident #3 in their room in bed with their breakfast tray on their overbed table. The surveyor observed that on the resident's breakfast tray, there was a yellow and a tan puree on a plate and an apple juice on the tray. No other food items were observed on the resident's breakfast tray, overbed table, or in their hands. Resident #3 stated that their breakfast was good but did not respond to any additional questions.
The surveyor observed the resident's meal ticket on the resident's breakfast tray. The meal ticket indicated that the resident's tray should contain the following food items:
6 OZ - Pureed super cereal
4 OZ- Pureed Spanish Tortilla [NAME]
2 SL- Pureed bread
4 OZ- Orange juice
6 OZ- Coffee
The surveyor reviewed Resident #3's medical record:
According to the admission Record, Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Dysphagia (swallowing difficulties), Cachexia (a metabolic syndrome related to muscle mass loss), and Mild Protein-Calorie Malnutrition.
The quarterly MDS dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, which indicated the resident had moderate cognitive impairment. The MDS also indicated that the resident received a mechanically altered diet.
The OSR indicated that Resident #3 had an active PO dated 01/20/23 for Regular diet Pureed texture, Regular (None/Thin) consistency, for diet.
The OSR also revealed an active PO dated 04/14/23 for Super cereal w/ [with] breakfast one time a day for to increase energy/ PO [by mouth] intake.
3. On 07/18/23 at 09:03 AM, the surveyor observed Resident #1 in their room in bed being served their breakfast tray by Certified Nursing Assistant (CNA) #1. The surveyor observed a yellow and tan puree on the resident's plate, a cup of tan puree, milk, coffee, and orange juice. No other food items were observed on the resident's breakfast tray, overbed table, or in the resident's or CNA's hands.
The surveyor observed Resident #1's meal ticket at this time. The meal ticket indicated that Resident #1 should have the following food items on their tray:
6 OZ- Pureed super cereal double portions
6 OZ- Pureed spiced oatmeal
8 OZ- Pureed Spanish tortilla double portions
2 SL- Pureed bread
4 OZ - Orange juice
8 OZ -Whole milk
6 OZ -Coffee
The surveyor interviewed CNA #1 at this time. CNA #1 stated that the super cereal was in the bowl. The surveyor asked where the resident's oatmeal was. CNA #1 stated that this was all the resident was given on the tray and that they did not have oatmeal. CNA #1 stated that because the meal ticket says the resident should have oatmeal, it should be on the resident's tray. CNA #1 stated that she checked the tray items against the meal ticket, and she asked where the oatmeal was and was told by the person serving the food that there was no more oatmeal.
The surveyor reviewed Resident #1's medical record:
The admission Record indicated that Resident #1 was admitted to the facility on [DATE] with medical diagnoses, which included but were not limited to Unspecified Severe Protein-Calorie Malnutrition and Alzheimer's Disease.
The quarterly MDS dated [DATE] indicated that the resident had a BIMS score of 1 out of a possible 15, which indicated the resident had severely impaired cognition.
The MDS also indicated that the resident received a mechanically altered diet, had a weight loss of 5% or more in a month or 10% or more in 6 months, and required the assistance of one staff member with eating.
The OSR revealed that Resident #1 had an active PO dated 01/20/23 for Regular diet Pureed texture, Regular (None/Thin) consistency, Double portions.
The OSR also revealed an active PO dated 02/17/23 for super cereal w/ [with] breakfast one time a day for malnutrition provides super cereal w/ [with] breakfast daily.
During an interview with the surveyor on 07/18/23 at 09:18 AM, CNA #2 stated that she was Resident #3's usual CNA. The surveyor described Resident #3's breakfast tray that morning and that it did not have all of the items indicated on the meal ticket. CNA #2 stated that it was not right and that they needed to fix that tray before serving it to the resident because the resident would not get to eat or drink the missing food items.
During an interview with the surveyor on 07/18/23 at 09:31 AM, the Licensed Practical Nurse/ Unit Manager (LPN/UM) stated that the super cereal was not brought up to the nursing unit, so no residents, including Resident #1, received it today. The LPN/UM stated that since there was no super cereal today, they gave the residents exactly what was on their meal tickets except for the items they could not give. The LPN/UM continued that it was iffy if the kitchen sent the super cereal up and that they might not receive it once or twice a week. The LPN/UM stated that if a resident who was supposed to receive super cereal asked for something else upon the resident's request, they would give them double portions of something else. The LPN/UM stated that the purpose of giving super cereal was because it had additional nutritional value, so it was given to a resident if they started to lose weight. The LPN/UM stated that Resident #3's tray should have included coffee and the right kind of juice.
