Aristacare At Cedar Oaks

COMPLAINT #: NJ00183422, NJ00186468 Based on observation, interviews, medical record review, and review of other pertinent facility documentation on 08/22/25, it was determined that the facility failed to immediately implement their abuse policy to ensure residents were protected from abuse by not removing the accused staff from resident care pending full investigation of an abuse allegation. This deficient practice was identified for 1 of 3 residents reviewed for abuse (Resident #1) and had the potential to affect all residents. According to Facility Reportable Event (FRE), at approximately 6:00 AM on 05/03/2025 Resident #6 (the roommate of Resident #1) reported to Registered Nurse #1 (RN #1) that Resident #1 moaned in pain while a Certified Nursing Assistant (CNA) was providing morning care (turning and repositioning) for the resident. The FRE included that RN #1 assessed the resident and reported the incident to the Nursing Supervisor. No further action was taken to investigate Resident #6's report as an abuse allegation. On 05/05/2025, the Unit Manager (UM) #1 and the Director of Nursing (DON) interviewed Resident #1 about a CNA being rough during care and performed a skin assessment. The resident denied being hurt at that time. No further action was taken to investigate the concern as possible abuse. On 05/13/2025, Resident #6 again reported to facility staff that on 05/02/2025 or 05/03/2025 a CNA caused Resident #1 pain while turning and positioning the resident. On 05/13/2025, an investigation which included conducting staff and resident interviews, obtaining staff statements, and suspension of the accused CNA was conducted. The facility's failure to implement their abuse policy by initiating an investigation and removing the accused CNA from resident care when staff were first alerted to the concern on 05/03/2025 allowed the alleged abuser to continue to have access to residents on 05/05/2025, 05/06/2025, 05/07/2025, 05/08/2025, and 05/10/2025. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 5/03/2025 after Resident #6 alerted RN #1 of their concern that Resident #1 was mishandled by a CNA. The facility Administration was notified of the IJ on 08/22/2025 at 6:05 PM. The facility submitted an acceptable Removal Plan (RP) on 08/25/2025 at 4:07 P.M., indicating the actions the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: the 11-7 nursing supervisor's employment was terminated, all staff were immediately in-serviced on the facility abuse policy with a focus on implementation procedures and resident safety, the administrative team which consisted the DON, Administrator and Medical Director reviewed the facility abuse prevention policy and no change to policy required. All current residents or their designee were interviewed to ensure that they felt safe, and assessments were done on all non-verbal residents. Started 10 weekly staff interviews on the facility abuse policy and 10 weekly resident interviews about resident safety. Resident and staff interviews will be reviewed weekly with the Administrator for 3 months and will be reported monthly to the Quality Assurance Performance Committee. Implementation of the RP was verified during the continuation of the on-site survey on 08/25/2025 and determined that IJ was removed as of 08/23/2025. The evidence was as follows: This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for abuse and was evidenced by the following:The facility policy document titled Abuse dated April 9, 2024, was reviewed. Under POLICY, page 2 of the policy revealed, It is the policy that each resident will be free from Abuse. [.] Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. [.] The facility will strive to educate staff and other applicable individuals in techniques to protect all parties.Under C. PREVENTION page 5 of the facility policy revealed, It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns, incidents and grievances without fear of reprisal or retribution. This section of the facility policy further revealed, The facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse. Under E. INVESTIGATION, page 7 of the facility policy revealed, It is the policy of this facility that reports of abuse' (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. This section of the policy further revealed under PROCEDURE: a. Investigation of abuse: When an incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation may include: [.] iv. Involved staff and witness statements of events [.] ix. Interview of other residents who were cared for by the accused (if applicable). Under F. PROTECTION, page 9 of the facility policy revealed, It is the policy of this facility that the resident(s) will be protected from the alleged offender(s). This section of the facility document revealed under, PROCEDURE, Immediately upon receiving a report of alleged abuse, the Administrator and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of utmost priority. [.] a. Procedures must be in place to provide the resident with a safe, protected environment during the investigation: i. The alleged perpetrator will immediately be removed and resident protected. Employees or visitor accused of alleged abuse will be immediately removed from the facility and will remain removed pending the results of a thorough investigation.Under G. REPORTING AND RESPONSE page 11 of the facility policy revealed under, PROCEDURE: INTERNAL REPORTING: a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator, Director of Nursing, or designee. **Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to unspecified nondisplaced fracture of fifth cervical vertebra (broken bone in the neck that remained in its original position), subsequent encounter for fracture with routine healing; unspecified nondisplaced fracture of fourth cervical vertebra (broken bone in the neck that remained in its original position), subsequent encounter for fracture with routine healing; cognitive communication deficit (breakdown in the cognitive processes that affects how individuals think and communicate); need for assistance with personal care; abdominal aortic aneurism (enlarged area in the lower part of the body's main artery, which can be fatal if ruptured), without rupture, unspecified; and nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissues that cover the brain). According to the Minimum Data Set (MDS), an assessment tool dated 03/27/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated that the resident's cognition was moderately impaired. The MDS revealed that Resident #1 required assistance to roll left and right, move from sitting to laying, to move from laying to sitting, and to move from sitting to standing. The MDS also revealed that Resident #1 was occasionally incontinent of urine and was always incontinent of stool. An undated facility document, titled: Investigation Summary, regarding Resident #1 was reviewed. Under Narrative Description of Event: page 1 of the document, on 05/13/2025, Resident #6 reported that staff did not know how to care for Resident #1 and that Resident #1 was in pain. Resident #6 heard the concern but did not witness it. This section of the document further revealed that an immediate investigation was initiated, the physician was notified, the resident's sponsor and facility administration were notified. Under, Interview statements from staff who worked with the resident on 05-03-25 11pm - 7am, page 1 of the document, at approximately 6:00 A.M., RN #1 became aware that Resident #6 heard Resident #1 scream in pain during care. RN #1 assessed Resident #1 and immediately reported the concern to the Supervisor. The Supervisor then assessed Resident #1. The document revealed no further action taken by the Supervisor or other facility staff on the day that Resident #6 expressed concerns that Resident #1 was hurt by a CNA #1 that morning. According to the Investigative Summary/Conclusion: page 2 of the document, CNA #1 was suspended due to the facility's protocol pending the results of the investigation. The same section of the document on page 3 revealed that the allegations made by Resident #6 were unsubstantiated. Page 3 of the document further revealed, Due to the nature and potential risk to all resident facility staff were re-educated on abuse prevention. A facility document titled: Statement form, hand-written by CNA #1, dated 05/02/2025 was reviewed. The statement revealed that Resident #1 did not complain of pain while CNA #1 was providing care, and that the resident was left comfortably in bed. The statement revealed that as CNA #1 was leaving the resident's room, she dropped garbage on the floor which disturbed Resident #6, who then complained to CNA #1 about the noise. A telephone interview was conducted with CNA #1 on 08/22/2025 at 12:05 P.M. CNA #1 stated that she provided a written statement at the request of a Nursing Supervisor and was unsure of when she provided the statement but thought it could have been 05/02/2025. CNA #1 stated that she worked until 7:00 A.M. on the morning that Resident #6 got upset with her for making noise in their room. CNA #1 stated that she was not suspended or sent home on that day. A facility document, titled: statement form, handwritten by RN #1, dated 05/16/2025 and timed 7:00AM, was reviewed. The statement revealed that at approximately 6:00 A.M., Resident #6 reported that they heard their roommate (Resident #1) scream while a CNA was providing care. The statement further revealed that Resident #1 was assessed immediately by RN #1 and the facility Supervisor was immediately notified of the concern.The surveyor attempted to reach RN #1 for an interview without success. Review of the Progress Notes (PN) for Resident #1 revealed that on 05/05/2025 at 2:44 P.M., UM #1 interviewed Resident #1 about a recent complaint of a CNA being rough with them. The PN further revealed that Resident #1 did not recall being treated roughly and denied being hurt by anyone. An interview was conducted with UM #1 on 08/22/2025 at 1:15 P.M. UM #1 stated that the process after an allegation of rough treatment was to immediately interview the resident and their roommate, if possible; assess the resident's skin; and notify the Director of Nursing (DON) or Licensed Nursing Home Administrator (LNHA). UM #1 stated that the process included obtaining statements from staff members who cared for the affected resident. UM #1 stated that nurses, UMs, and Supervisors were responsible for obtaining statements. UM#1 stated that the process included assembling statements and skin assessments in a folder and giving it to the DON. UM #1's statement to the surveyor regarding the accused staff did not follow the facility policy reviewed under F. Protection, which stated that employees or a visitor accused of abuse will be immediately removed and will remain removed pending the results of a thorough investigation. UM #1 stated that the process included changing the assignment of the accused staff member when an accusation was made and sending the staff member home if it was determined that, something really happened. UM #1 further stated that the DON or LNHA made the decision about whether an employee should have been sent home, which is not in accordance with facility policy. During the same interview, UM #1 stated that she recalled that in May 2025, Resident #6 complained that Resident #1 was in pain during care. UM #1 stated that she was made aware of the allegation when she arrived at work at on 05/05/2025 around 7:00 A.M., and that was when she completed a skin assessment of Resident #1. UM #1 stated that she interviewed Resident #1 who denied being hurt by facility staff. UM #1 stated that she believed that the facility's DON or Assistant Director of Nursing (ADON) obtained statements about this allegation. UM #1 further stated that she was familiar with the facility's abuse policy but was not sure if the policy was followed on 05/05/2025. An interview was conducted with the DON on 08/22/2025 at 2:08 P.M. The DON stated that an allegation of rough treatment during care would have been considered an abuse allegation. The DON stated that the expectation was for staff to notify a Nurse or Supervisor immediately when there was an abuse allegation and for the DON or LNHA to be notified immediately. The expectation was for the nurse or Supervisor to assess the resident involved, and for the Supervisor to collect statements as soon as they were made aware of an accusation. The DON stated that the process when an abuse allegation was made included sending the accused staff member home pending the results of the investigation. The DON further stated that this process was important to ensure that residents were not left in the care of someone who was hurting them. During the same interview, the DON stated that she and the LNHA did the investigation of Resident #6's allegation that Resident #1 received rough treatment by a CNA. The DON stated that she was made aware of the accusation on 05/13/2025 and that is when the investigation was started. The DON stated that CNA #1's statement was obtained on 05/13/2025 and the date written on the statement (05/02/2025) refers to the date that CNA #1 started the 11:00 P.M. to 7:00 A.M. shift which was when the 05/03/2025 allegation was made. The DON stated that the statement obtained from RN #1 was dated 05/16/2025 but the statement was about the allegation made on 05/03/2025. The DON stated that it was concluded that the alleged event occurred on 05/03/2025 at approximately 5:30 A.M., RN #1 reported the allegation to the Supervisor right away. The DON further stated that the Supervisor did not report the allegation to the DON, obtain statements, or send the accused CNA home according to facility policy. A 05/05/2025 at 2:44 P.M., Progress Note by UM #1 was reviewed with the DON. The DON stated that her expectation was that she should have been notified right away of the allegation of rough treatment. A follow up interview was conducted with the DON on 08/22/2025 at 4:11 P.M. The DON stated that on 05/03/2025 the Supervisor should have notified her of the accusation made by Resident #6 and the CNA would have been suspended. The DON stated that on 05/05/2025, she (the DON) and UM #1 assessed and spoke with Resident #1 about the allegation that they were hurt by a CNA. The DON stated that no further investigation was done on 05/05/2025. The DON stated that on 05/13/2025 Resident #6 informed the facility's Assistant Administrator of the allegation of rough treatment of Resident #1, and it was on 05/13/2025 that the facility's abuse policy was fully implemented. During the same interview the DON stated that the purpose of the facility's abuse policy was to inform staff of what to do when an abuse accusation was made. The DON further stated that if the abuse policy was not followed, we put the resident in potential danger. During an interview with the LNHA on 08/22/2025 at 5:39 P.M., the LNHA stated that the expectation was that if there was an allegation of abuse the facility's abuse policy, which included starting an immediate investigation, should be implemented quickly. The LNHA stated that there was no need to follow the facility's abuse policy on 05/03/2025 and there was no need to implement the policy related to resident #6's accusation until 05/13/2025 because there were no suspicions or complaints of abuse until that date. The LNHA further stated that that facility's abuse policy is in place to safeguard the residents and because it is a regulation. NJAC 8:39-4.1(a)5

Based on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to a.) ensure a resident received liquids in the appropriate consistency at bedside in accordance with physician orders and b.) follow the guidance on the resident's individualized comprehensive care plan. This deficient practice was identified for 1 of 3 residents reviewed for nutrition (Resident #60).
This deficient practice was evidenced by the following:
On 11/13/24 at 10:40 AM, two surveyors observed Resident # 60 in bed awake and alert. The surveyors observed a 16-ounce (oz.) water cup with a straw on the bedside table which was not in the resident's reach. The resident was unable to state whether he/she had a thickened liquid diet order.
A review of the admission Record (an admission summary) reflected the resident had diagnoses that included but were not limited to: cerebral infarction (stroke), asthma and dementia.
A review of a Quarterly Minimum Data Set, a tool used to facilitate the management of care, dated 10/18/24, reflected the resident had a Brief Interview of Mental Status of 12 out of 15, which indicated the resident had a moderately impaired cognition. The MDS also indicated that the resident had a diagnosis of dysphagia and was on a mechanically altered diet that required a change in texture of food or liquids such as pureed food or thickened liquids.
A review of the Order Summary Report reflected the resident had a physician's order (PO) for a Honey consistency diet dated 11/6/24.
A review of the comprehensive care plan reflected the resident received honey thickened liquids with a revised date of 11/9/24.
A review of a Nurse Practitioner's progress note dated 11/7/24, reflected the resident had chronic oropharyngeal dysphagia (difficulty swallowing) related to advanced dementia. It also reflected the resident had a modified barium swallow (a swallowing test) on 11/6/24, which indicated the resident aspirated (inhaled) with liquids and required thickened liquids.
A review of a Speech Language Pathologist (SLP) treatment progress note, dated 11/11/24, reflected the resident had a diagnosis of oropharyngeal dysphagia and required honey thick liquids. It also reflected that nursing was educated on the resident's downgrade to honey thick liquids and verbalized understanding.
A review of the modified barium swallow results, dated 11/6/24, reflected a recommendation for honey thick liquids.
On 11/13/24 at approximately 10:40 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) #1 in the presence of a second surveyor, who stated that the resident was on a honey thick liquid diet. In addition, she stated that she prepared thier bedside water earlier in the day. LPN #1 demonstrated how she prepared the honey thick water at the medication cart in the presence of two surveyors. She used preportioned powdered thickener in packets. In total, she mixed 16 oz. of water from a gallon jug with three thickener packets. She stated the longer it sat the thicker the fluid would become. The surveyor reviewed the packet instructions with LPN #1, which indicated two packets should have been used for every four oz. of water to achieve a honey thick liquid consistency. LPN #1 stated that she determined the appropriate consistency by visual assessment.
On 11/13/24 at 10:56 AM, the surveyor interviewed the SLP, in the presence of a second surveyor. The SLP reviewed the packet instructions and verified that for every four oz. of water, two packets were required to achieve a honey thick liquid consistency. In addition, she stated that the kitchen had prethickened nectar and honey thick liquids. At that same time, LPN #1 showed the SLP and surveyors a four oz. portioned lemon-flavored nectar thick water and stated there was no prethickened honey thick water on the unit and could not state whether she contacted the kitchen for it.
On 11/13/24 at 11:01 AM, the SLP and two surveyors went to the resident's room to observe the bedside water. The SLP lifted the 16 oz. clear plastic cup of water and acknowledged that it (the liquid and the powder) was separated. The bottom was cloudy, and the top was clear thin liquid. She stated, that happens a lot with the powder we use. She further stated the resident recently had a swallowing test.
On 11/13/24 at 11:10 AM, the SLP mixed the contents of the cup with the straw, in the presence of two surveyors. She acknowledged that the liquid was not a honey consistency and further stated I don't think this was ever honey thick. She also acknowledged that according to the thickener packet instructions, eight packets were required to thicken 16 oz. of water to a honey thick consistency.
On 11/13/24 at 11:16 AM, the surveyor interviewed the Registered Dietitian (RD) and the Regional Food Service Director (RFSD), in the presence of a second surveyor. Both stated that the kitchen had prethickened portioned honey thick juice, milk and water. The RFSD showed a full unopened case of four oz. lemon flavored honey thick water to the surveyors.
On 11/13/24 at 11:31 AM, the surveyor gave the resident's 16 oz. water cup to the RFSD to assess. He stated that the fluid was not thick enough to be a nectar or honey consistency. He stated that two packets of thickener were required for every four oz. of water to achieve a honey thick liquid consistency. He further stated that the cup had too much water verse packets. At this same time, the RD also stated that the liquid was not thick, and both acknowledged the liquid was not honey thick.
On 11/13/24 at 12:35 PM, the surveyor interviewed Director of Nursing (DON), in presence of the survey team. She stated that the kitchen had prethickened liquids and in the event they did not the nursing staff would have to use the powdered thickener. The DON stated that the nurses were clinically astute (able) to determine liquid consistencies visually. She stated that she would have expected the nurse to contact the kitchen for prethickened liquids if they were not available on the unit.
On 11/13/24 at 12:46 PM, the surveyor provided the residents 16 oz. cup of liquid to the DON to observe. She stated, this is pretty thin, not a honey consistency. She further stated the nurse did not follow the PO.
On 11/14/24 at 11:15 AM, the SLP provided an undated document to the surveyor in presence of the survey team. The document titled Liquid Consistencies indicated that the definition/description of a honey consistency were Liquids can be poured but are very slow. Liquids will require a thickening agent to reach this consistency. Food slowly drips in dollops (or blobs) off the end of a spoon.
A review of the facility policy Thickened Liquids, Fluid Restrictions and NPO [nothing by mouth] dated 8/2024, included Assure that there is no water pitcher or other thinned liquids at the resident's bedside who is ordered thickened liquids .
A review of the undated facility policy Care Plans, included that it reflected treatment goals and objectives.
NJAC 8:39-17.4(a)(1)

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following:
On 11/07/24 at 9:39 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and a second surveyor. The following was observed:
1. Two top reach in refrigerators that held milk. The refrigerator on the right stored four- and eight-ounce milks and the refrigerator on the left stored gallon milk. Both had gray gaskets on the doors which had a heavy buildup of a black substance on the underside of the top gaskets. The FSD stated it was mold and needed to be cleaned.
2. In the room outside the main kitchen, the surveyor observed a windowsill next to a metal rack which stored boxes of salt and pepper packets. The sill had large amount of debris, leaves and twigs. The FSD stated that when the staff opened the window debris gets in.
3. The bread rack had multiple opened bags of bagels which had a heavy build up of a green fuzzy substance. Three bags were dated 10/25/24. One bag had six bagels and the two other bags had two bagels. A fourth bag dated 10/29/24 had four bagels. The FSD stated the Assistant FSD was responsible for rotating the bread but was not working today. The surveyor observed the designated dented can area next to the bread rack.
4. In the dry storage area, there were dented cans which were in rotation for use. The surveyor observed the following dented cans:
- One #10 sized cans of stewed tomatoes
- One #10 sized can of sliced potatoes
The FSD acknowledged that the cans were dented and should not have been in the dry storage area.
5. The double stack convection ovens had a large build up of black debris which the FSD acknowledged and stated they needed to be cleaned.
6. The two metal shelves over the range had a heavy build up of black debris on the underside of the shelves above the cooking area. The FSD acknowledged this and stated there could be cross contamination.
7. There was a slicer (not in use) which had a soiled oven mitt stored directly on the area where sliced food would be. In addition, there was a light brown debris on the blade and base. At that time, the cook stated she had not used the slicer today.
A review of an undated facility policy Sanitation, included that the food service area should be maintained in a clean and sanitary manner. It also included that all kitchen areas should be kept clean and free from litter and rubbish. It further included that shelves and equipment should be kept clean and the Food Service Manager was responsible for scheduling staff for regular cleaning.
A review of an undated facility policy Food Storage, included food storage areas should be maintained in a clean, safe and sanitary manner. It also included that food should be rotated as delivered and a first-in, First-out method should be used.
NJAC 8:39-17.2(g)

Compliant #: NJ169617
Based on observation, interviews, review of the medical record and other pertinent facility documents, it was determined that the facility failed to ensure that a resident received preferred and accurate meal items at lunch service and in accordance to what was indicated on the meal ticket. This deficient practice occurred for 1 of 8 residents observed during dining service (Resident #147), and was evidenced by the following:
On 11/08/24 at 12:29 PM, during the lunch meal service, the surveyor observed Resident #147 sitting in a wheelchair in their room. The resident was accompanied by a family member who stated that the resident consistently received incorrect meals. The resident stated that he had ordered pork chops but was served fish instead. The resident confirmed he has previously informed the staff that he did not like fish.
A review of the admission Record (an admission summary) included that the resident was admitted with diagnoses that included but were not limited to; cerebral infarction (stroke), essential hypertension, Alzheimer's disease, unspecified dementia, psychotic disturbance, mood disturbance and anxiety.
A review of the Quarterly Minimum Data Set (MDS), a tool that facilitates the management of care, dated 10/03/2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15. This score indicated a moderate cognitive impairment.
A review of the physician orders (PO) for Resident #147, dated 11/08/2024, revealed a PO for: No Added Salt (NAS), regular texture, thin consistency diet.
A review of the nutrition care plan, dated 10/2/24, did not reflect any documented food preferences.
On 11/08/24 at 12:42 PM, the surveyor observed the resident's lunch tray in the presence of Licensed Practical Nurse (LPN) #1 and the Unit Manager LPN (UMLPN) #1.
The lunch tray contained a fish fillet with lemon dill sauce, rice pilaf, oriental zucchini, skim milk, and juice. A review of the meal ticket on the tray indicated the resident should have received herb breaded pork chops, rice pilaf, braised cabbage, fruited yogurt, whole milk, juice, and coffee. LPN #1 and UMLPN #1 acknowledged that the lunch tray items did not match what was indicated on the resident's meal ticket.
On 11/12/24 at 10:01 AM, the surveyor interviewed the Food Service Director (FSD). The FSD stated that the kitchen ran out of pork chops, which was an alternate and popular meal choice that day. He stated that several residents had requested to change their orders from fish to pork chops and as a result, the facility ran out of pork chops. In addition, the FSD acknowledged that the facility should have notified the resident of the substitution and stated that the staff was in a rush.
On 11/14/24 at 11:40 AM, the surveyor interviewed the FSD, in the presence of a second surveyor. The surveyor inquired why Resident #147 did not receive yogurt for lunch on 11/08/24. The FSD could not explain why fruit yogurt was indicated on the meal ticket but the resident did not receive it. He further stated that resident's food preferences should have been accommodated. The FSD acknowledged the importance of honoring resident's meal preferences was because it was a resident right. The FSD also stated that the Caller/Checker position at the end of the tray line was responsible to ensure meal tray accuracy and that he was ultimately responsible for the accuracy of this process.
On 11/14/24 at 12:04 PM, the surveyor interviewed the Registered Dietitian (RD), in the presence of a second surveyor. The RD stated that if a resident did not receive the meal they requested or preferred consistently, this could place the resident at nutritional risk as residents are less likely to eat meals they do not want.
A review of the facility-provided Week-At-A-Glance menu, which is used for residents to make their meal selections, indicated that Resident #147 had selected herb breaded pork chops, braised cabbage, rice pilaf, whole milk, juice, and coffee for their lunch meal on 11/08/2024. The meal served to the resident did not match their selection, as the tray contained fish fillet with lemon dill sauce, rice pilaf, and other items inconsistent with their choice.
On 11/13/24 at 1:16 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled Resident Food Preferences, with a revision date of 8/1/24. Under the Policy Interpretation and Implementation section, the policy included:
The resident's clinical record (including orders, care plans, or other appropriate locations) will document the resident's likes and dislikes, as well as any special dietary instructions or limitations, such as altered food consistency and caloric restrictions.
The LNHA also provided the surveyor with a facility policy titled Meal Distribution and Tray Line Policy, with a revision date of 8/1/24. This policy included the following:
Tray Assembly: Meals must be accurately assembled according to each resident's dietary plan, which includes special diets, allergies, and preferences. Each tray should be checked against the resident's meal ticket for accuracy.
Quality Control: Supervisory staff will review trays for presentation and completeness before leaving the kitchen, ensuring that each resident receives their correct meal.
NJAC 8:39 17.4 (a)1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 3 of 37 residents reviewed (Resident #16, Resident #34, and Resident #429). This deficient practice was evidenced by the following:
1. On 11/7/24 at 11:08 AM, the surveyor observed Resident #16 to be out of bed, in a wheelchair, and in the dayroom participating in activities. On 11/8/24 at 1:10 PM, the surveyor observed Resident #16 in a wheelchair, outside smoking with staff supervision. A smoking apron was visible on Resident #16's lap.
A review of the admission Record face sheet (an admission summary) reflected Resident #16 had diagnoses which included but not limited to: Alzheimer's disease.
A review of the admission MDS, an assessment tool dated 4/23/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderately impaired cognition and Section J1300 was coded no for current tobacco use.
On 11/13/24 at 11:00 AM, the surveyor interviewed the MDS Coordinator and asked about the current tobacco use coding, she stated oh gosh, I see it, it was not coded. It was missed.
2. On 11/7/24 at 10:40 AM, the surveyor observed Resident #34 to be out of bed, sitting in a wheelchair in the room. On 11/8/24 at 12:38 PM, the surveyor was informed by staff that Resident #34 was out to dialysis.
A review of the admission Record face sheet reflected that Resident #34 had diagnoses which included but not limited to; end stage renal disease (kidney disease), diabetes, and dependence on renal dialysis (a machine that removes waste products and excess fluid from the blood).
A review of the annual MDS, dated [DATE], revealed a BIMS score of 14 out of 15, which indicated intact cognition, and Section O0110 question J1 was not coded for dialysis while a resident.
A review of the individual comprehensive care plan (ICCP) included a focus area dated 3/22/18 and revised 9/11/23, that the resident had a potential for complications due to hemodialysis; a focus area dated 7/18/18 and revised on 9/11/23 regarding the resident's dialysis schedule; and a focus area dated 3/23/18 and revised 7/18/24 that the resident has end stage renal disease on hemodialysis with an increased protein need.
On 11/13/24 at 11:03 AM, the surveyor interviewed the MDS Coordinator and asked about the dialysis coding, she stated, I didn't see a note at that time.
3. On 11/07/24 at 11:34 AM, the surveyor observed Resident #429 in the dayroom.
A review of the admission Record face sheet reflected that Resident #429 had diagnoses which included but not limited to; moderate dementia with behavioral disturbance.
A review of the electronic medical record indicated that on 10/30/24 at 6:38 PM Resident #429 was noted cursing on and off, kicking and throwing objects. On 10/31/24 at 10:54 PM, the Resident #429 was noted to be kicking, pushing, throwing objects, and cursing on and off.
A review of the admission MDS, dated [DATE], revealed a BIMS of 0, indicating severe cognitive impairment and section E200 and E300 were coded to reflect no behavior symptoms.
On 11/14/24 at 12:28 PM, the surveyor interviewed the MDS Coordinator, who indicated that the MDS assessments should be accurate. When asked about the above mentioned MDS and the coding of behaviors, she stated that she would check and get back to the surveyor.
On 11/14/24 at 1:21 PM, the surveyor interviewed the MDS Coordinator in the presence of the survey team. She stated she did not code the resident's behaviors and it should have been done.
A review of an undated facility policy Resident Assessment Instrument MDS included:
2. The Interdisciplinary Assessment Team must use the MDS form currently mandated by Federal and State regulations to conduct the resident assessment. Other assessment forms may be used in addition to gather other pertinent data.
3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity.
8. If an error is made when completing the MDS, the error will be corrected when discovered.
N.J.A.C 8:39-11.1

Based on observation, interview, and record review, it was determined that the facility failed to ensure the necessary respiratory care and services were provided in a manner to prevent the spread of infection for 1 of 4 residents (Resident #4) reviewed for respiratory care. This deficient practice was evidenced by the following:
On 11/7/24 at 10:57 AM, the surveyor observed Resident #4's nebulizer machine (an electric machine that converts liquid medication to a fine mist) on the dresser in their room, surrounded by personal items. The tubing attached to the nebulizer was not labeled or dated. Additionally, the nebulizer mask was not covered and was left exposed to the air. The exterior of the nebulizer machine showed yellowish stains and a brown fuzzy debris accumulation on the surface.
On 11/12/24 at 12:09 PM, the surveyor observed the same nebulizer machine. The stains on the exterior of the machine and the brown fuzzy debris covering the surface remained present. The nebulizer mask was uncovered and exposed to the air.
On 11/13/24 at 9:51 AM, the surveyor interviewed Resident #4 about the care and maintenance of their nebulizer equipment. The resident informed the surveyor that the staff changed the tubing on a weekly basis. However, the resident also stated that they had never seen staff clean the nebulizer machine and acknowledged that the machine was not clean. The stains on the exterior of the machine and the brown fuzzy debris on the surface were still present, and the nebulizer mask remained uncovered and exposed to air.
A reviewed the admission Record, which reflected that Resident #4 was admitted to the facility with medical diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (COPD) (a lung disease that makes breathing difficult), acute on chronic systolic heart failure, and cardiomyopathy (a disease of the heart muscle making it difficult to pump blood).
A review of the Minimum Data Set (MDS), an assessment tool, dated 9/5/24, revealed that Resident #4 had a Brief Interview for Mental Status (BIMS) score 14 out of 15, which indicated intact cognition.
A review of the physician orders for Resident #4, revealed a physicians order dated 11/8/24 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally three times a day for shortness of breath (SOB) for five days.
On 11/13/24 at 12:51 PM, the surveyor interviewed the Unit Manager Licensed Practical Nurse (UMLPN). The UMLPN described the facility's process for changing the nebulizer tubing and masks, noting that this occured every Tuesday. The UMLPN stated the tubing and mask should be dated and placed in a bag after use, the mask should be cleaned after each use and stored in a bag. The UMLPN acknowledged that there was no established procedure for cleaning the exterior of the nebulizer machine.
On 11/13/24 at 1:02 PM, the surveyor interviewed the Infection Preventionist (IP). The IP explained that the nebulizer tubing and masks were changed weekly, typically on Tuesday nights for the entire building. The mask should be dated and placed in a bag after use. She further explained the nursing staff was responsible for cleaning the nebulizer masks after each use and allowing them to air dry and ensuring that the masks were returned to the bag once cleaned. The IP further clarified that the nebulizer machines should be wiped down daily by nursing, with the final cleaning should be performed by housekeeping. During the interview, the surveyor made the IP aware of the above mentioned observations. The IP responded that this should not be like that and emphasized that the equipment should have been properly cleaned and maintained to prevent any risk of contamination.
On 11/13/24 at 1:08 PM, the surveyor and the IP entered Resident #4's room to observe the nebulizer equipment. The resident was in their room at the time. The nebulizer mask was found to be bagged. Resident #4 informed the surveyor and the IP that the nurse had just been in the room about five minutes prior, changed the tubing, and placed the mask into the bag.
On 11/13/24 at 1:13 PM, the surveyor and the IP went to the nurses' station, where the Unit Manger Licensed Practical Nurse (UMLPN) and the Licensed Practical Nurse (LPN), who was responsible for Resident #4's care, were present. The LPN verified that she had been in Resident #4's room and changed the tubing, and bagged the mask prior to the surveyor and the IPs observation.
On 11/13/24 at 1:16 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment with a revision date of 8/1/24. Under the Policy Interpretation and Implementation section, the policy included: Respiratory-Tubing/Equipment (nebulizer chamber) changed weekly. In between use items will be stored in a plastic bag.
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 maintain proper infection control practices during tracheostomy care. This deficient practice was identified for one of two residents reviewed for tracheostomy care, (Resident #117) and was evidenced by the following:
On 8/2/23 at 11:29 AM, the surveyor observed Resident #117 in their room in bed. The resident had a tracheostomy (a hole made surgically through the front of the neck into the trachea (windpipe) with a tube placed through the hole to help the person breath) which was attached to an oxygen concentrator (machine that provides oxygen).
The surveyor reviewed the medical record for Resident #117.
A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in January of 2019 and readmitted in June of 2023 and had diagnoses which included tracheostomy, respiratory failure and dementia.