During an interview with the surveyor on 07/18/23 at 10:58 AM, the Registered Dietitian (RD) stated that the kitchen should always have super cereal and that the nurse should have called the kitchen to have it sent up. The RD continued that it was not acceptable that the super cereal was not served to the residents who had it ordered because it contained additional calories and nutrition.
During an interview with the surveyor on 07/18/23 at 12:44 PM, the [NAME] stated that the super cereal did not get delivered to the 6th-floor nursing unit today and that it was his fault because he was supposed to deliver it. The [NAME] stated that the nurses usually call for the super cereal if he forgets to deliver it, but they did not call today.
During an interview with the surveyor on 07/18/23 at 12:50 PM, the Food Service Director stated that the [NAME] might have forgotten to deliver the super cereal but that if the nurses called, then they could have gotten the super cereal delivered.
During an interview with the surveyor on 07/18/23 at 2:07 PM, the Director of Nursing (DON) stated that the breakfast trays should not have been served if they were missing items. The DON stated that the nurses were supposed to call the kitchen and ask for items if they did not have them delivered. The DON stated that Resident #3's tray should have had the coffee and the orange juice because they were always available. The DON continued that it was not acceptable not to serve super cereal during breakfast because it was used for residents who need a boost to their nutrition and because it was a doctor's order.
The facility policy, Meal Service, with a reviewed date of 02/01/23, indicated under the Procedure section, Remove one tray at a time from the food cart; check tray card for the resident's name and room number; type of diet, consistency, food preferences; check for utensils and appropriate condiments.
The facility policy, Therapeutic Diet Orders, with a reviewed date of 05/22 indicated under the Policy Explanation and Compliance Guidelines, Therapeutic diets will be provided to residents in the appropriate form and/or the appropriate nutritive content as prescribed by the physician and/or assessed by the interdisciplinary team to support the treatment and plan of care.
NJAC 8:39-17.2(a).
NJAC 8:39-17.4(a)(1).

Based on interview, and review of facility documentation, it was determined that the facility failed to test unvaccinated staff for COVID-19 at a frequency based on the county COVID-19 level of community transmission. This deficient practice was identified for 5 of 5 unvaccinated staff members in the facility reviewed for COVID-19 testing and was evidenced by the following:
According to the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 [COVID-19] Spread in Nursing Homes updated 9/10/21 included, In nursing homes located in counties with substantial to high community transmission, unvaccinated HCP should have a viral test twice a week.
According to the Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements revised 9/10/21 included, Routine testing of unvaccinated staff should be based on the extent of the virus in the community .Facilities should use their community transmission level as the trigger for staff testing frequency .Routine Testing Intervals by County COVID-19 Level of Community Transmission: Low (blue) testing frequency: not recommended; Moderate (yellow) testing frequency: once a week; Substantial (orange) testing frequency: twice a week; and high (red) testing frequency: twice a week.
On 10/12/21 at 10:22 AM during the Entrance Conference, the Director of Nursing (DON) and the Infection Preventionist (IP) stated that the facility tested unvaccinated staff once a week on Tuesdays. The surveyor requested a list of facility staff and their vaccination status.
The surveyor reviewed the level of community transmission via the CDC COVID-19 Integrated County View site which indicated the facility's level of community transmission was high and in the red.
The surveyor selected five unvaccinated facility staff for COVID-19 testing. The surveyor identified that 5 of the 5 facility staff did not have evidence of twice a week COVID-19 testing in accordance with the aforementioned testing requirements. The following was revealed:
A review of the IP's work schedule revealed the IP worked on the following dates: 9/20/21, 9/21/21, 9/22/21, 9/23/21 9/24/21,9/27/21, 9/28/21, 9/29/21, 9/30/21, and 10/1/21. The IP was tested for COVID-19 via rapid antigen on 9/21/21 and 9/29/21.
A review of Certified Nurses Aide #1 (CNA #1) work schedule revealed the CNA worked on 9/27/21, 9/28/21, 9/29/21, 10/1/21, and 10/2/21. CNA #1 was tested for COVID-19 via rapid antigen on 9/27/21.
A review of CNA #'2's work schedule revealed CNA #2 worked on 9/28/21, 9/29/21, 9/30/21, and 10/2/21. CNA #2 was tested for COVID-19 via rapid antigen on 9/28/21.
A review of an Occupational Therapist's (OT) work schedule revealed the OT worked on 9/27/21, 9/28/21, 9/29/21, 9/30/21, and 10/1/21. The OT was tested for COVID-19 via rapid antigen on 9/27/21.
A review of the Staffing Coordinator's (SC) work schedule revealed the SC worked on 9/27/21, 9/28/21, 9/29/21, 9/30/21, and 10/1/21. The SC was tested for COVID-19 via rapid antigen on 9/27/21.