A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 5/12/23, reflected that the resident had severely impaired cognition. Further review of Section G - Functional Status reflected that the resident was totally dependent on staff for all activities of daily living (ADLs). A review of Section O - Special Treatments, Procedures, and Programs reflected the resident received the following respiratory treatments: oxygen therapy and trach care.
A review of the Order Summary Report dated as of 8/3/23, included the following Physician's Orders (PO):
A PO dated 6/14/23, trach care every shift.
A PO dated 6/16/23, suction secretions from tracheostomy every shift and when needed.
On 8/8/23 at 10:15 AM, the surveyor observed the Licence Practical Nurse (LPN) provide trach care for Resident #117 and observed the following:
The LPN cleaned the Overbed Table (OBT) with bleach wipes.
The LPN gathered the trach supplies from the treatment cart which included a sterile suction catheter kit, sterile trach care tray, normal saline (NSS) bottles and an inner cannula. The LPN placed the supplies on the OBT.
The LPN washed her hands and donned (put on) a disposable gown, faceshield and gloves. The LPN proceeded to open the suction catheter kit and trach care tray, removed the sterile drape, covered the OBT, and opened the NSS. The LPN donned the sterile gloves and then with her right hand poured the normal saline into the pop-up basin that was inside the kit and with the same gloved hand (which was no longer sterile) reached into the sterile suction catheter kit and removed the suction catheter. The surveyor intervened just before the LPN inserted the catheter into Resident
#117's tracheostomy and asked the LPN to step away from the resident to discuss the breaks in sterile technique.
The LPN acknowledged the breaks, discarded all the supplies and obtained a new suction kit, trach tray, normal saline bottle and inner cannula. The LPN placed the supplies on the OBT. The LPN stated that her right hand was her dominant hand so she planned to keep that hand sterile. The LPN suctioned Resident #117's catheter 2x. The LPN removed her sterile gloves and without sanitizing her hands donned a new pair gloves. The LPN removed the drape from the trach care tray and placed it on the OBT, touching the drape with her non sterile gloves then proceeded to open and place all the supplies on the OBT. The surveyor intervened and discussed the breaks. LPN acknowledged that she had contaminated the sterile field and discarded all the supplies.
The LPN gathered new supplies, put all sterile supplies on the OBT and then used the outside of the inner cannula package (which was not sterile) to separate the supplies, moving them around the sterile field. The surveyor asked the LPN if the outside of the trach cannula package was sterile. The LPN replied no and stated that she should not have touched the sterile supplies with the non sterile package. The surveyor asked the LPN if she would like to take some time to review the policy for trach care. The LPN replied, No, I do this every day.
The LPN gathered new supplies, set up her sterile field and then reached over the field which caused her badge and blouse to touch and contaminate the pop up container which contained the NSS. The LPN discarded all supplies and obtained all new supplies.
The surveyor asked the LPN if she had received training for trach care and suctioning. The LPN replied that the Assistant Director of Nursing (ADON) had given her a video to watch and was not sure if or when she had a competency.
On 8/8/23 at 11:49 AM, the surveyor interviewed the Infection Preventionist/LPN
(IP/LPN) who stated trach care and suctioning should be a sterile procedure. She further stated that she and the Assitant Director of Nursing (ADON) were responsible for providing nurses with inservices and competencies. The surveyor asked the IP/LPN when the most recent trach inservice was and if or when the LPN had received a competency. The IP/LPN replied that the LPN had been inserviced upon hire but was not sure if she had any training or competencies since. The IP/LPN acknowledged that the LPN had been working at the facility since May of 2019. The IP/LPN further stated that it was the Unit Manager's responsibility to spot check, monitor and observe the nurses perform care and then to notify her or the ADON with any concerns.
On 8/8/23 at 11:58 AM, the surveyor interviewed the LPN/UM who stated that he had never observed the LPN perform trach care for Resident #117. The LPN/UM stated that it was his responsibility to monitor and observe the nurses on his unit so that he could identify any concerns and then bring them to the attention of the IP/LPN and the ADON. The LPN/UM further stated that going forward he planned to monitor the nurses more closely while they provide care and treatments to the residents.
On 8/8/23 at 12:52 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the ADON of the concerns identified during the trach care and suctioning observation for Resident #117. The DON acknowledged that the LPN should be practicing sterile technique and proper hand hygiene when providing trach care.
On 8/10/23 at 12:49 PM, the DON stated that it was the facility's policy to ensure that the nurses had annual competencies for trach care and suctioning and that she was in the process of reestablishing that. The ADON stated that he had not observed the LPN during trach care or suctioning and had never completed a competency for her.
A review of the facility's undated Tracheostomy Care policy included .it is the policy of the facility to establish standards for the care and maintenance of tracheostomy tubes to assist in maintaining a patent airway, reduce the risk for nosocomial infection . and help to reduce infection of surrounding skin . inner cannulas are changed during trach care every day shift.
A review of the facility's Handwashing/ Hand Hygiene policy, undated included . hand hygiene is the primary means to prevent the spread of infections .all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .employees must wash their hands for forty to sixty seconds using antimicrobial of non-microbial soap and water .before and after direct contact with residents .after removing gloves .before donning sterile gloves, before performing any non-surgical invasive procedures .before handling clean or soiled dressings, gauze pads. Hand hygiene is always the final step after removing and disposing of personal protective equipment
NJAC 8:39-25.2 (b), (c)4

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to: a.) ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 5 of 6 forms provided; and b.) accurately document the administration of controlled medication for 2 sampled residents, (Resident #27 and Resident #44) identified upon inspection of 1 of 5 medication carts (Willow unit, high-side cart).
This deficient practice was evidenced by the following:
1.) On 8/9/23 at 12:52 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the [NAME] unit, high-side cart. The surveyor and the LPN reviewed the narcotic medication located in a secured and locked narcotic box. When the narcotic inventory was compared to the corresponding declining inventory sheet, the surveyor identified the following concerns.
Resident #27's methadone 8 milligram (mg)/1 milliliter (ml) oral solution, a medication used for pain or opioid withdrawal, did not match the physical inventory. The plastic bag contained two bottles and the declining inventory sheet indicated there should be three bottles remaining.
Resident # 44's methadone 10 mg tablet also did not match. The blister pack contained 17 tablets and the declining inventory sheet indicated there should be 18 tablets remaining.
At this time, the surveyor interviewed the LPN who stated she had administered the medications earlier to both residents and had not signed the declining inventory sheet for the doses she had administered. The LPN acknowledged the declining inventory sheet should be signed when the medication was removed from the packaging.
On 8/9/23 at 1:11 PM, the surveyor interviewed the Director of Nursing (DON) who stated as soon as the medication was removed from the packaging, the nurse must sign the declining inventory sheet. This was the process to avoid potential drug diversion.
On 8/10/23 at 11:29 AM, the surveyor attempted to interview the facility Consultant Pharmacist via telephone, but was unable to do so, as the pharmacist was not available.
A review of the facility's undated Administering Medications policy did not include a process for the administration of narcotic medications and completion of a declining inventory log.
A review of the facility undated Controlled Substances policy included . the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of schedule II and other controlled substances .
2.) On 8/9/23 at 12:00 PM, the surveyor reviewed the facility provided DEA 222 forms which revealed on five of the six provided forms Part 5, had not been completed upon receipt of the medications from the Provider Pharmacy as instructed on the reverse of the ordering form. The forms were as follows:
Order form number: 220927856; 220927859; 220927860; 220927861; 220927867.
On 8/9/23 at 12:46 PM, the surveyor and DON reviewed the provided DEA 222 forms. The DON acknowledged she should have completed in Part 5 as instructed on the reverse of the DEA 222 form as required.
On 8/10/23 at 11:29 AM, the surveyor attempted to interview the facility Consultant Pharmacist via telephone, but was unable to do so, as the pharmacist was not available.
A review of the Instructions for DEA Form 222, under Part 5. Controlled Substance Receipt, 1. The purchaser fills out this section on its copy of the original order form.
2. Enter the number of packages received and date received for each line item .
NJAC 8:39- 29.2(d), 29.7(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure safe and appetizing temperatures of food for 3 of 4 meal entrees observed during 1 of 1 meal observations (lunch) for 1 of 2 residents reviewed for food (Resident #122). This deficient practice was evidenced by the following:
On 8/2/23 at 12:57 PM, the surveyor observed Resident #122 in their room. The resident stated that they did not receive their lunch tray today; that it was not on the meal cart, and they were waiting for staff to bring their lunch tray to them.
On 8/3/23 at 12:00 PM, the surveyor observed the lunch meal trays arrive to the Oak nursing unit day room. The surveyor made the following observations:
At 12:03 PM, Certified Nursing Aide (CNA#1) placed milk on all the trays.
At 12:10 PM, Licensed Practical Nurse (LPN #1) passed out the first meal tray to an unsampled resident.
At 12:13 PM, Resident #122 received their meal tray and asked CNA #1 to heat up their water for their hot chocolate; that it was cold. The surveyor observed on the resident's lunch tray chicken pot pie, turkey with gravy, rice, and green beans. The resident picked up the turkey and informed the surveyor that it was cold.
At 12:20 PM, the last tray was passed to an unsampled resident.
On 8/3/23 at 12:07 PM, the surveyor interviewed Resident #122 who stated the food was not good; he/she did not like the taste and the food was always cold. The resident continued and told the surveyor that yesterday the kitchen forgot to send their lunch meal tray, so they received their tray late. The resident stated he/she always received their food last, and it was always cold.
On 8/7/23 at 11:59 AM, the surveyor interviewed Resident #122 who stated last night for dinner, they received frozen turkey sticks and a hamburger. The resident stated the turkey sticks were cold and the hamburger was burnt on the outside and cold on the inside.
On 8/7/23 at 12:00 PM, the surveyor observed the lunch meal trays arrive to the Oak nursing unit day room. The surveyor made the following observations:
At 12:07 PM, Resident #122 asked LPN #1 if the lunch trays had arrived yet, and LPN #1 stepped out of the resident's room looked at the lunch trays, and then informed the resident the meal trays were on the floor.
At 12:13 PM, Resident #122 received their meal tray which consisted of chicken pot pie, rice, yellow squash, and peaches. The resident reported that the squash was cold, they disliked the rice and pushed it off their tray, and the chicken pot pie was not hot, it was warm but would be better if it was hotter.
On 8/8/23 at 11:07 AM, the surveyor informed the Food Service Director (FSD) they wanted to observe the lunch meal for the day which included food temperatures. The surveyor asked the FSD to calibrate two digital thin probed thermometers in their presence; which the FSD completed using an ice bath, and the thermometers reached 32 degrees Fahrenheit (F). The surveyor asked the FSD what the minimum temperature for hot food and the maximum temperature for cold food should be. The FSD stated hot food should be at 145 degrees F or higher and cold food should be at 41 degrees F. The FSD stated the main entree was penne pasta with meat sauce, garlic bread, and steamed mixed vegetables; and the alternative regular meal was a chicken breast with mashed potatoes and cauliflower.
On 8/8/23 at 11:15 AM, the surveyor observed the [NAME] using one of the thermometers calibrated to 32 degrees F take the following temperatures:
Meat sauce 174 F
Penne pasta 132 F
Steamed mixed vegetables 162 F
Alternative regular steamed cauliflower 154 F
Alternative regular main chicken breast 170 F
Pureed vegetables 136 F
Puree beef 167 F
Ground beef 167 F
Mashed potatoes 162 F
Orange juice 56 F
Yogurt 46 F
Vanilla pudding 57 F; the FSD stated the pudding was pre-portioned and placed in the refrigerator yesterday.
Mandarin orange slices 57 F; the FSD stated the oranges were pre-portioned and placed in the refrigerator yesterday.
Apple juice 54 F
Nutritional health shakes 54 F
Ham and cheese sandwich 53 F; the FSD stated it was made that morning at 8:00 AM, and placed in the refrigerator. At this time the surveyor observed the reach-in refrigerator for the tray line was at 45 F.
Gravy 165 F.
Garlic bread 124 F
At this time, the surveyor did not observe anyone in the kitchen attempt to bring the temperature down for the cold food and beverage above 41 F; and the surveyor did not observe any foods that were below 135 F heated up prior to service. The FSD stated that the facility used open air carts to transport the food, and the facility used a plate warmer (a device used to heat the plates prior to serving), pellets (heated metal plate liners that go inside the insulated base), and insulated dome lids and bases to maintain heat.
On 8/8/23 at 12:21 PM, the surveyor observed the first meal tray for the Oak nursing unit be plated.
On 8/8/23 at 12:29 PM, the surveyor was informed by the [NAME] the last tray was plated for the Oak nursing unit and the surveyor requested sample meal trays that included a regular meal, alternative regular meal, ground texture meal, and pureed texture meal to accompany the meal cart.
On 8/8/23 at 12:34 PM, the Dietary Aide (DA) left the kitchen with the meal cart which included the surveyor's requested sample meal trays. At this time, the surveyor and the FSD accompanied the DA with the calibrated thermometer to the Oak nursing unit.
On 8/8/23 at 12:36 PM, the DA arrived at the Oak nursing unit and left the meal cart in the day room.
On 8/8/23 at 12:36 PM, CNA #2 passed out the first resident meal tray.
On 8/8/23 at 12:39 PM, CNA #3 placed milks on all the residents' meal trays and continued passing out the meal trays.
On 8/8/23 at 12:45 PM, the last resident's meal tray was delivered to an unsampled resident.
At this time, the surveyor observed the FSD obtained the following meal temperatures of the test trays:
Regular meal texture:
Penne pasta with meat sauce 122 F
Mixed vegetables 115 F
Garlic bread 110 F
Mandarin oranges 60 F
four-ounce (4 oz) whole milk 40 F
4 oz fat free milk 41 F
Apple juice 51 F
Yogurt 57 F
Coffee 120 F
Vanilla pudding 54 F
Ham sandwich 56 F
Regular alternative texture meal:
Chicken breast 136 F
Mashed potatoes 124 F
Cauliflower 120 F
Ground meal texture:
Ground beef 123 F
Mashed potatoes 130 F
Pureed vegetables 120 F
Pureed meal texture:
Pureed beef 126 F
Mashed potatoes 130 F
Pureed vegetables 133 F
On 8/8/23 at 12:53 PM, the surveyor asked if the food and beverage temperatures were acceptable, and the FSD stated the only food that was acceptable for temperature to serve was the alternative chicken breast and the milks for beverages. The surveyor asked if the chicken was below the 145 F that the FSD stated was for hot food, how was that acceptable, and the FSD stated the temperature could be less and she would let the surveyor know the minimum temperature.
On 8/8/23 at 12:55 PM, the surveyor interviewed Resident #122 who received the regular meal of penne pasta with meat sauce with mixed vegetables and a chicken pot pie. Resident #122 informed the surveyor that the food was served warm but not hot, and the food would be better if it was hot.
On 8/9/23 at 11:06 AM, the FSD informed the surveyor that hot food should be a minimum of 135 F and not the 145 F as stated yesterday, so the chicken was the only hot food item above 135 F. The FSD also provided a copy of the facility's Food Temperature policy which indicated the same.
A review of the facility's undated Food Temperature policy included .all hot food items must be cooked to the appropriate internal temperatures, held and served at temperatures of at least 135 F and all cold food items must be stored and served at a temperature of 41 F or below.
A review of the undated facility provided Handling Cold Foods for Trayline policy included cold food items (such as canned fruits, desserts, salads, puddings, cottage cheese, juice, milk) will be placed in the refrigerator at least three to four hours before serving. Food should be chilled to 41 F or less .at the time of service .cold food temperatures will be taken and recorded prior and halfway through service to assure foods are 41 F or below.
NJAC 8:39-17.4(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) maintain, store, and hold potentially hazardous foods in acceptable temperatures to prevent food-borne illness; b.) maintain multi-use food-contact surfaces in a manner to prevent bacterial growth; c.) maintain kitchen equipment in a sanitary manner; d.) store potentially hazardous foods to prevent food-borne illness; and e.) maintain handwashing sinks to ensure appropriate infection control practices.
This deficient practice was evidenced by the following:
On 8/3/23 at 9:12 AM, the surveyor entered the kitchen and requested to wash their hands in the kitchen's handwashing sink. The Food Service Director (FSD) showed the surveyor the handwashing sink, and the surveyor proceeded to turn on the hot water handle, but the water came out in drops only. The surveyor then proceeded to turn on the cold water handle, and the water came out in a steady flow. The surveyor asked the FSD if there was another handwashing sink in the kitchen, and the FSD replied no. The surveyor asked how kitchen staff washed their hands without hot water, and the FSD stated that the staff could wash their hands in the bathroom and then sanitize their hands. The surveyor asked if hand sanitizer was an acceptable hand hygiene practice to use in the kitchen, and the FSD responded no. The FSD informed the surveyor that the sink was just fixed last week, so it must have just stopped working now, and that maintenance was unaware there was no hot water.
On 8/3/23 at 9:20 AM, the surveyor in the presence of the FSD calibrated a thin probed digital thermometer in an ice bath to 32 degrees Fahrenheit (F). The surveyor then obtained a water temperature from the handwashing sink which was 79 F. At this time, the FSD confirmed 79 F was not an acceptable temperature for handwashing, and they would find out what the acceptable temperature was to wash hands in the kitchen.
On 8/3/23 at 9:30 AM, the surveyor in the presence of the FSD toured the kitchen and observed the following:
1.) On a spice rack, one opened thirty-two ounce (32 oz) lemon juice container labeled opened 7/9/23, and use by 8/9/23. The packaging indicated refrigerate after opening.
2.) On the meal tray line steam table, an attached long white cutting board. The cutting board was deeply pitted and discolored black and brownish. The FSD confirmed the kitchen should not be using the cutting board; it could cause contamination and bacterial growth.
3.) Under the steam table, two covered white plastic bins with lids that contained serving utensils. The outside of the bins and lids were soiled with debris and stained with a brownish color dried substance. The FSD confirmed the bins should be cleaned.
4.) Behind the convection ovens and between the stove, a buildup of a black substance and loose debris on the floors, and the tiling on the wall behind was stained with brownish drip patterns. The FSD confirmed the floor and tile walls needed to be cleaned; that staff cleaned once a week.
5.) On a drying rack, two small green, one medium, one small white, and one large white cutting boards all pitted and discolored black and brownish. The large white cutting board was also melted. The FSD confirmed the cutting boards should not be in use.
6.) In the walk-in refrigerator, the surveyor observed a plastic bus bin which contained a variety of approximately 30 resident milk cartons. The surveyor felt the milk cartons that were warm to touch. Using the calibrated thermometer, the surveyor obtained the following temperatures: 8 oz fat free milk 55 F; 4 oz whole milk 50 F; and 8 oz lactose free milk 50 F. The ambient temperature of the back of the walk-in refrigerator was 40 F. At this time, the FSD stated that the milk should be at 41 F or below.
7.) In a storage area outside the main kitchen, milk reach-in refrigerator box number one that was partially ajar. The ambient temperature was 50 F. The surveyor using the calibrated thermometer obtained the following temperatures: 8 oz fat free milk 55 F; 4 oz whole milk 58 F; and 4 oz fat free milk 53 F.
8.) In a storage area outside the main kitchen, milk reach-in refrigerator box number two, the ambient temperature was 50 F. The surveyor using the calibrated thermometer obtained a temperature of an 8 oz whole milk that was 45 F.
9.) In the Indian cultural reach-in freezer chest, an accumulation of ice. The FSD confirmed it should not have ice accumulation.
10.) In the ice cream freezer chest, ice accumulation. The FSD confirmed it should not be there.
11.) In a storage area outside the main kitchen area on a storage rack, one small red, two small white, and one small blue cutting boards that were pitted and discolored. The FSD confirmed they should not be used.
On 8/3/23 at 10:00 AM, the surveyor and FSD toured the Indian cultural kitchen and observed in a cabinet, a spice container labeled [NAME] soda and another spice container labeled black salt. Both containers had spoons stored directly inside. The FSD confirmed spoons and scoops should not be left inside spices.
On 8/3/23 at 10:10 AM, the surveyor interviewed the Maintenance Director (MD) who stated he was now aware that the hot water for the handwashing sink was not working; someone had fixed the sink last week, and the hot water valve was shut off and not turned back on. The MD acknowledged that 79 F was not an acceptable temperature to wash your hands in the kitchen.
On 8/3/23 at 11:58 AM, the surveyor re-interviewed the MD who stated the sink was still not fixed; that last week the FSD informed him in passing that the sink was dripping so one of his maintenance workers replaced the sink and had to shut off the valve. The MD stated the hot water valve was stuck in the off position, and not turned back on, so the valve needed to be replaced. The MD stated the maintenance department fixed the sink so there was no work order or invoice as to when the sink was replaced.
On 8/8/23 at 1:01 PM, the MD informed the surveyor that the kitchen handwashing sink was now fixed. The MD confirmed the hot water valve was stuck in the off position, and acknowledged he would have expected staff to have informed him that there was no hot water.
On 8/3/23 at 1:15 PM, the surveyor in the presence of the FSD calibrated a digital thin probed thermometer in an ice bath to 32 F.
On 8/8/23 at 1:18 PM, the surveyor accompanied by the FSD went into the walk-in refrigerator and using the calibrated thermometer obtained the following resident milk carton temperatures:
8 oz fat free milk 56 F
4 oz fat free milk 54 F
8 oz fat free lactose milk 53 F
8 oz reduced fat free milk 51 F
4 oz whole milk 54 F
8 oz whole milk 54 F
On 8/3/23 at 1:22 PM, the surveyor observed milk reach-in refrigerator box number one was turned off. The FSD stated that the refrigerator was not operating properly, so the kitchen transferred the milk to the walk-in refrigerator. The FSD acknowledged that the milk temperatures were still not an acceptable temperature, and stated the milk was only delivered that morning. The surveyor asked the FSD if they accepted deliveries on food and milk that were not at 41 F or below, and the FSD stated no. The surveyor then asked the FSD if the kitchen staff took temperatures of cold food and beverages when delivered, and the FSD responded no. The FSD acknowledged that the milk was above 41 F for at least four hours and needed to be discarded now.
On 8/3/23 at 8:56 AM, the FSD informed the surveyor that new milk was delivered an hour ago at a receiving temperature of 35 F.
On 8/3/23 at 12:57 PM, the FSD provided the surveyor with a document titled Proper Handwashing Fact Sheet, which included to wet your hands with running water as hot as you can comfortably stand (at least 100 F). The FSD confirmed the hot water should have been at least 100 F.
On 8/8/23 at 11:07 AM, the surveyor informed the FSD they wanted to observe lunch meal temperatures including the tray line. The surveyor asked the FSD what the minimum temperature hot food and the maximum temperature cold food should be. The FSD stated hot food should be at 145 F (the FSD later informed 135 F) and cold food should be 41 F or below. At this time, the FSD calibrated two thin probed digital thermometers to 32 F in an ice bath.
On 8/8/23 at 11:15 AM, the surveyor observed the [NAME] obtain the food and beverage temperatures from the lunch tray line. The following hot foods were below 135 F, and the following cold food and beverage was above 41 F:
Penne Pasta 132 F
Garlic Bread 124 F
Yogurt 46 F
Vanilla pudding 57 F; the FSD stated it was pre-portioned and placed in the refrigerator yesterday.
Mandarin oranges 54 F; the FSD stated it was pre-portioned and placed in the refrigerator yesterday.
Ham and cheese sandwich 53 F; the FSD stated it was made around 8:00 AM and placed in the refrigerator. The surveyor observed the reach-in tray line refrigerator the sandwich was held in was at 45 F.
Orange juice 56 F
Apple juice 54 F
Nutritional health shake 54 F
At this time, the surveyor did not observe any kitchen staff attempt to heat any food that was below 135 F or cool down any cold food or beverage that was above 41 F prior to meal service.
On 8/9/23 at 11:06 AM, the FSD informed the surveyor that hot food should be maintained at 135 F or above and provided the facility's undated Food Temperature policy which indicated the same.
A review of the undated facility provided Food Temperature policy included .all hot food items must be cooked to the appropriate internal temperatures, held and served at temperatures of at least 135 F. The Food Temperature policy further indicated, All cold food items must be stored and served at a temperature of 41 F or below.
A review of the undated facility provided Handling Cold Foods for Trayline policy included cold food items (such as canned fruits, desserts, salads, puddings, cottage cheese, juice, milk) will be placed in the refrigerator at least three to four hours before serving. Food should be chilled to 41 F or less .at the time of service .cold food temperatures will be taken and recorded prior and halfway through service to assure foods are 41 F or below.
A review of the undated facility provided General Sanitation of Kitchen policy included food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule .
A review of the undated facility provided Food Storage policy included .scoops must be provided for bulk foods (such as sugar, flour, and spices). Scoops are not to be stored in food or ice containers, but are kept covered in a protected area near the containers .perishable foods such as meat, poultry, fish, dairy products, fruits, vegetables and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality. Refrigerator temperatures should be thermostatically controlled to maintain food temperatures at or below 41 F .Time/Temperature Control for Safety [TCS] foods must be maintained at or below 41 F .refrigerated foods should be stored upon delivery .
A review of the undated facility provided Receivable and Storage Policy included upon delivery, all foods will be checked to ensure packaging is intact and marked off against the packaging slip. Check for signs or thawing and refreezing on perishable food items .immediately after delivery, store all refrigerated and frozen foods first, with-in the hour. Check temperatures to ensure that all frozen foods are frozen and all refrigerated foods are 40 F or lower.
NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 8/2/23 at 11:29 AM, the surveyor observed Resident #117 in bed with his/her eyes open. The resident did not respond to the surveyor.
The surveyor reviewed the medical record for Resident #117.
A review of the resident's admission Record face sheet (admission summary) reflected that the resident was admitted to the facility in January 2019 and readmitted in June 2023 with diagnoses that included but were not limited to stage 3 sacral ulcer, tracheostomy, diabetes mellitus, dementia, aphasia (inability to speak), and cerebral infarction (stroke).
A review of the quarterly MDS dated [DATE], reflected the resident had severely impaired cognition. The MDS further indicated that Resident #117 was dependent on staff for activities of daily living, and had a range of motion impairment on both sides of the upper and lower extremities. A further review of the resident's MDS, Section M - Skin Conditions indicated the resident had one Stage 3 pressure ulcer (a bed sore with full thickness breakdown of tissue down to the fatty layer under the skin).
A review of the August 2023 Order Summary Report which was transcribed onto the Treatment Administration Record (TAR) included a physician's order (PO) dated 8/2/23, to cleanse the wound with Normal Saline (NSS); apply Silvadene Cream (antimicrobial cream used to prevent and treat wound infections); calcium alginate (absorbs fluid from wounds); and cover with a dry dressing two times a day and when needed for wound care.
On 8/4/23 at 11:24 AM, the surveyor observed the LPN perform a wound treatment to Resident #117's sacrum, while the CNA assisted with the positioning of Resident # 117. The LPN disinfected the over-bed table (OBT) with bleach wipes and then applied a clean barrier.
The LPN applied soap to her hands and immediately put them under running water without lathering or applying friction. She then assembled the needed supplies from the treatment cart and placed them on the OBT in the resident's room. Among the supplies was a tube of silvadene ointment, calcium alginate, 4 x 4 gauze sponges, 4 x 4 dressing, a bottle of normal saline solution, an applicator and a pair of scissors.
The LPN provided the treatment to Resident # 117's sacrum per the physician's orders. The LPN applied soap to her hands and immediately put them under running water for 18 seconds without lathering or applying friction. The LPN donned a disposable gown, face shield, and gloves. During the treatment, the LPN cleansed the wound with normal saline solution (NSS) then dried the wound using a 4 x 4 gauze pad, doffed the soiled gloves, and without performing hand hygiene donned a new pair of gloves. The LPN opened and cut the calcium alginate dressing, applied the silvadene ointment to the applicator, and applied the ointment to the wound while the LPN held the tube of silvadene ointment in her left hand which was touching the resident's bare skin.
On 8/4/23, at the same time the LPN reached into her pocket with the same gloved hands and removed a marker and a cell phone. The LPN dated and initialed the 4 x 4 dressing and then put the marker back into her pocket and left the cell phone on the OBT. The LPN removed her gloves and donned a new pair without washing or sanitizing her hands. The LPN applied the calcium alginate and applied the 4 x 4 dressing to the wound. The LPN gathered all of the supplies and with the same gloves, opened the treatment cart and placed the tube of silvadene cream, opened calcium alginate dressing , package of 4x4 gauze and NSS back into the treatment cart. The LPN removed her gloves and gown, discarded them in the trash, and removed the trash from the resident's room. The LPN did not sanitize her hands or sanitize the OBT before leaving the resident's room.
On 8/4/23 at 12:18 PM, the surveyor discussed the breaks in technique with the LPN. The LPN acknowledged she should have performed hand hygiene by first wetting her hands with water and then applying friction and lathering for at least 20 seconds. The LPN further stated that she should have cleansed or sanitized her hands each time she removed her gloves and before she donned a new pair of gloves. The LPN further acknowledged that she should not have opened the treatment cart with soiled gloves and should not have returned the supplies to the treatment cart.
A review of the facility's Handwashing/ Hand Hygiene policy, undated included . hand hygiene is the primary means to prevent the spread of infections .all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .employees must wash their hands for forty to sixty seconds using antimicrobial of non-microbial soap and water .before and after direct contact with residents .after removing gloves .before donning sterile gloves, before performing any non-surgical invasive procedures .before handling clean or soiled dressings, gauze pads. Hand hygiene is always the final step after removing and disposing of personal protective equipment.
A review of the facility's Wound Care policy, updated May 28, 2015, included .wipe reusable supplies as indicated (outsides of containers that were touched by unclean hands) .take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart.
On 8/8/23 at 12:52 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), DON, and ADON and discussed the concerns observed during the wound treatment. The DON acknowledged that the LPN should have performed hand hygiene using acceptable techniques including each time she removed her soiled gloves and before putting on new gloves. The DON stated that the entire process should take between 40 - 60 seconds. The DON further stated that the LPN should only have brought the supplies she was going to use into the resident's room.
Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) implement Transmission Based Precautions for a resident with a multidrug-resistant organism (MDRO) infection for 1 of 3 residents, (Resident #133) reviewed for antibiotic use, b.) provide appropriate infection control practices to prevent the spread of infection during one of one wound care treatment observation for, (Resident #117), and c.) follow appropriate infection control practices and perform hand hygiene as indicated during dining observations on 1 of 4 nursing units, (Willow Unit) for, (Resident #8, #19, #29, #115, #138 and #167).
The deficient practice was evidenced by the following:
1.) On 08/02/23 at 10:42 AM, the surveyor observed Resident #133 sitting in a chair in his/her room. The resident stated that he/she had an infection, but was unsure where. The surveyor observed that the entrance to the resident's room did not include any signage for Transmission Based Precautions (TBP) or any supply of personal protective equipment (PPE).
The surveyor reviewed the medical record for Resident #133.
According to the admission Record, Resident #133 had diagnoses which included, but were not limited to, chronic kidney disease, end stage renal disease, and retention of urine.
Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/12/23, included the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident was occasionally incontinent of bladder.
Review of a Progress Note written by the Nurse Practitioner (NP) dated 07/27/23 at 1:11 PM, revealed the resident reports of pain during urination, and a urinary analysis with culture and sensitivity (UA C&S) lab test was ordered.
Review of the UA C&S lab result revealed the lab received the urine sample on 07/28/23 at 8:25 AM and reported the results to the facility on [DATE] at 11:25 AM. The results were flagged as abnormal and indicated the urine contained the bacteria E. Coli and was Extended Spectrum Beta Lactamase (ESBL) positive, a MDRO. Further review of the UA C&S revealed, contact precautions indicated, and, after multiple attempts, unable to reach nurse, faxed to client 7/30.
Review of a Progress Note written by the NP, dated 07/31/23 at 2:11 PM, revealed the NP ordered Bactrim DS (an antibiotic) for ten days for cystitis (bladder infection), but did not include TBP.
Review of the Order Summary Report, as of 08/03/23, did not include a physician's order for TBP.
Review of the Care Plan, dated 08/03/23, included a focus of, I am on Bactrim DS antibiotic therapy for my UTI. The care plan did not include TBP.
During an interview with the surveyor on 08/04/23 at 10:42 AM, the Certified Nursing Aide (CNA) stated Resident #133 was continent of bladder and used the toilet. The CNA further stated the resident was not on TBP. When asked how the CNA would know which residents were on TBP, the CNA stated she would receive that information in report, there would be a sign on the resident's doorway, and PPE supplies would be outside of the resident's room.