During an interview with the surveyor on 10/15/21 at 11:29 AM, the DON and IP stated that the unvaccinated staff were tested weekly for COVID-19. The DON and IP stated they were unaware of the change in testing requirements.
A review of a facility policy titled, COVID-19 Testing revised 9/2021, included that the facility will test all residents and staff according to CDC and NJDOH guidelines. Routine testing of unvaccinated staff should be based on the extent of the virus in the community.
NJAC 8:39-5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. According to the facility's admission Record, Resident #18 was admitted to the facility in 5/2021 with diagnoses which included but were not limited to; Acute Respiratory Failure.
Review of the resident's Order Summary Report revealed an order dated 5/27/21 for Ipratroplum-Albuterol Solution 0.5-2.5 (3) milligrams per 3 milliliters 1 vial inhaled orally every six hours for Chronic Obstructive Pulmonary Disease.
Review of Resident #18's October Medication Administration Record (MAR) reflected the above physician's order and was documented as administered.
On 10/13/21 at 09:15 AM during the initial tour of the 3rd floor, the surveyor observed a nebulizer machine in Resident #18's room. The nebulizer machine was on the resident's dresser on top of an opened plastic bag. There were dark brown/red dried substances on the nebulizer machine. The nebulizer mask was exposed, connected to the medication cup, and the tubing was connected to the nebulizer machine. Condensation was observed inside the nebulizer medication cup.
On 10/14/21 at 10:17 AM, the surveyor brought the assigned Licensed Practical Nurse (LPN) to Resident #18 's room. The nebulizer mask, medication cup, and tubing were in an unlabeled bag and were connected to the nebulizer machine. The LPN stated that nebulizer equipment should be detached, cleaned after use, and stored in a bag to prevent infection.
During an interview with the surveyor on 10/18/21 at 10:09 AM, the Infection Preventionist stated that the mouthpiece should be detached and washed after each use, air-dried, and then stored in a plastic bag. The IP further stated that the nebulizer machine should be cleaned if it was soiled. The IP stated the Resident #18's respiratory equipment should have been clean and properly stored.
Review of a facility policy titled, Nebulizer Treatment, revised 8/2021, included that when the treatment was complete, remove the mask, disconnect the T-piece, mouthpiece, and medication cup. Rinse and disinfect the nebulizer equipment according to the manufacturer's recommendations or wash the pieces with warm water after each use. When the equipment is completely dry, store it in a plastic bag marked with the resident's name and the date. Clean equipment if visibly soiled and change tubing, mask/mouthpiece, and other parts of the equipment regularly (every Tuesday night) and if needed.
NJAC 8:39-19.4 (m)(n), NJAC 8:39 27.1(a)
Based on observation, interviews, and review of facility documentation, it was determined that the facility failed to a.) follow appropriate infection control practices and perform hand hygiene as indicated during dining observation for 1 of 5 units (6th floor dining room) observed and b.) ensure respiratory equipment was kept in a clean and sanitary condition, and stored properly to reduce the risk of infection for 1 of 6 residents reviewed for respiratory equipment, Resident #18.
The deficient practice was evidenced as follows:
1. On 10/14/21 the surveyor observed the following:
At 12:24 PM, an Activity Aide (AA) delivered a lunch tray to room [ROOM NUMBER]. The AA placed the tray on the bedside table (BST). The AA adjusted the height of the BST and used the resident's bed remote control to raise the head of the bed. The AA did not perform hand hygiene before or after delivering the meal to the resident. The AA went back to dining room and picked up another lunch tray, filled a mug with a brown liquid from a white carafe and put it on the tray. She then placed a milk and a juice container on the tray. The AA did not perform hand hygiene before picking up the new lunch tray.
At 12:27 PM, the AA knocked on the door for room [ROOM NUMBER]. The AA entered the room, placed the lunch tray on the BST and used her hands to push the curtains out of the way. The AA unwrapped the resident's salad, opened the milk and pushed the BST over to resident. The AA donned (put on) gloves and helped the resident with their shoes. The AA doffed (removed) the gloves. She then opened the salad dressing and put it on the salad. The AA exited room. The AA did not perform hand hygiene before or after delivering the meal to the resident, or before or after she donned and doffed the gloves.
At 12:30 PM, the AA returned to the dining room without performing hand hygiene. She picked up another lunch tray. She took the tray to room [ROOM NUMBER] and placed it on the BST. She moved BST over to the resident, she adjusted height of the table for the resident. The AA the opened the clear wrap on the silver ware and opened resident's straw. The AA did not perform hand hygiene before or after delivering the meal to the resident.