During an interview with the surveyor on 08/04/23 at 10:46 AM, the Licensed Practical Nurse (LPN) stated Resident #133 was continent of bladder and used the toilet. The LPN further stated the resident started an antibiotic for UTI (urinary tract infection) three days prior but was not on TBP. When asked how the LPN would know which residents were on TBP, the LPN stated the Infection Preventionist (IP) would notify staff and place a sign on the resident's doorway and PPE supplies outside of the resident's room. The LPN also stated it was important that staff follow TBP to prevent the spread of infection.
During an interview with the surveyor on 08/04/23 at 10:51 AM, Licensed Prcatical Nurse/Unit Manager (LPN/UM) stated Resident #133 was continent of bladder and used the toilet. The LPN/UM further stated the resident had complained of burning during urination and was prescribed an antibiotic for a UTI. The LPN/UM further stated that the resident was not on TBP because the UA C&S result showed E. Coli, and not a MDRO (multi-drug resistant organism, bacteria that resist treatment with more than one antibiotic). The LPN/UM explained that if a resident had a MDRO infection, the resident would be placed on contact precautions which was indicated by a sign on the resident's doorway. The LPN/UM also stated that it is important for staff to wear PPE for residents on TBP to protect the staff and residents from infection.
During an interview with the surveyor on 08/04/23 at 11:47 AM, the Licensed Practical Nurse/Infection Preventionist (LPN/IP) stated that residents with a suspected UTI were evaluated by the physician or NP and a UA C&S was ordered. When the UA C&S results were received, the IP would review the results and initiate TBP if indicated. The LPN/IP explained that residents with a MDRO infection would be placed on contact precautions, would have an isolation sign on their doorway, and a yellow apron hung on the door that contained the PPE needed for the resident's care. When asked about Resident #133's UA C&S results, the LPN/IP stated she was just notified by the Assistant Director of Nursing (ADON) that the resident had a UTI with ESBL. The LPN/IP further stated that the LPN/UM should have notified the LPN/IP on 07/30/23 when the UA C&S results were received, so contact precautions could have been initiated for the resident.
During a follow-up interview with the surveyor on 08/04/23 at 12:10 PM, the LPN/UM stated Resident #133's UA C&S results showed E. Coli with ESBL and that the resident should have been placed on contact precautions as soon as the results were received by the facility. The LPN/UM further stated that she had received verbal report of the UA C&S results, but was not told it was ESBL positive. The LPN/UM added that she should have reviewed the UA C&S results herself and that the ESBL positive portion of the lab result was missed by facility staff. When asked who reviewed the lab results, the LPN/UM stated there was always a nursing supervisor in the facility who could review the results and initiate the TBP.
During an interview with the surveyor on 08/04/23 at 12:25 PM, the (Director of Nursing (DON) stated that if a lab result included a MDRO, the nurse should call the physician for orders and initiate TBP. The DON further stated that staff knew which residents were on TBP because there was a sign posted on the resident's doorway and a yellow apron containing PPE on the door. The DON explained that staff should wear a gown and gloves when providing care to prevent the spread of infection. The DON then acknowledged that TBP should have been initiated on 07/30/23 for Resident #133 when the facility received the UA C&S report which indicated ESBL positive bacteria.
Review of the facility's Multidrug-Resistant Organisms policy, undated, included, The staff and practitioner will evaluate each individual known or suspected to have infection or colonization with a multidrug-resistant organism for room placement and initiation of Contact Precautions on a case-by-case basis, and, Should a resident be placed on Contact Precautions implement the following: Consult appropriate isolation policy . Have supply of gowns readily available . Place facility-specific signs/stickers on the door and on the chart. Further review of the policy included, Notify physicians and other healthcare personnel who provide care for the resident that the resident is colonized/infected with a multidrug-resistant organism.
Review of the facility's Isolation - Categories of Transmission-Based Precautions policy, undated, included under the Contact Precautions section, In a addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment.
Review of the facility's Infections - Clinical Protocol policy, undated, included, The nurse will notify the physician of the findings, including all pertinent details about the resident's condition, not just the temperature or lab test results, and, The physician and staff will identify individuals with infections that may represent infection transmission risks and (in conjunction with the infection control coordinator) will implement relevant precautions.
3.) On 08/02/23 at 12:41 PM, the surveyor observed the CNA on the [NAME] unit approach the food cart, remove a tray from the cart and place the tray it in front of Resident #19, who was seated in the main dining area. The surveyor further observed the CNA return to the food cart, remove another tray and place it on the bedside table (BST) in Resident #138's room.
The CNA then returned to the dining area and used her hands to remove four milk containers from an ice filled bin. She then placed the milk containers on trays which were in the food cart. Next the CNA was observed removing a tray from the cart and placed it on the BST in Resident #115's room. She removed the plastic food lid, and return to the dining area where she placed the plastic lid on a table with other lids.
The CNA then returned to the food cart, removed another food tray and placed the tray of food in front of Resident #29, who was seated in the dining area. The CNA removed the plastic food lid from the tray, opened two milk containers, removed the foil lid from a juice container, opened the plastic ware and placed a spoon in a cup. She further removed the lid from the yogurt, removed the lid from the cup of grapes, then went to another table that contained a pitcher filled with liquid and a stack of cups. The CNA then obtained a plastic cup, returned to Resident #29, poured a container of milk into the cup and placed it in front of the resident who then picked up the cup of milk and drank from it. The CNA then touched the handle of the resident's wheelchair and went directly to the food cart and removed a tray that she placed in front of Resident #167.
The surveyor further observed the CNA remove the plastic food lid from Resident #167's tray, remove the lid from the soup, pour the soup over the rice, open the plastic ware and place a spoon in the rice. The CNA then removed the lid from the yogurt, removed the lid from the pudding, and moved the tray closer to the resident.
The CNA then went directly to the food cart and removed a tray which she placed on the BST in Resident #8's room. She removed the plastic food lid, touched the resident's leg and hand and assisted the resident to sit on the edge of the bed. She then moved the BST closer to the resident, removed the lid from the soup, opened the plastic ware, moved the wheelchair closer to the wall, opened a clothing protector, placed the clothing protector on the resident, and carried the tray lid from the room.
In the dining area, the CNA picked up an empty plastic baggie from the floor and went to speak with another resident in the dining area where she touched the tray lid that was sitting on the resident's table. No hand hygiene (HH) was observed during these observations.
On 08/02/23 at 12:49 PM, the surveyor interviewed the CNA who stated that it was the CNA's and the nurse's responsibility to pass the meal trays. She stated that before the trays were touched, when food was touched and when the resident was fed that her hands were washed with soap and water and that HH was performed between each resident. The surveyor informed the CNA of the tray pass observation. The CNA stated that no HH needed to be performed when delivering trays or when food was opened. She stated that if she touched dirty stuff such as something sticky on the table, that then she would then have washed her hands. When the surveyor inquired as to whether HH should have been done during the meal tray pass, the CNA acknowledged that she should have performed HH and stated she forgot. She stated that it was important for infection control to perform HH between each resident and any time she touched the resident or their food tray.
On 08/07/23 at 10:34 AM, the surveyor interviewed the LPN who stated that the CNA was responsible for distributing the meal trays to the residents and that HH was performed when a resident was fed, touched, between residents, when items near the resident were touched and upon exiting the resident's room. The surveyor informed the LPN of the meal tray pass observation from 08/02/23 and she acknowledged that the CNA did not perform HH correctly. The LPN stated that it was important to perform HH correctly, so germs were not transferred between residents.
On 08/07/23 at 10:44 AM, the surveyor interviewed the LPN/UM, who stated that prior to the meal tray pass that resident's hands were wiped with sanitizing wipes and that staff washed their hands with soap and water. The LPN/UM stated that once anything was opened on the resident's tray that HH was performed before going to the next tray. The surveyor informed the LPN/UM of the meal tray pass observation from 08/02/23 and she acknowledged that the CNA did not perform HH correctly. The LPN/UM stated that the CNA should have used hand sanitizer any time that she touched anything outside of the clean tray and that it was important to perform HH correctly for infection prevention.
On 08/08/23 at 10:33 AM, the surveyor interviewed the ADON who stated that during the meal tray pass, staff performed HH if the resident needed to be set up, if containers were opened, if food was cut, or if the BST needed to be moved closer to the resident. The surveyor informed the ADON of the meal tray pass observation from 08/02/23 and he acknowledged that the CNA did not perform HH correctly. The ADON stated that the CNA should have performed HH after she touched each tray, when she touched the wheelchair, when the resident was touched, and when she touched the trash on the floor. The ADON further stated that it was important to perform HH correctly during the meal tray pass for infection prevention.
On 08/08/23 at 10:44 AM, the surveyor interviewed the LPN/IP who stated that during the meal tray pass that staff washed their hands with soap and water before and after trays were passed, and that hand sanitizer was used between residents. The surveyor informed the LPN/IP of the meal tray pass observation from 08/02/23 and she acknowledged that the CNA did not perform HH correctly. The LPN/IP stated that the CNA should have performed HH when she touched each tray, after she touched the wheelchair, after touching the resident and after picking up the trash from the floor. The LPN/IP further stated that it was important to perform HH correctly, so germs were not spread.
On 08/08/23 at 10:54 AM, the surveyor interviewed the DON who stated that staff washed their hands prior to passing the meal trays, if food items were opened, or any other items were touched. The surveyor informed the DON of the meal tray pass observation on 08/02/23 and she acknowledged that the CNA did not perform HH correctly. The DON stated that the CNA should have performed HH after opening any food item, when she touched the wheelchair, when she picked the trash from the floor, when she obtained the cup, and when she touched the resident. The DON further stated that it was important to perform HH correctly during the meal tray pass for infection prevention.
On 08/08/23 at 12:48 PM, the surveyors met with the LNHA who was made aware of the meal tray pass observation from 08/02/23.
A review of the undated facility policy, Handwashing/Hand Hygiene, revealed, Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Employees must wash their hands for forty (40) to sixty (60) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents, e. After handling items potentially contaminated with blood, body fluids, or secretions. 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub .for all the following situations: a. Before and after direct contact with residents, g. After contact with a resident's intact skin, i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.
A review of the facility documentation, In Service and Continuing Education, Topic: hand hygiene prior to serving food and handling trays, dated 07/07/23, revealed CNA #1's signature confirming attendance.
A review of the facility documentation, In Service and Continuing Education, Topic: handwashing, dated 02/21/23, revealed CNA #1's signature confirming attendance.
NJAC 8:39-19.4 (m)(n); 27.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) appropriately discard unused medication and b.) properly label and date medication in accordance with manufacturer recommendations for medications being stored in 1 of 2 medication storage rooms inspected (Cedar unit medication room).
This deficient practice was evidenced by the following:
1.) On 8/3/23 at 9:15 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN) in the room of Resident #145. The surveyor observed the LPN informing Resident #145 that she would be administering the resident's medications. The surveyor observed that the resident was in their bed and just finished eating breakfast.
On 07/12/23 at 9:20 AM, the surveyor observed the LPN preparing to administer seven medications to Resident #145 which included: Losartan/Hydrochlorothiazide (medication for lowering blood pressure), Potassium Chloride 20 MEQ ER tablet (potassium supplement), Furosemide 20 mg tablet (medication for lowering blood pressure), Norvasc 10 mg tablet (medication for lowering blood pressure), Enteric Coated Aspirin 81 mg (medication used for treating coronary artery disease), Namenda 5 mg (medication used for treating dementia), and Plavix 75 mg (medication used for treating coronary artery disease). The surveyor observed the LPN prepared the resident's medication and place them inside a medication cup with apple sauce. During the administration of the resident's medications, the surveyor observed Resident #145 spit out the medications. Resident #145 refused being administered the medications. The surveyor observed the LPN sign the Electronic Medication Administration Record (EMAR) which indicated the medications were not administered, and the resident refused.
At that time, the surveyor asked the LPN how she was going to destroy the medications. The LPN stated that she had no drug buster inside her medication cart and that she would bring the medications to her Registered Nurse/Unit Manger (RN/UM). The surveyor followed the LPN to the nursing station and then followed her to the medication room. The LPN was observed looking around the medication room and then she left. The surveyor then observed the LPN hand the medications to the RN/UM. The medications were observed whole, mixed with apple sauce and were inside the medication cup.
On 08/03/23 at 9:40 AM, the surveyor interviewed the LPN and the RN/UM regarding the process of destroying unused medications. The RN/UM stated that controlled medications were brought to the Director of Nursing (DON) and the destruction of the medications were observed with a license nurse. The RN/UM further told the surveyor that non-controlled medications could be crushed and thrown into the garbage.
On 08/03/23 at 9:45 AM, after surveyor inquiry the surveyor observed the RN/UM bring a pill buster (liquid container used for destroying medications) to the nursing area and destroy the unused medication.
On 8/3/23 at 11:45 AM, the surveyor interviewed the DON who stated that every nursing unit medication room should contain a pill buster and medication should be destroyed in the pill buster.
On 8/4/23 at 11:15 AM, the surveyor interviewed the Consultant Pharmacist (CP) over the telephone who stated that all prescription medications should be destroyed in a pill buster. The CP further stated that prescription medications should never be crush and thrown into the garbage.
On 8/04/23 at 1:45 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and DON. No further information was provided by the facility.
A review of the facility's undated policy for Discarding and Destroying Medications was provided by the DON. The policy indicated the following:
Policy: Medications that cannot be returned to the dispensing pharmacy (e.g., non-unit-dose medications, medications refused by the resident, and/or medications left by residents upon discharge) shall be destroyed
3. Schedule II, III, and controlled drugs must be destroyed by the Director of Nursing Services and another licensed nurse.
4. Ointments, creams, and other like substances may be discarded into the trash receptacle in the medication room.
5. Drug buster is used for other types of medications.
2.) On 8/8/23 at 12:14 PM, the surveyor in the presence of the LPN inspected the Cedar unit medication room refrigerator. The surveyor observed two opened and undated multi-dose bottles of Lorazepam 2 milligrams per 1 milliliter (mg/ml) concentrated oral solution in active inventory. The prescription label as well as the product label instructed, Discard opened bottle after 90 days. The LPN acknowledged that neither the medication bottle nor the medication box had been dated when opened and should have been.
On 8/8/23 at 12:29 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) for the Cedar unit. Together the surveyor and the LPN/UM reviewed the findings of the Cedar unit medication room refrigerator. The LPN/UM acknowledged there was no date on the multi-dose Lorazepam bottles as to when the bottles were opened. The LPN/UM also acknowledged the manufacturer label which indicated short dating, and to discard the opened medication bottle 90 days after being opened. The LPN/UM further stated that if the medication bottle was not dated then the expiration date could not be calculated properly.
On 8/9/23 at 12:46 PM, the surveyor interviewed the DON and together they reviewed the findings of the inspection of the Cedar unit medication storage room. The DON stated the Lorazepam concentrated oral solution should have been dated when it was opened. The DON acknowledged the short dating for Lorazepam concentrated oral solution, that opened multi-dose bottles must be discarded after 90 days.
A review of the facility undated Administering Medications policy included .7 . When opening a multi-dose container, place the date on the container.
A review of the facility undated Controlled Substances policy included . the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of schedule II and other controlled substances .
NJAC 8:39-29.4 (a) (d) (h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ#: 151826
Based on observation, interview, and review of pertinent facility documentation, it was identified that the facility failed to provide the residents with a safe, comfortable, clean, homelike environment. This deficient practice was identified on 4 of 4 nursing units, (Oak, Willow, Cedar, and Maple) and in 2 of 36 resident rooms, (Resident #112 & Resident #190) reviewed for residing in a clean, comfortable, homelike environment.
This deficient practice was evidenced by the following:
On 08/03/23 at 10:46 AM, the surveyor started the environmental tour on the [NAME] unit. Between rooms [ROOM NUMBERS], the surveyor observed a long, black in color indentation and scratch mark along the wall. There was an area to the left of the television screen on the wall where the peach-colored paint was peeling. Exposing green colored paint underneath. [NAME] colored paint was further observed above the television.
At 10:48 AM, the surveyor observed to the right of room [ROOM NUMBER] above the floorboard a hole in the wall exposing white spackle and debris.
At 10:51 AM, the surveyor observed peach-colored paint chipping above the handrail between rooms [ROOM NUMBERS].
At 10:52 AM, the surveyor observed inside Resident #190's room, holes, and indentations in the baseboard. The alert and oriented resident stated that the baseboard in the room, could use some patching up.
At 11:07 AM, the surveyor observed between rooms [ROOM NUMBERS], above and to the left of the computer mounted on the wall peach-colored paint peeling, exposing green paint underneath.
At 11:09 AM, the surveyor observed above the medical records sign, across from room [ROOM NUMBER] paint on the wall which was peeling off. Underneath the paint exposed indentations of brown cardboard like material, surrounded by white spackle. The surveyor further observed the peach-colored paint peeling with green paint exposed underneath.
At 11:13 AM, the surveyor observed underneath the supply room sign on the [NAME] unit, holes, indentations in the wall, and peeling paint.
At 11:14 AM, the surveyor observed between rooms [ROOM NUMBERS] black and brown colored stains throughout the tile floor.
At 11:16 AM, the surveyor observed black and brown stains on the tile floor between rooms [ROOM NUMBERS].
At 11:16 AM, the surveyor further observed outside room [ROOM NUMBER], next to the plaque presenting the room number and resident names, peach-colored paint peeling and ripping off the wall which exposed green and white paint.
At 11:18 AM, the surveyor observed between rooms [ROOM NUMBERS], black and brown discoloration on the tile floor by the wall.
At 11:19 AM, the surveyor observed between room [ROOM NUMBER] and 248, black, brown, and yellow discoloration on the tile floor by the wall.
At 11:20 AM, the surveyor observed between rooms [ROOM NUMBERS], scuff marks and black and brown discoloration on the tile floor by the wall.
At 11:22 AM, the surveyor observed between rooms [ROOM NUMBERS], black and brown discoloration on the tile floor by the wall. At that time, the surveyor further observed that the brown baseboard between rooms [ROOM NUMBERS] had scratches and indentations throughout, exposing a lighter colored wood.
At 11:25 AM, the surveyor observed 21 square tables in the main open area on the [NAME] unit. 15 of the 21 square tables were observed to have a brownish colored material caked onto the bottom base of the table. There were residents seated at these tables.
At 11:29 AM, the surveyor attempted to conduct an interview with the housekeeping staff member who was working on the [NAME] unit. The housekeeper was unable to conduct an interview due to English as a second language.
On 08/03/23 11:37 AM, the surveyor toured Cedar unit and observed brownish colored splatter on the metal plate at the bottom of the stairwell door.
At 11:38 AM, the surveyor observed between rooms [ROOM NUMBERS] scratches and indentations in the paint on the bottom portion of the wall. At that time, the surveyor further observed brownish-orange colored splatter throughout the wall.
At 11:40 AM, the surveyor observed between rooms [ROOM NUMBERS] brownish-orange splatter on the bottom portion of the wall.
At 11:42 AM, the surveyor observed between rooms [ROOM NUMBERS] scratches and indentations in the paint on the bottom portion of the wall. The surveyor further observed black discolorations on the beige painted wall.
At 11:45 AM, on the Cedar unit the surveyor observed to the left of the plaque for room [ROOM NUMBER], brownish colored splatter on the wallpaper.
At 11:46 AM, the surveyor observed on the wall in front of the door frame outside of room [ROOM NUMBER], brownish colored stains on the walls.
On 08/03/23 at 12:12 PM, the surveyor began an environmental tour on the Oak unit and observed that the brown covering on the handrail between rooms [ROOM NUMBERS] was peeling at the edges on the left-hand side.
At 12:20 PM, the surveyor toured the Maple unit and observed between rooms [ROOM NUMBERS] that the wall underneath the grab bar had white indentations throughout and brownish colored stains on the yellow paint.
At 12:27 PM, the surveyor observed between rooms [ROOM NUMBERS], multiple scratches and indentations in the wall underneath the grab bar. The paint on the wall was yellow and the surveyor observed white and black marks where the indentations existed.
At 12:29 PM, the surveyor observed between rooms [ROOM NUMBERS], multiple scratches in the wall underneath the grab bar. At that time, the surveyor further observed brown splatter on the wall. The paint on the wall was yellow in color and the surveyor observed white and black marks where the indentations existed.
At 12:31 PM, the surveyor observed between rooms [ROOM NUMBERS], black colored scratch marks throughout the wall underneath the grab bar.
On 08/07/23 at 10:25 AM, the surveyor entered Resident 112's room and observed a large horizontal indentation in the wall in front of the door bed. The indentation in the wall revealed black and white indentations of color that extended throughout the length of the wall. The surveyor further observed a crack, exposing a hole in the wall by the floorboard. The ceiling tile above the resident's bed toward the bathroom was observed discolored brown throughout. Behind the resident's bed, the surveyor observed paint peeling off the wall exposing white plaster. In addition, behind Resident 119's roommates' bed, there were dents in the wall which exposed white and black markings. At that time, the surveyor attempted to interview Resident #112, but the residents speech was garbled and unintelligible.
On 08/08/23 at 10:35 AM, the surveyor interviewed the facility's Maintenance Director (MD) who stated that painting the facility was an ongoing process. The MD added that he started working at the facility about a year a half ago and the first thing he noticed was the building needed to be painted. The MD stated that he noticed in June 2022 that the facility needed fresh coats of paint, so he started painting the doors and door frames. The MD explained that the next step was to paint the walls throughout the facility. The MD told the surveyor that during COVID he understood that you couldn't enter the resident's rooms, but the hallways should have been done to maintain the resident's environment and the facility staff, were definitely working on it. The MD explained that they had started on the third floor and the staff was working their way down through the building. The MD further stated that the facility had a staff member working two to three times a week from 4:00 PM to 7:00 PM to paint and he did the best that he could with the staff and the resources he had.
On 08/08/23 at 10:54 AM, the surveyor interviewed the Housekeeping Director (HD) who stated that all the housekeeping staff knew they were supposed to wash the floors. The HD stated, we are so far behind in terms of cleaning the floors. The HD told the surveyor that the facility was doing their best with the staff they had.
On 08/08/23 at 12:56 PM, the surveyor reviewed the above findings with the facility's Licensed Nursing Home Administrator (LNHA). The LNHA stated that a lot of the things had already been identified so the surveyor was not bringing anything knew to his attention and he was, well aware of the situation and was working on it. At that time the surveyor asked the LNHA how long ago he identified the issues? The LNHA told the surveyor that he started working at the facility January of 2022 had identified that things needed to be fixed and the facility was fixing things on an ongoing basis.
A review of the facility's undated Housekeeper Job Position indicated that the purpose of the housekeepers job position was, to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, and/or Director of Housekeeping, to assure that our facility is maintained in a clean, safe, and comfortable manner. The Housekeeper Job Description further indicated that the housekeeper was responsible for ensuring, that assigned work areas are maintained in a clean, comfortable, and attractive manner.
A review of the facility's undated Director of Housekeeping Job Position indicated that the purpose of the Director of Housekeeping Job was, to plan, organize, develop, and direct the overall operation of the Housekeeping Department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a clean, safe. And comfortable manner. The Director of Housekeeping's Job Position further indicated that the Director of Housekeeping's was responsible for ensuring, that the facility is maintained in a clean and safe manner for resident comfort and convenience.
A review of the facility's undated Maintenance Assistant Job Position indicated that the purpose of the Maintenance Assistants job position was, to maintain the grounds, facility, equipment in a safe and efficient manner in accordance with current applicable federal, state, and local standards, guidelines and regulations. The Maintenance Assistant Job Position further indicated that the Maintenance Assistant was responsible for maintaining the facility in good repair, ensuring a safe, clean and orderly environment.
A review of the facility's undated Maintenance Supervisor Job Position indicated, The primary purpose of your job position is to assist in supervising the day-to-day activities of the Maintenance Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Director of Maintenance, to assure that our facility is maintained in a safe and comfortable manner.
NJAC 8:39-31.2 (e), 31.4(a)(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ#: 154501
Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This deficient practice was identified for 5 of 39 residents, (Resident #45, #57, #58, #81, and #418) reviewed for the development and implementation of a comprehensive person-centered care plan and was evidenced by the following:
1.) On 8/2/23 at 11:08 AM, the surveyor observed Resident # 58 in bed. Resident #58 stated that they have been on peritoneal dialysis (PD) for four years and performed their PD daily. The PD supplies were observed in boxes in the resident's room.
The surveyor reviewed the medical records for Resident #58.
A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in May of 2022 with diagnoses which included diabetes (too much sugar in the blood), end-stage renal disease (loss of kidney function), peritoneal dialysis catheter (catheter in the abdomen used to remove excess fluid, correct electrolyte problems, and remove toxins).
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 7/25/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was cognitively intact.
A review of the Medication review order summary included a physician order dated 5/17/23, for PD total volume of 12,000 ml low calcium, 1.5% dextrose, run time of 12 hours starting on the evening shift.
A review of the August 2023 Medication Administration Record (MAR) reflected the above physician order and was documented as administered by a nurse.
A review of the individualized comprehensive care plan included a focused care plan for peritoneal dialysis that did not address the self-administration of the PD.
On 8/8/23 at 10:10 AM, the surveyor interviewed the 3:00 PM - 11:00 PM evening shift Registered Nurse Supervisor, who stated Resident #58 did their own PD in the evening. She stated that the resident should have a care plan that indicated the resident's self-administered PD.
On 8/8/23 at 10:15 AM. the surveyor interviewed the Unit Manager Registered Nurse (UM), who stated Resident #58 had a care plan for self-administration of PD. The UM reviewed the care plan in the presence of the surveyor and stated that the care plan did not address the resident's self-administered PD and the resident's care plan should have addressed that.
On 8/8/23 at 12:50 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the care plan not addressing the self-administration of the PD.
5.) The surveyor reviewed the closed medical record for Resident #418.
A review of the resident's admission Record (an admission summary) reflected that the resident was admitted to the facility in March of 2022 with diagnoses that included but were not limited to benign prostatic hyperplasia with lower urinary tract symptoms (a condition in men in which the prostate gland is enlarged and not cancerous that produces symptoms that feel like a urinary tract infection), unspecified symptoms and signs involving cognitive functions and awareness, other lack of coordination, and other abnormalities of gait and mobility.
A review of the resident's admission MDS dated [DATE], indicated that the resident's cognitive skills for daily decision making were moderately impaired. A further review of the resident's MDS, Section H - Bladder and Bowel reflected that the resident had an indwelling catheter (a flexible tube inserted into the bladder that drains urine).
A review of Resident 418's May 2022 Order Summary Report revealed a physician's order dated 03/27/22 for foley catheter care every shift.
A review of the resident's March 2022 Treatment Administration Record (TAR) reflected that the nurses were signing for foley catheter care and recording the amount of urine output from the foley catheter during the day (7:00 AM - 3:00 PM), evening (3:00 PM - 11:00 PM), and night (11:00 PM - 7:00 AM) shifts from 03/27/22 through 03/31/22.
A review of the resident's April 2022 TAR indicated that the nurses were signing for foley catheter care and recording the amount of urine output from the foley catheter during the day, evening, and night shifts from 04/01/22 through 04/30/22.
A review of the resident's May 2022 TAR indicated that the nurses were signing for foley catheter care and recording the amount of urine output from the foley catheter during the day, evening, and night shifts on 05/01/22.
A review of the resident's comprehensive person-centered care plan in its entirety did not reveal that the resident had a care plan in place for the care of his/her foley catheter.
On 08/04/23 at 12:07 PM, the surveyor interviewed the CNA who stated that if she was caring for a resident with a foley catheter, it would be her responsibility to change the indwelling urinary catheter drainage bag to a leg bag during the day. The CNA explained the process in which she would remove the indwelling urinary catheter drainage bag, empty the urine, wipe the indwelling catheter tubing with alcohol prior to placing a leg drainage bag on the resident, wash and clean the indwelling urinary catheter drainage bag, and store the indwelling catheter drainage bag in a closed system with a cap at the end of the tubing to prevent the spread of infection. The CNA further explained that the CNA caring for the resident at bedtime would remove the leg drainage bag, wipe the catheter tubing with alcohol, and place a clean drainage bag on the resident. The CNA told the surveyor that her responsibilities also included notifying the resident's nurse of the amount and urine emptied from the catheter bags during her shift.
On 08/04/23 at 12:14 PM, the surveyor interviewed the resident's LPN who stated that if a resident had a foley catheter she would make sure the site was clean and dry with no redness or odor. The LPN further stated that the foley catheter bag had to be stored below the level of the bladder and the color of the urine should be, straw yellow. The LPN told the surveyor that if a resident had a foley catheter, there should definitely be a care plan because it guided the care of the resident.
On 08/04/23 at 12:19 PM, the surveyor interviewed the Registered Nurse/Unit Manger (RN/UM) who stated that if the resident had a foley catheter there should be a care plan that reflected the care of the foley catheter. The RN/UM explained that upon admission, the evening supervisor and admitting nurse were responsible for creating the resident's care plan and then the unit manager of the unit was responsible for the oversite and additions of personalized care to the resident's care plan.
On 08/04/23 at 12:49 PM, the surveyor interviewed the DON who stated that a resident with a foley catheter should have a care plan for the care of the foley catheter.
A review of the facility's Care Plans - Comprehensive policy, undated, included the following:
3. Each resident's Comprehensive Care Plan has been designed to: .
d. Reflect treatment goals and objectives in measurable outcomes .
e. To attain or maintain the Resident's highest practical physical, mental psychosocial well being .
g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels .
h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program .
4. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS) .
5. Care plans are revised as changes in the resident's condition dictate
NJAC 8:39-11.2 (e) (f)
3.) On 08/02/23 at 10:16 AM, the surveyor observed Resident #45 lying in bed. The resident's right hand and right knee appeared to be contracted.
The surveyor reviewed Resident #45's medical record.
According to the admission Record, Resident #45 had diagnoses which included, but were not limited to, cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis on one side of the body), right wrist contracture, cognitive communication deficit, and unspecified dementia.
Review of the quarterly MDS dated [DATE], included the resident had a BIMS score of 5 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident had a functional limitation in range of motion (ROM) to one side of his/her upper and lower extremities.
Review of the Order Summary Report included a physician's order dated 04/21/23 to, Apply knee brace to right knee at all times when in bed.
Review of the Occupational Therapy (OT) Discharge summary, dated [DATE], included, Instructed nursing caregivers in proper body mechanics, safe transfer techniques, safety precautions and self care/skin checks in order to facilitate improved functional abilities with 100% carryover demonstrated by primary caregivers.
Review of the Physical Therapy (PT) Discharge summary, dated [DATE], included discharge recommendations for a right knee brace.
Review of the Care Plan included a focus of, I have an ADL [activities of daily living] self-care performance deficit r/t [related to] hemiparesis/hemiplegia secondary to cerebral infarction and DX [diagnosis] of dementia. Further review of the Care Plan did not include interventions related to the resident's right wrist contracture and right knee brace.
During an interview with the surveyor on 08/07/23 at 9:59 AM, the Director of Rehab (DOR) stated Resident #45 had a history of a stroke and was previously receiving PT and OT for ROM and contracture management. The DOR further stated the resident was recommended to wear a right knee brace while in bed and for staff to perform ROM exercises to the right wrist. The DOR explained that when the resident was discharged from PT and OT services, therapy educated the nursing staff on how to perform the ROM interventions. When asked about resident care plans, the DOR stated that while residents were receiving PT and OT services, the therapy department would create care plans relevant to the resident's treatment and that care plan would remain in place after the resident was discharge from therapy if the care was still applicable.
During an interview with the surveyor on 08/08/23 at 10:38 AM, Certified Nursing Assistant (CNA) stated that Resident #45 was paralyzed on the right side and had contractures to the right wrist and knee. The CNA further stated that he put the resident's right knee brace on while the resident was in bed and performed ROM exercises to the resident's right wrist to prevent stiffness in the joints.
During an interview with the surveyor on 08/08/23 at 11:35 AM, the LPN stated Resident #45 had contractures to the right wrist and knee. The LPN further stated that the CNA applied the resident's knee brace and performed ROM exercises to prevent worsening of the contractures. When asked about resident care plans, the LPN stated the nurses were responsible for updating resident care plans so that it included all of the resident's needs. The LPN stated Resident #45's contractures should have been included on the care plan in order to improve the care he/she received.