At 12:31 PM, the AA returned to the dining room without performing hand hygiene. She then poured a brown liquid from a white carafe into a mug and placed a lid on it. The AA held the lid down on the mug with her hand and delivered it to the resident in room [ROOM NUMBER]. The AA did not perform hand hygiene before or after delivering the mug to the resident. The AA exited the room and walked behind the nurse's station. While speaking to other staff members, the AA placed both her hands on the counter at the nurse's station.
At 12:34 PM, the AA returned to the dining room without performing hand hygiene. The AA picked up another lunch tray. She took the tray to room [ROOM NUMBER]. She knocked on the door, opened door, and placed the tray on BST. She closed the door after exiting the room. The AA did not perform hand hygiene before or after delivering the meal to the resident.
At 12:36 PM, the AA returned to the dining room without performing hand hygiene. She rested her hand on the white carafe. She took another tray and gathered condiments and placed them on the tray.
At 12:39 PM, the AA knocked on the door for room [ROOM NUMBER] and entered the room. The resident refused the tray. The AA did not place tray down, exited the room and closed door. She returned to the dining room without performing hand hygiene. The AA fixed her hair with her left hand and then picked up a wrapped sandwich with the same hand without performing hand hygiene. She walked to the elevator to a resident that was sitting in a wheelchair and touched the resident's shoulder and gave the resident the sandwich. The resident handed the sandwich back to the AA and she unwrapped it and handed it back to him/her.
At 12:44 PM, the AA returned to the dining room without performing hand hygiene. She fixed the jacket that was tied around her waist. She opened a juice and gave it to a resident sitting in the dining room. The AA did not perform hand hygiene before or after delivering the juice.
During an interview with the surveyor on 10/14/21 at 12:45 PM, the AA stated that hand hygiene should be performed when you come in to work in the morning and when you eat. The AA stated that she had not received in-services on hand hygiene. She stated that she did not receive orientation on how to serve meals to residents. The AA said she was just told to put the meal trays down. The AA stated that she should have washed her hands after doffing gloves when she assisted the resident with the shoes.
During an interview with the surveyor on 10/14/21 at 12:48 PM, the Licensed Practical Nurse (LPN) stated that hand hygiene should be performed before you start serving food and in between residents. She stated the purpose of hand hygiene is to get rid of germs.
During an interview with the surveyor on 10/14/21 at 12:50 PM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated that staff should wash their hands before delivering the meal tray. She stated that hand hygiene should be performed between each resident to prevent spread of any germs. The ADON/IP stated that hand hygiene should be performed before and after donning and doffing gloves.
Review of the facility's, Certificate of Completion form dated June 16, 2021, revealed that the AA had completed and earned 0.5 contact hours for the program on Hand Hygiene.
Review of the facility's In-Service sign in sheet, Creating a homelike dining experience and Dining room Process and Hand Hygiene Procedure during mealtime dated 7/23/21, revealed that the AA had attended the in-service. Review of the In-Service on the Aspects to consider for Dining Room, revealed Infection Control: Staff need to wash their hands before meals are served. If staff come in direct contact with a residents skin (such as while feeding) they must re-wash their hands before coming in contact with another resident.
Review of the facility's Hand Hygiene policy, reviewed 10/2021, revealed Purpose: Hand hygiene is a simple and effective method for preventing the spread of pathogens, such as bacteria and viruses, which cause infections. Pathogens can contaminate the hands of a staff member during direct contact with residents or contact with contaminated equipment and environmental surfaces within close proximity of the resident. Failure to clean contaminated hands can result in the spread of these pathogens to residents, staff (including the person whose hands were contaminated), and environmental surfaces. Hand washing with a non-antimicrobial soap and water or with anti-microbial soap and water is indicated for the following: before having direct contact with patients; after contact with inanimate objects in the immediate vicinity of the patient; after removing gloves; before and after preparing food; before delivering meal tray and prior to leaving the resident's room.
Review of the facility's Nutritional Services policy and procedure, revised 1/2021, revealed ESSENTIAL POINTS: Staff must wash hands before and after serving trays.

Based on observation, interview, and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of foodborne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross-contamination and c.) maintain sanitation in a safe and consistent manner to prevent foodborne illness.
This deficient practice was observed and evidenced by the following:
On 10/12/21 from 09:48 AM until 11:12 AM, the surveyor toured the kitchen in the presence of the Director of Dietary Services (DDS) and observed the following:
1. Handwashing sink #2 had no trash can nearby to discard paper towels. The DDS acknowledged there was no trash can and stated there should be one next to the sink.
2. In refrigerator #1, there was one opened plastic bag of cheddar cheese wrapped in clear plastic wrap with a received date sticker of 9/30/21 with no opened or use by date. There was one opened package of white turkey breast wrapped in clear plastic wrap with an opened date of 10/7 and no use by or received on date.
During an interview at that time, the DDS acknowledged the missing dates and stated the cheese should have had an open date and the turkey should have had a received on date. She further stated that the opened turkey was only good for three days and that the turkey and the cheese would be discarded.
3. In refrigerator #2, there was a one quarter sized deep metal pan containing eggs that the DDS identified as hard-boiled, with a received sticker dated 10/12/21 with no label and no use-by date. There was a one quarter sized deep metal pan containing a yellow substance that the DDS identified as scrambled eggs, with a received sticker dated 10/12/21 with no label and no use by date. There was one quarter sized deep metal pan containing a brown substance that the DDS identified as pureed sausage, with a received sticker dated 10/12/21 with no label and no use by date. There was a one half sized deep metal pan containing brown strips of meat that the DDS identified as cooked bacon, with a received sticker dated 10/12/21 with no label and no use by date. There was one 10 pound unsealed package of genoa salami, wrapped in clear plastic wrap, dated received on 10/3 and opened on 10/3 with no use by date. There was one large opened cardboard box containing 30 raw eggs with a received sticker dated 9/1/21 with no use by date.
During an interview at that time, the DDS stated the salami and the eggs were good for three days once they were opened and that they would be disregarded or thrown away. She stated it was important to date food items so it was known when they were received and when they should be used by to prevent food poisoning.
4. In the freezer there was one 20 pound box of frozen chicken with no received on or use by date. There was one clear sealed bag of brown round balls, with a large amount of white ice crystals in the bag, with no label and no dates. The DDS identified the food as meatballs and stated they should have had a received on date and a label and that they would be discarded.
5. On a metal rack in the clean and dry pot area, there was a metal cover, that the DDS identified as the top cover to the robot coup, with pieces of dried white debris and dried white liquid debris. The DDS acknowledged the cover was dirty and moved it to the dishwashing area.
6. In the free standing deep freezer, there was one frozen bundle of small brown long oval shaped pieces of meat wrapped in clear plastic wrap that were dated 10/9/21 with no label and no use by date. The DDS acknowledged there was no label, identified them as hot dogs and stated that the marked date was the open date. There were two frozen red circular patties wrapped in clear plastic wrap with no label and no dates. There were three frozen red circular patties wrapped in clear plastic wrap with a received date 9/19/21 with no label and no use by date. The DDS identified the patties as hamburgers, acknowledged there was no use by date and stated she was unsure when they should be used by. There was one frozen bundle of large brown oval shaped pieces of meat partially wrapped in clear plastic wrap with the meat visible and exposed to air with a received sticker dated 9/24/21 with no label or use by date. The DDS identified the meat as kielbasa and stated they were no good and to disregard them. The DDS threw all of the meat into the garbage.
7.On top of a plastic storage bin, there was a metal basket containing sealed bags of coffee that were resting directly on seven large coffee filters that were uncovered and exposed to air. The DDS stated they should not be stored there and that they were usually stored in the dry storage area.
8. In the dry storage area, there was one 10 pound opened box of unbagged egg noodles, with the noodles visible and exposed to air, with a received sticker dated 9/30/21 with no open or use by date. The DDS stated she would discard the noodles.
9. On the canned goods metal rack #1, there was one dented 6 pound 10 ounce can of mandarin oranges. The DDS acknowledged the can was dented and removed the can to the dented can rack.
10. On the spice rack there were:
One opened 28 ounce jar of seasoning salt with a received date 10/6/21 with no open date.
One opened 1 pound jar of pure ground pepper with a received date 10/12/21 with no open date.
One opened 12.5 ounce jar of ground ginger with a received date 7/20/21 no open date.
One opened 10 ounce jar of parsley flakes with no received date and no open date.
During an interview at that time the DDS stated the spices should have had an open date.
11. On the floor, under the flat top grill where chicken was being cooked, there was a large full sized metal pan that contained a large amount of yellow greasy liquid. The DDS stated they were drippings from the flat top grill.
12.In the oven, below the flat top grill, there were large amounts of dried white debris covering the bottom of the oven and the door of the oven.
During an interview at that time the cook acknowledged the flat top grill was not draining correctly. He stated the grill should not drain into the oven nor into the pan on the floor.
13. On the canned goods metal rack #2, there was one dented 5 pound 12 ounce can of mashed potatoes. The DDS acknowledged the can was dented and removed the can to the dented can rack.