During an interview with the surveyor on 08/08/23 at 11:54 AM, the LPN/UM stated that residents with contractures were sometimes given devices, such as splints and braces, and staff provided ROM exercises to prevent worsening of contractures. The LPN/UM further stated that when residents were discharged from therapy services, the therapy staff would educate the nursing staff on how to perform ROM exercises for the resident. When asked about resident care plans, the LPN/UM stated that the nurses were responsible for updating the care plans quarterly and as needed. The LPN/UM further stated that the care plans should include everything about the resident and that Resident #45's care plans should have included the contractures with the interventions in place.
During an interview with the surveyor on 08/08/23 at 12:15 PM, the DON stated that resident contractures were identified by the therapy department and the therapy department determined if the resident needed devices, such as splints or braces, and/or ROM exercises. The DON further stated that the therapy department educated the nursing staff on the devices and ROM exercises when the resident was discharged from therapy. When asked about resident care plans, the DON stated that care plans were updated upon admission, quarterly, or when a new condition was identified. The DON further stated that Resident #45's care plan should have included the contractures along with the interventions so that all facility staff had the information to provide individualized care.
Review of the facility's Range of Motion Exercises policy, undated, included, Review the resident's care plan to assess for any special needs of the resident.
4.) The surveyor observed Resident #57 lying in bed with the bed height raised to the surveyor's hip level on the following dates and times:
08/02/23 at 10:11 AM
08/03/23 at 9:18 AM
08/04/23 at 9:44 AM
08/07/23 at 9:45 AM
08/08/23 at 9:24 AM
According to the admission Record, Resident #57 had diagnoses which included, but were not limited to, muscle weakness and unspecified dementia.
Review of the annual MDS dated [DATE], included the resident had a BIMS score of 10 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS included the resident's balance during transfers was, not steady, only able to stabilize with staff assistance.
Review of the resident's Care Plan included a focus area initiated 10/17/22, of, I am at risk for falls related to poor balance in sitting, with an intervention of, place bed in lowest position.
Review of the Progress Notes revealed a Plan of Care Note dated 07/28/22 at 2:18 PM with a focus of I am at risk for falls related to history. The documentation included, 1/7/19 lowered to floor (unwitnessed fall), and, 5/21/21 slipped to the floor.
During an interview with the surveyor on 08/08/23 at 10:15 AM, the CNA stated Resident #57 did not have any fall risk interventions in place. The CNA further stated that she did not keep the resident's bed in the lowest position because she had to check the resident's brief and reposition the resident every two hours. At that time, the CNA accompanied the surveyor and entered Resident #57's room. The CNA confirmed in the presence of the surveyor that the bed was not in the lowest position.
During an interview with the surveyor on 08/08/23 at 11:35 AM, the LPN stated Resident #57 did not have any fall risk interventions in place. The LPN further stated that the importance of keeping the resident bed in the lowest position was to prevent injury from falls.
During an interview with the surveyor on 08/08/23 at 11:54 AM, the LPN/UM stated that CNAs should adjust the height of the residents' beds depending on the residents' preferences, however the staff should not keep the residents' beds positioned high for the staff's convenience. The LPN/UM further stated that keeping the resident beds in the lowest position prevented injury from falls.
During an interview with the surveyor on 08/08/23 at 12:15 PM, the DON stated individual fall risk interventions depended on the resident's care plan and that beds should be kept in the lowest position if the care plan indicated that. The DON further stated that staff should not position beds high for their own convenience and that beds are kept in the lowest position to minimize injury from falls.
During a follow-up interview with the surveyor on 08/10/23 at 1:02 PM, the DON stated that staff should have been following Resident #57's care plan if it had an active intervention to keep the bed in the lowest position.
2.) On 08/02/23 at 10:12 AM, during the initial tour the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated that Resident # 81 was currently on an antibiotic (abt).
On 08/02/23 at 10:39 AM, during the initial tour Resident #81 was not in their room. At that time, the resident's roommate informed the surveyor that he/she was in the common area/dining area.
On 08/02/23 at 10:43 AM, during the initial tour the surveyor observed Resident # 81 participating in a group activity in the common area/dining room.
The surveyor reviewed the medical record for Resident #81.
A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in September of 2018 with diagnoses which included overactive bladder, major depressive disorder, and extended spectrum beta lactamase (ESBL) resistance (an enzyme found in some strains of bacteria).
A review of the most recent annual MDS dated [DATE], reflected the resident had a BIMS score of 13 out of 15, which indicated an intact cognition. A further review in Section N - Medications, included the resident received an abt.
A review of the resident's individualized comprehensive care plan (ICCP) included a focus area initiated on 12/4/21, may present with alteration in elimination as evidence by urinary incontinence at times related to overactive bladder. Interventions included monitor and report any signs and symptoms of UTI, dysuria (difficult urination), hematuria (blood in urine), alteration in mental status, voiding (the process of removing urine from your body), and increased temperature. A further review of the ICCP did not reflect that the resident was on an abt.
A review of the Order Summary Report dated active orders as of 8/4/23 included a physician's order (PO) as follows:
Dated 7/20/23, with a start date of 7/21/23 and end date 10/19/23, a PO for Keflex (used to treat a wide variety of bacterial infections) oral capsule 500 milligrams (mg) Give one (1) capsule by mouth one time a day for leukocytosis (high levels of leukocytes in the urine typically indicate an infection in the urinary system) for 90 days.
Dated 7/26/23, monitor Keflex every shift until 10/19/23; document infection notes [for] Keflex.
A review of the July 2023 and the August 2023 Medication Administration Record (MAR) reflected the above physician's order and was documented as administered.
A review of the Progress Notes from 7/21/23 to 8/4/23, reflected that the resident was on Keflex with no adverse reactions.
On 08/03/23 at 09:34 AM, the surveyor observed Resident # 81 in his/her room sitting in wheelchair going through their belongings. Resident # 81 stated that everything was great, and that the care was good. Resident #81 further stated that he/she had no concerns at that time. The surveyor asked if the resident was on an antibiotic? Resident #81 replied that he/she wasn't sure because they took a lot of medications.
On 08/04/23 at 11:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that any nurse could update the care plan. She stated that the importance of the care plan was it showed the interventions needed to care for the resident. She explained it was the plan of action. The LPN stated that if a resident was on an abt then it would be on the care plan and the care plan would indicate why the resident was receiving the abt and for how many days.
On 08/04/23 at 12:01 PM, the surveyor interviewed the UM/LPN who stated that all the nurses were responsible for updating the care plan. She stated that the care plan was the resident's plan of care and what needed to be done to care for that individual resident. The UM/LPN stated that the care plan was important because it ensured everyone knew how to care for the resident and what their needs were. She further stated that some medications were also included especially if the resident was at risk for something and on certain medications. She explained those medications included psychotropics (any drug that affects behavior, mood, thoughts, or perception) and antibiotics. The UM/LPN stated that if the resident was on an abt, then the care plan would reflect why they were on it and how long the resident would be on it. She stated Resident # 81 was on an abt because he/she had colonized urine leukocytosis, went to the urologist and would be on the abt for 90 days. She then stated that the abt was on the resident's care plan. At that time, the surveyor asked the UM/LPN to review the care plan with the surveyor.
On 08/04/23 at 12:05 PM, the surveyor and the UM/LPN reviewed the care plan in the electronic medical record (EMR) together. Upon review of the care plan the UM/LPN realized and stated, I did not update the care plan. She then stated, of course you found the one I forgot. The UM/LPN stated that the abt was under the resolved section of the care plan and confirmed it was not currently in the care plan to address that the resident was currently on the abt for 90 days. The UM/LPN acknowledged that it should have been on the care plan. After surveyor inquiry the UM/LPN stated that she was now updating the care plan to include the abt in the presence of the surveyor.
On 08/04/23 at 12:14 PM, the surveyor interviewed the DON who stated that a care plan was all the details related to the specific care of the residents. The DON stated that everyone which included therapy, social services, dietary, nurses, and recreation were responsible for updating the care plan. She stated that the care plan was important because it provided specific individualized care on how to care for that resident. She further stated that they included medications such as abt on the care plan. The DON explained that the abt should be on the care plan because it shared the information with everyone and allowed staff to know how to care for that resident. When asked was Resident # 81 on an abt? The DON stated that offhand I am not sure.
On 08/04/23 at 12:18 PM, the surveyor and the DON reviewed the EMR together. Upon review the DON stated that resident was on Keflex and had started it on 07/21/23. The DON then went to the care plan and stated that the abt was mentioned. The surveyor informed the DON that the original care plan did not reflect the abt and that the UM/LPN had just updated the care plan in the presence of the surveyor. At that time, the surveyor showed the DON the original care plan and the DON compared it to the care plan revised (8/4/23). The DON confirmed that the original care plan had not addressed the abt and acknowledged that it should have been on the care plan prior to surveyor inquiry. The DON explained that they did rounds daily and addressed everyone that was on an abt.
On 8/7/23 at 09:05 AM, the DON provided the facility Care Plans - Comprehensive policy. At that time, the DON confirmed the policy was undated but stated that she had reviewed the policy in January of 2023.
On 08/08/23 at 01:10 PM, the DON in the presence of the LNHA, the Assistant Director of Nursing (ADON), and the survey team stated that the resident's long-standing use of an abt should have been documented on the resident's care plan.

**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.) obtain a physician's order to perform Range of Motion (ROM) exercises and b.) document the performance of ROM exercises in the resident's medical record for 1 of 3 residents, (Resident #45) reviewed for position and mobility.
This deficient practice was evidence by the following:
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes 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 08/02/23 at 10:16 AM, the surveyor observed Resident #45 lying in bed. The resident's right hand and right knee appeared to be contracted (a fixed tightening of muscles, tendons, ligaments, or skin that prevents normal movement and causes stiffening of the associated body part).
The surveyor reviewed Resident #45's medical record.
According to the admission Record, Resident #45 had diagnoses which included, but were not limited to, cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis on one side of the body), right wrist contracture, cognitive communication deficit, and unspecified dementia.
Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 07/26/23, included the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident had a functional limitation in range of motion (ROM) to one side of his/her upper and lower extremities.
Review of the Order Summary Report included a physician's order for Apply knee brace to right knee at all times when in bed, with a start date of 04/21/23. There were no orders related to the resident's right wrist contracture.
Review of the August 2023 Treatment Administration Record included the aforementioned knee brace order, but there was no treatment for the resident's right wrist contracture.
Review of the Task List Report, as of 08/03/23, did not include ROM exercises for the resident's right wrist contracture.
Review of the Care Plan included a focus area of, I have an ADL [activities of daily living] self-care performance deficit r/t [related to] hemiparesis/hemiplegia secondary to cerebral infarction and DX [diagnosis] of dementia. Further review of the Care Plan did not include interventions related to the resident's right wrist contracture.
Review of the Occupational Therapy (OT) Discharge summary, dated [DATE], included, Instructed nursing caregivers in proper body mechanics, safe transfer techniques, safety precautions and self care/skin checks in order to facilitate improved functional abilities with 100% carryover demonstrated by primary caregivers.
During an interview with the surveyor on 08/07/23 at 9:59 AM, the Director of Rehab (DOR) stated Resident #45 had a history of a stroke and was previously receiving PT and OT for ROM and contracture management. The DOR further stated the resident was recommended to wear a right knee brace while in bed and for staff to perform ROM exercises to the right wrist. The DOR explained that when the resident was discharged from PT and OT services, therapy educated the nursing staff on how to perform the ROM interventions. When asked where nursing staff document the performance of ROM exercises, the DOR was unsure and stated the facility no longer had a formal restorative nursing program (RNP) where it was documented previously.
During an interview with the surveyor on 08/08/23 at 10:38 AM, the Certified Nursing Assistant (CNA) stated that Resident #45 was paralyzed on the right side and had contractures to the right wrist and knee. The CNA further stated that he put the resident's right knee brace on while the resident was in bed and performed ROM exercises to the resident's right wrist to prevent stiffness in the joints, as instructed by the therapy department. When asked where ROM exercises were documented in the resident's medical record, the CNA stated he did not document the exercises anywhere.
During an interview with the surveyor on 08/08/23 at 11:35 AM, the Licensed Practical Nurse (LPN) stated Resident #45 had contractures to the right wrist and knee. The LPN further stated that the CNA applied the resident's knee brace and performed ROM exercises to prevent worsening of the contractures. When asked where the ROM exercises were documented in the resident's medical record, the LPN stated the CNAs document the ROM exercises in the kiosk, which included the resident's Task List.
During an interview with the surveyor on 08/08/23 at 11:54 AM, the LPN/Unit Manager (UM) stated that residents with contractures were sometimes given devices, such as splints and braces, and staff provided ROM exercises to prevent worsening of the contractures. The LPN/UM further stated that when residents were discharged from therapy services, the therapy staff would educate the nursing staff on how to perform ROM exercises for the resident. When asked where the ROM exercises were documented in the resident's medical record, the LPN stated the CNAs document it in the kiosk, which included the resident's Task List.
During an interview with the surveyor on 08/08/23 at 12:15 PM, the Director of Nursing (DON) stated that resident contractures were identified by the therapy department who determined if the resident needed devices, such as splints or braces, and/or ROM exercises. The DON further stated that the therapy department educated the nursing staff on the devices and ROM exercises when the resident was discharged from therapy. When asked where the ROM exercises were documented in the resident's medial record, the DON stated they were not documented anywhere specifically since the RNP no longer existed at the facility.
During a follow-up interview with the surveyor on 08/10/23 at 1:12 PM, the DON stated Resident #45 should have had a physician's order for ROM exercises to the right wrist contracture and the exercises should have been documented in the resident's medical record.
During a follow-up interview with the surveyor on 08/11/23 at 9:47 AM, the DON acknowledged that because there was no physician's order and the ROM exercises were not included on the Task List, there was no way to determine whether the ROM exercises were being performed for Resident #45.
Review of the facility's undated Range of Motion Exercises policy included, Verify that there is a physician's order for this procedure. If there is no order for treatment, contact the attending physician to obtain treatment orders. Further review of the policy included, The following information should be recorded in the resident's medical record:
1. The date and time that the exercises were performed.
2. The name and title of the individual(s) who performed the procedure.
3. The type of ROM exercise given.
4. Whether the exercise was active or passive.
5. How long the exercise was conducted.
6. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure.
7. Any problems or complaints made by the resident related to the procedure.
8. If the resident refused the treatment, the reason(s) why and the intervention taken.
9. The signature and title of the person recording the data.
NJAC 8:39-27.1(a); 27.2(m)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility documents, it was determined that the facility failed to: a.) notify the physician or Nurse Practitioner (NP) of an abnormal urine lab result and b.) administer antibiotic treatment in a timely manner for 1 of 3 residents, (Resident #133) reviewed for antibiotic use.
This deficient practice was evidenced by the following:
On 08/02/23 at 10:42 AM, the surveyor observed Resident #133 sitting in a chair in his/her room. The resident stated that he/she had an infection but was unsure where.
According to the admission Record, Resident #133 had diagnoses which included, but were not limited to, chronic kidney disease, end stage renal disease, and retention of urine.
Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/12/23, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident was occasionally incontinent of bladder.
Review of a Progress Note written by the NP, dated 07/27/23 at 1:11 PM, revealed the resident, reports of pain during urination, and a urinary analysis with culture and sensitivity (UA C&S) lab test was ordered.
Review of the UA C&S lab result revealed the lab received the urine sample on 07/28/23 at 8:25 AM and reported the results to the facility on [DATE] at 11:25 AM. The results were flagged as abnormal and indicated the urine contained the bacteria E. Coli and was Extended Spectrum Beta Lactamase (ESBL) positive, a Multidrug-Resistant Organism (MDRO, bacterial organisms that are resistant to multiple antibiotics or anifungals). Further review of the UA C&S revealed, after multiple attempts, unable to reach nurse, faxed to client 7/30.
Review of the Progress Notes, dated 07/30/23, did not indicate the physician or NP was notified of the abnormal lab result.
Review of a Progress Note written by the NP, dated 07/31/23 at 2:11 PM, revealed the NP reviewed the UA C&S Results and ordered Bactrim DS (an antibiotic) for ten days for cystitis (bladder infection).
Review of the August 2023 Order Summary Report included a physician's order dated 07/31/23, for Bactrim (Sulfamethoxazole-Trimethoprim) DS Oral Tablet 800-160 MG (milligrams) Give one tablet by mouth one time a day for Cystitis for 10 days.