14. The meat slicer was covered with a clear plastic bag. The DDS removed the bag and there was white and pink dried debris on the slicer blade and on the slicer handle. The DDS acknowledged the debris should not be there and that once the slicer was used it was cleaned and bagged.
On 10/12/21 at 11:05 AM the surveyor observed the cook cooking chicken on the flat top grill wearing a surgical mask with facial hair visible around the surgical mask. The cook acknowledged he was not wearing a beard cover and stated staff were to wear hairnets in the kitchen at all times. The cook further stated that he did not get a policy on facial hair but that it was important to wear a hairnet so no hair would get into the food.
On 10/14/21 from 08:58 AM until 09:22 AM, the surveyor toured the kitchen in the presence of the Director of Dietary Services (DDS) and observed the following:
1. In refrigerator #1, there was one opened 5 pound container of cottage cheese with a received sticker dated 9/15/21 and manufacturer's expiration date of 10/7/21 with no opened or use by date. There was one opened 5 pound container of cottage cheese with a received sticker dated 9/13 and manufacturer's expiration date of 10/7/21 with no opened or use by date. The DDS stated the containers are expired and discarded them into the trash.
2. On the floor, under the unused flat top grill, there was a large full sized metal pan that contained a large amount of dark yellow greasy liquid.
A review of personal hygiene inservice, dated 2/23/21, revealed the cook was inserviced on hairnet usage.
A review of the facility's policy, Personal Hygiene, with a revision date of 6/3/2013, revealed Procedure: 3. Cover all hair and facial hair with restraint (hairnet, beard net, cap or hat).
A review of the facility's policy, Receivable and Storage, with a revision date of 6/3/2013, revealed Procedure: 11. Ensure that all food are securely covered, dated, and labeled.
A review of the facility's policy, Kitchen Equipment General Cleaning, with a revision date of 4/2019, revealed Policy: The director of dining services or designee will ensure that all equipment is maintained, kept clean, and in a sanitary condition before and after each use. Procedure: 1. Conventional/convection ovens a. clean, inside and out, using soap and water. 4. Griddle/flat top c. be sure to clean grease tray.
A review of the facility's policy, Dishwashing, with a revision date of 2/20/2017, revealed Procedure: 10. Remove dishes and inspect for cleanliness and dryness.
A review of the facility's policy, Pot Washing, with a revision date of 2/14/2017, revealed Policy: Kitchen will wash, rinse, and sanitize all pots, pans and cook ware and small wares following each meal. Procedure: 7. Wash all dirty pots and wares .8. Rinse all clean pots and wares .9. Sanitize all clean pots and wares .10. Air dry all clean and sanitized pots and wares .
NJAC 8:39-17.2(g)

Based on observation, interview and review of pertinent facility documentation it was determined that the facility failed to serve hot foods at an acceptable temperature for the residents. This deficient practice was identified for 1 of 7 residents who attended a Resident Council group meeting, and on 1 of 5 nursing units (2nd floor) during the lunch meal service and was evidenced by the following:
1. On 10/15/21 at 10:33 AM, a surveyor conducted a group meeting with seven residents who regularly attended the facility resident council meetings. One out of seven residents indicated the food was cold.
2. On 10/18/21, the surveyor conducted a regular diet and a pureed diet test tray with the Director of Dining Services (DDS) and the Regional Director of Dining Services which resulted in the following:
At 11:47 AM the DDS stated the 2nd floor was a patient under investigation (PUI) unit, a potentially contagious patient unit, so all the dishware for that unit was disposable.
At 11:50 AM the surveyor observed the cook checking food temps with a thermometer prior to serving on the food line.
At 12:17 PM the dietary aide exited the kitchen with the meal cart, which included the test trays, accompanied by the surveyor and the DDS.
At 12:19 PM the dietary aide delivered the meal cart, which included the test trays, to the dining room on the 2nd floor nursing unit.
At 12:20 PM the resident meal pass began.
At 12:33 PM the last resident meal tray was served.
During an interview with the surveyor at that time, the DDS confirmed the thermometer she brought to take the food temps was calibrated.
At 12:34 PM, in the presence of the surveyor, the DDS took the following food temperatures:
Lasagna: 135.1 degrees Fahrenheit (F)
Broccoli: 122.8 degrees F
Pureed potatoes: 123.9 degrees F
Pureed pasta: 115.5 degrees F
Pureed bread 117.3 degrees F
At that time, the surveyor interviewed the DDS regarding what the appropriate food temperature should be when the food was served. The DDS stated the hot foods should be 120 degrees or above when served.
At 12:39 PM the surveyor again interviewed the DDS regarding appropriate food temperatures when the food was served. The DDS stated the serving temperature should be 135 degrees or above on the nursing units and acknowledged that not all of the temps were 135 degrees. She further stated it was important to maintain proper temps so the food would remain hot when it was served.
Review of the facility's policy, Hot Food, dated 6/3/2013, revealed Procedure: 7. d. Hot foods should be at 135 degrees F or above at the time food is served to the residents.
NJAC 8:39-17.4 (a)

Based on observation, interview, and record review, it was determined that the facility failed to a.) ensure that a resident's environment was as free from hazards as possible by failing to ensure that medical equipment was plugged directly into an electrical receptacle without the use of a power strip or adapter for 1 of 35 residents reviewed, Resident #39 and b.) ensure residents remained free of accident hazards by failing to provide residents with proper hand sanitizing wipes on 1 out of 5 floors, 6th floor day room.
This deficient practice was evidenced by the following:
1. According to the admission Record, Resident #39 was admitted to the facility in 01/2020 with diagnoses that included but were not limited to: acute and chronic respiratory failure with hypercapnia (low blood oxygen levels), diabetes (high blood sugar), and hypertension (high blood pressure).
Review of Resident #39 Quarterly Minimum Data Set (MDS), an assessment tool dated 7/23/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident's cognition was intact.
On 10/15/2021 at 09:03 AM, the surveyor observed Resident #39 in bed with a nasal bi-level positive airway pressure (bi-pap) (a machine that sends air into the lung) in use.
On 10/19/2021 at 12:20 PM, the resident was out of his/her room. The surveyor observed the bi-pap machine and the oxygen concentrator running and plugged into an extension cord that was plugged into overbed light and draped over the headboard.
During an interview on 10/19/2021 at 12:30 PM, the Licensed Practical Nurse Unit Manager (LPN/UM) stated she moved the plugs all the time into the wall. She stated the resident kept using the extension cord that the resident purchased. She began to unplug the bi-pap machine and the oxygen concentrator from the extension cord.
During an interview with the surveyor on 10/19/21 at 12:35 PM, Resident #39 stated there are not enough plugs in his/her room and he/she purchased an extension cord. Resident #39 stated they cannot plug the bi-pap machine or the oxygen concentrator into the extension cord, and that the staff does it for him/her.
During an interview with the surveyor on 10/19/21 at 12:40 AM the maintenance director stated the medical equipment could not be plugged into extension cords and all medical equipment must be plugged directly into an outlet. He stated that the oxygen concentrator could be plugged into the wall outlet and the BiPAP into the overbed light outlet.
During a meeting with the survey team on 10/21/2021 at 10:01 AM, the Administrator was made aware of the concerns. He stated the maintenance director made rounds every week.
A review of the facility's policy and procedure labeled Power Strip Use revealed that the use of extension cords is prohibited in the facility. Power strips that are in residents' rooms are not used for patient care-related electrical equipment. The purpose of the policy was to reduce fire hazards and health risks.
2. On 10/14/21 at 12:33 PM, Surveyor #1 observed lunch service on the 6th floor in the 6th floor Day Room. Multiple residents and staff were present in the Day Room. During that time, after residents were finished eating, Surveyor #1 observed a Corporate Administrator (CA) handing four residents wipes out of a plastic orange and white cylinder container.
Surveyor #1 observed the following:
Resident #124 blew their nose and wiped their hands with the wipe, Resident #112, #168, and #101 wiped their hands with the wipe.
At 12:38 PM, Surveyor #1 observed the plastic orange and white cylinder container sitting on a table next to the CA. Upon review of the orange and white cylinder container, the surveyor identified the wipes as disinfecting wipes. Continued review of the disinfecting wipes revealed the instructions, do not use as diaper wipe or for personal cleansing. During an interview with Surveyor #1 at that time, the CA stated the wipes in the container were the wipes he had given to the residents.
At 12:47 PM, Surveyor #1 observed resident #168 using the wipe to wipe the table and bilateral arms.
At 12:50 PM, Surveyor #1 observed the CA and Activity Aide asking Resident #112 to use hand sanitizer.
During an interview with Surveyor #2 on 10/14/21 at 12:50 PM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated that residents should perform hand hygiene before and after they eat. The ADON/IP reviewed the wipes in the plastic orange and white cylinder container in the presence of the two surveyors. She stated that the wipes did not contain bleach so they were safe for the residents to use.
At 1:36 PM, Surveyor #1 observed LPN #2 instructing resident #101 to wash their hands with soap and water. During an interview with the surveyor at that time, Resident #101 stated, they gave me a towel that has some type of soap in it. Resident #101 denied irritation from the use of the wipes.
During an interview with Surveyor #1 on 10/14/21 at 01:39 PM, Resident #168 denied irritation from the use of the wipes.
During an interview with Surveyor #1 on 10/14/21 at 01:47 PM, Resident #124 denied irritation to skin from the use of the wipes.
During an interview with Surveyor #1 on 10/19/21 at 12:22 PM, the ADON/IP stated residents were offered hand hygiene before and after they eat to prevent infection. Residents were typically given hand wipes designated for disinfecting hands. The ADON/IP stated the wipes used on 10/14/21 were accidently given to the residents and that the resident's skin could get irritated from using the wrong wipes.
During an interview with Surveyor #1 on 10/19/21 at 12:31 PM, the CA stated that he didn't notice he gave the residents the incorrect wipes. He stated it was important to give the residents the correct hand wipes to prevent skin irritation or an allergic reaction.
NJAC 8:39-31.2(e)

Based on observation, interview, and review of medical records, it was determined that the facility failed to properly assess the need for, obtain a physician order and develop a care plan for a wander guard consistent with professional standards of clinical practice for 1 of 35 residents reviewed, Resident #70.
This deficient practice was evidenced by the following:
Reference: New Jersey Statutes, Title 45,Chapter 11,Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such
counseling, and provision of care supportive to or restorative of life and well being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, 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 task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist.
According the the facility admission Record, Resident #70 was admitted to the facility in 8/2021 with diagnoses which included but were not limited to; Hypertensive heart disease ( heart problems that occur because of high blood pressure), Diabetes (high blood sugar) and cerebral infarction (lack of blood supply to the brain).
A review of the admission Minimum Data Set (MDS), an assessment tool, dated 08/17/2021, revealed Resident #70 scored a 15/15 on the Brief Interview for Mental Status (BIMS) which indicated the resident had intact cognition. Further review revealed wander/elopement alarm was not in use.
A review of the Physician Orders revealed no order for a wander guard.
A review of the resident's care plans revealed no care plan for the use of a wander guard.
A review of the elopement risk dated 08/11/2021 revealed a score of 4 that indicated the resident was low risk for elopement.
A review of the Wander Guard Check for August 2021, September 2021 and October 2021 revealed the wander guard was located on the resident and checked daily.
On 10/13/21 at 08:58 AM, during tour of the unit, the surveyor observed Resident #70 walking in the hallway with a wander guard was on his/her left ankle.
During an interview with the surveyor on 10/15/21 at 02:20 PM, Resident #70 stated the staff placed the wander guard on him/her when he/she came into the facility in August. Resident #70 stated he/she would not try to leave because he/she was in the process of getting an apartment in the community.
During an interview with the surveyor, on 10/15/21 at 02:30 PM, the Licensed Practical Nurse (LPN) stated that when residents have wander guards there was usually an order and it would pop up on the Electronic Medication Administration Record (EMAR). In the presence of the surveyor, the LPN was unable to find an order or see in on the EMAR. She stated she did not know why the resident did not have an order for the wander guard.
During an interview with the surveyor, on 10/15/21 at 02:50 PM, the Assistant Director of Nursing (ADON) stated there should be a physician order, a care plan and documentation for the wander guard.
During an interview with the surveyor on 10/15/21 at 03:00 PM, the Certified Nursing Assistant (CNA) stated she monitored and logged the residents with wander guards daily.
During an interview with the surveyor on 10/18/21 at 08:30 AM, The Director of Nurses (DON) stated the resident did not have an order or a care plan for the wander guard and did not know why.
During an interview with the surveyor on 10/20/21 at 11:15 AM, the 2nd floor Registered Nurse (RN) stated when completing an admission, the nurse must assess the residents' need for a wander guard. She stated would assess if the resident was alert and oriented, check the elopement risk. If a resident required a wander guard, she would call the doctor to get an order and complete a care plan for the wander guard. She stated wander guards were checked every shift, by a nurse, for placement and documented on the Treatment Administration Sheet (TAR).
During a meeting with the survey team on 10/20/21 at 02:00 PM, administration was informed of the findings. The DON stated there was an elopement assessment for Resident #70, whose score was 4 (indicating low risk). The DON stated the resident was admitted to the facility with altered mental status and a wander guard was placed on the resident. She stated there should have been a physician order, a care plan, and the resident should be assessed quarterly.
A review of the policy labeled Wandering Resident with a revised date of 04/2021, revealed residents who are admitted to the facility will be evaluated for potential risk for wandering/elopement. The residents who meet the at-risk characteristic will also have an order for wander guard device and the use of the wander guard will be documented and care planned. The care plan will include appropriate interventions for potential and actual occurrences of wandering.
NJAC 8:39-27.1(a)