Review of the July 2023 Medication Administration Record (MAR) did not include the physician's order for Bactrim DS.
Review of the August 2023 MAR revealed the first dose of Bactrim DS antibiotic was administered on 08/01/23 at 9:00 AM.
Review of a list of antibiotics available in the facility's automated pharmacy dispensing unit (APDU, a computerized storage device in which extra medication is stored) provided by the Assistant Director of Nursing (ADON) included SMZ-TMP (Sulfamethoxazole-Trimethoprim) DS.
During an interview with the surveyor on 08/08/23 at 11:48 AM, the Licensed Practical Nurse (LPN) stated that when a UA C&S report was available, the nurse should have looked for the results in the electronic medical record (EMR). The LPN further stated that if the results were abnormal, the nurse should have notified the NP or telehealth physician, the same shift that the results from the abnormal lab were received. The LPN also stated that if the NP or physician ordered an antibiotic treatment and the medication was available in the APDU, the nurse should have administered the first dose of the antibiotic as soon as it was ordered. The LPN explained that the nursing supervisor could obtain the antibiotic from the ADPU and give it to the floor nurse to administer. The LPN added that it was important to administer antibiotics as soon as the antibiotic was available to prevent the resident from suffering from an infection, and to help treat the infection.
During an interview with the surveyor on 08/08/23 at 11:54 AM, the LPN/Unit Manager (UM) stated that when a UA C&S report became available, it was the nurses' responsibility to check the lab results in the EMR at the end of their shift. The LPN/UM further stated that if the results were abnormal, the nurse should notify the NP or telehealth physician the same shift that the results were received. The LPN/UM added that if the NP or physician ordered an antibiotic treatment, and the medication was available in the APDU, the nurse should have administered the antibiotic immediately. The LPN/UM explained that the nursing supervisor had access to the APDU to obtain medications for the floor nurses. The LPN/UM added that it was important to start antibiotic treatment as soon as possible to not delay care.
During an interview with the surveyor on 08/08/23 at 12:15 PM, the Director of Nursing (DON) stated the results of the UA C&S results are uploaded into the EMR and the nurses, physicians, and NP had access to check the results. The DON further stated abnormal lab results should be addressed within 24 hours depending on the resident's condition. The DON also stated that many antibiotics were available in the APDU so that they could be initiated in a very short time. The DON then explained that antibiotics should be administered as soon as possible to treat the infection.
During a follow-up interview with the surveyor on 08/08/23 at 1:09 PM, the DON stated that Resident #133's lab result should have been addressed the same day it was available due to the resident experiencing burning with urination.
During an interview with the surveyor on 08/09/23 at 12:44 PM, the NP stated that when a UA C&S result is available, the nurse or nursing supervisor should review the lab results and notify the NP or telehealth physician that same day if the result is abnormal. The NP further explained that the lab results were usually available by 1:00 or 2:00 PM and the nurse should notify the NP or telehealth physician by the evening shift (3:00 - 11:00 PM). The NP also stated that if an antibiotic is ordered, the facility has an ADPU where they can obtain the first dose and administer it as soon as possible. When asked about Resident #133, the NP stated she was not notified of the abnormal UA C&S result on 07/30/23 when it was available, and had looked it up herself on 07/31/23 when she came in. The NP further stated that the lab result should have been reported to the NP or telehealth physician on 07/30/23 and the antibiotic should have been started as soon as possible if the resident was symptomatic to treat the infection.
Review of the facility's Lab and Diagnostic Test Results - Clinical Protocol policy, undated, included, A nurse/NP/Physician will review all results . If the NP is not in the building to review the results - The person who is to communicate results to a physician will review and be prepared to discuss the following . the individual's condition . How test results might relate to the individual's current status, treatment, or medications . Any concerns or issues the physician will be expected to address upon receiving the result. Further review of the policy included, Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medial record.
Review of the facility's Change in a Resident's Condition or Status policy, undated, included, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician/NP, Telemedicine, or On-Call Physician when there has been: . A need to alter the resident's medical treatment significantly.
Review of the facility's Antibiotic Stewardship - Orders for Antibiotics policy, undated, included, When a cultures and sensitivity (C&S) is ordered, it will be completed, and: Lab results will be communicated to the prescriber to determine if antibiotic therapy should be started, continued, modified, or discontinued.
NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that an air mattress was accurately set according to the resident's weight. This deficient practice was identified for 1 of 5 residents, (Resident #129) reviewed for pressure ulcers and was evidenced by the following:
The surveyor observed Resident #129 lying in bed with his/her air mattress set to 360 to 400 pounds (lbs) on the following dates and times:
-08/02/23 at 10:22 AM
-08/03/23 at 9:24 AM
-08/04/23 at 9:48 AM
According to the admission Record, Resident #129 had diagnoses which included, but were not limited to, paraplegia and unspecified protein-calorie malnutrition.
Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/13/23, included the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS included the resident had one unstageable pressure ulcer that was not present on admission.
Review of the Order Summary Report as of 08/08/23, included a physician's order dated 06/19/23, for, air pressure mattress - ensure placement and functionality every shift for wound.
Review of the August 2023 Treatment Administration Record included the aforementioned air mattress order and was signed with a check mark on each shift from 08/01/23 through 08/08/23.
Review of the Care Plan revised 06/29/23 included a focus area of, I have an actual alteration in skin integrity. A further review of the resident's care plan specified an intervention to ensure placement and functionality of the air mattress.
Review of the Braden Scale for Predicting Pressure Sore Risk, dated 06/17/23, revealed the resident was at moderate risk for pressure ulcers.
Review of the list of weights in the electronic medial record revealed the resident's weight on 07/25/23 was 134.4 lbs and the following weight recorded on 08/04/23 was 130.4 lbs.
During an interview with the surveyor on 08/08/23 at 10:48 AM, the Certified Nursing Assistant (CNA) stated Resident #129 was totally dependent on staff for activities of daily living, had a wound on his/her backside, and had an air mattress. The CNA further stated that the nurse was responsible for checking the function of the air mattress and that the importance of the air mattress was to promote wound healing.
During an interview with the surveyor on 08/08/23 at 11:35 AM, the Licensed Practical Nurse stated Resident #129 had a pressure ulcer on his/her sacrum and interventions included wound treatments, repositioning, and an air mattress. The LPN further stated that the maintenance staff installed the air mattresses and adjusted the settings to the resident's weight. The LPN added that the nurses could adjust the weight settings if necessary. The LPN explained the importance of the weight setting was to adjust the firmness of the air mattress to prevent the wound from worsening.
During an interview with the surveyor on 08/08/23 at 11:54 AM, the LPN/Unit Manager (UM) stated interventions for residents with pressure ulcers include air mattresses. The LPN/UM further stated that air mattresses were set up by the maintenance staff based on the resident's weight. The LPN/UM was unsure if the nurses were capable of adjusting the weight setting if it was incorrect. The LPN/UM also stated that the nurses and CNAs were responsible for checking to ensure the air mattresses were set properly and should notify maintenance if there was an issue. The LPN/UM stated that the importance of setting the air mattresses to the correct weight was to adjust the firmness of the mattress.
During an interview with the surveyor on 08/08/23 at 12:15 PM, the Director of Nursing (DON) stated interventions for residents with pressure ulcers included offloading, wound care, repositioning, and air mattresses. The DON further stated that either the facility maintenance staff set up the in-house air mattresses, or the rental company would set up their own air mattresses. The DON also stated that the nurses were responsible for checking the function of the air mattress daily and should adjust the weight settings to the resident's current weight. The DON explained the importance of the weight setting was to prevent too much or too little pressure which could worsen the wound.
Review of the facility's Support Surface Guidelines, undated, included, Pressure-reducing and pressure-relieving devices are to promote comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Further review of the policy included, Use a pressure ulcer risk scale such as the Braden Scale to help determine the need for and appropriate type of pressure-relieving devices, and, Any individual at risk for developing pressure ulcers should be placed on a pressure reducing device, such as foam, static air, alternating air, gel, or water mattresses when lying in bed.
NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to: a.) accurately sign for the accountability of continuous oxygen, b.) discontinue a physician's order for a chair alarm and accurately sign for the accountability of the chair alarm and, c.) follow a physician's order designating a pain scale for the administration of as-needed pain medication, (Percocet). This deficient practice was identified for 3 (three) of 35 residents reviewed for professional standards of nursing practice (Resident #39, Resident #109, and Resident #169).
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.
The evidence was as follows:
1. On 6/8/21, during the initial tour of the facility, the surveyor interviewed Resident #169 at 11:33 AM in their room. The surveyor observed an oxygen (O2) concentrator (a device that supplies oxygen for supplemental use) in the room, and it was turned off. The resident had no roommate at the time. The resident stated that they used the O2 once in a while.
On 6/11/21 at 9:29 AM and 6/14/21 at 11:21 AM, the surveyor observed that Resident #169 was not using O2.
The surveyor reviewed the medical record for Resident #169.
A review of the Face Sheet (an admission summary) revealed that Resident #169 was admitted with diagnoses that included: shortness of breath, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pleural effusion (a build-up of fluid between the tissues that line the lungs and chest) and end-stage renal disease.
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 5/7/21, reflected that the resident had a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). This score indicated that the resident was cognitively intact.
A review of the resident's electronic medical record revealed that there was a physician order dated 2/16/21 for O2 at 2 liters via nasal cannula continuous every shift for shortness of breath (SOB).
The surveyor reviewed the electronic Medication Administration Records (EMAR) for Resident #169 for April, May, and June 2021. The EMAR indicated that O2 was administered to Resident #169 continuously on every shift from 4/1/21 until the evening shift of 6/14/21. The surveyor had not observed Resident #169 using O2 during the course of the survey.
On 6/15/21 at 1:01 PM, the surveyor interviewed the Registered Nurse (RN), who stated that Resident #169 used supplemental O2 when in the facility's lobby. She noted that the resident sometimes uses the O2 concentrator in their room.
On 6/16/21 at 12:02 PM, the surveyor and the Licensed Practical Nurse/Unit Manager (LPN/UM) reviewed the current June 2021 EMAR regarding the nurse's signatures for the physician's order for O2. The LPN/UM stated that the nurses were recording O2 saturations (O2 Sats) (a measure of the oxygen levels carried in the resident's blood) on the EMAR. Further review of the EMAR had indicated that the O2 Sats corresponded with the physician's order for O2 at 2 liters via N/C (nasal cannula) Continuous every shift for SOB [Shortness of Breath]. The LPN/UM added that he thought the nurses were signing for the O2 Sats and that they were not signing that they had administered O2 continuously to Resident #169.
On 6/16/21 at 12:03 PM, the surveyor interviewed LPN #1, whose signature appeared numerous times on the EMAR. LPN #1 stated that she had documented the O2 saturation levels on the dates indicated on the EMAR. LPN #1 added that she did not think that she was signing for continuous O2 administration for Resident #169.
On 6/16/21 at 1:13 PM, the surveyor, with the Director of Nursing (DON), reviewed the current June 2021 EMAR regarding the physician's order for O2 for the resident. The DON stated that the nurses' signatures indicated that the resident's O2 was being administered continuously. The DON added that the O2 Sats were also documented on the EMAR.
On 6/16/21 at 2:01 PM, the survey team met with the administrative team. The DON presented to the surveyor documentation of a Summary Report of Meeting/In-service, which was conducted on 6/16/21 at 1:25 PM after the surveyor inquiry. The DON stated that she had inserviced the nurses regarding proper documentation of oxygen use.
2. On 6/8/21 at 11:24 AM, the surveyor, observed Resident #39 standing up from their wheelchair in front of their bed. The resident was straightening out the bedsheets on the bed. The surveyor did not observe a chair alarm on the back of the wheelchair or hear a chair alarm sounding.
At that time, the surveyor attempted but could not interview the resident due to a language barrier.
On 6/9/21 at 1:34 PM, the surveyor observed Resident #39 in a wheelchair, self-propelling in the hallway, and stopped to talk to a nurse. The surveyor did not observe a chair alarm on the back of the wheelchair.
The surveyor reviewed the medical record for Resident #39.
A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to Type 2 Diabetes Mellitus, Major Depressive Disorder, and Dementia without behavioral disturbance.
A review of the resident's June 2021 EMAR included a physician's order (PO), with a start date of 3/05/2020, for chair alarm and check placement every shift for monitoring. Each shift for each day of June indicated that the order was administered (done) except for June 9, 2021 evening shift which indicated the resident refused.
On 6/15/21 at 11:18 AM, in the presence of LPN #2, the surveyor observed Resident #39 sitting in their bed. The wheelchair was positioned next to the resident's bed. The surveyor did not observe a chair alarm on the wheelchair or hear a chair alarm sounding. The surveyor asked LPN #2 to confirm that Resident #39 did not have a chair alarm on their wheelchair. LPN #2 stated that she did not see a chair alarm on the resident's wheelchair. She then stated that she would look in the computer to see if there was an order and check with the Unit Manager (UM #2). She further noted that if the resident still needed the chair alarm, she would put it on, and if the resident did not need the chair alarm, she would call the physician to get an order to discontinue it.
At 11:26 AM, during the surveyor interview, UM #2 stated that the resident did not have or require a chair alarm and that it had been resolved in the care plan. She further noted that the resident did not want the chair alarm and that the family also did not want the chair alarm.
On 6/16/21 at 8:52 AM, during the surveyor interview, LPN #2 stated that Resident #39 had fallen in the past and that they had put on a chair alarm for a short time. She further noted that the order was not deleted when the chair alarm was taken off the wheelchair and resolved in the care plan.
A review of Resident #39's comprehensive care plan indicated a focus area that resident was at risk for falls. The resident had an intervention that included applying a chair alarm and re-evaluate for effectiveness as needed, which was initiated on 3/5/20. The intervention was resolved (discontinued) on 5/28/21.
At 12:17 PM, during the surveyor interview, UM #2 stated that the staff should not have been signing the eMAR that they were checking the chair alarm if there was no chair alarm on the resident's wheelchair.
On 6/21/21 at 11:03 AM, during the surveyor interview, the DON stated that the staff should not have been signing the EMAR that they were checking the chair alarm if there was no chair alarm on the resident's wheelchair. She further stated that the staff should have contacted the physician to have the chair alarm discontinued. The surveyor asked the DON to provide the facility policy for wheelchair alarms. The DON stated that the facility did not have a policy for wheelchair alarms.
3. On 6/8/21 at 1:32 PM, the surveyor, observed Resident #109 lying in bed. The resident stated that they had pain in their right shoulder and neck and that they requested pain medication when needed, and the pain medication provided relief.
The surveyor reviewed the medical record for Resident #109.
A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to Multiple Sclerosis, Type 2 Diabetes Mellitus, and Major Depressive Disorder.
A review of the quarterly MDS, dated [DATE], indicated that the resident had a brief interview for mental status (BIMS) score of 14 out of 15, indicating the resident had an intact cognition. It further included that the resident had received pain medication for seven of the last seven days.
A review of the resident's Physician Order Sheet (POS) dated 6/16/21 included a physician's order (PO) dated 6/8/21 for Percocet Tablet 5-325 MG (a narcotic medication used to provide relief from pain) give one tablet by mouth every 6 hours as needed for moderate pain 4-6.
A review of Resident #109's comprehensive care plan indicated a focus area that resident had an alteration in comfort due to pain evidenced verbally due to neck and shoulder pain. The resident had an intervention that included analgesic medication (to provide relief from pain) as ordered.
A review of the resident's June 2021 EMAR included the following dates and times of administrations that were not followed in accordance with the physician's order for the parameter of a pain level to be between 4 to 6 for the administration of Percocet:
6/8/21 20:09 administered for pain level of 3.
6/11/21 18:07 administered for pain level of 3.
6/12/21 10:19 administered for pain level of 3.
6/12/21 18:38 administered for pain level of 3.
6/13/21 09:48 administered for pain level of 3.
6/13/21 21:04 administered for pain level of 0.
6/14/21 17:34 administered for pain level of 8.
On 6/16/21 at 8:30 AM, during the surveyor interview, LPN #3 stated that the pain level number listed on the EMAR is the pain level of the resident prior to administering the pain medication. She further noted that the E listed on the EMAR indicated that the pain medication was effective, and the corresponding pain level after receiving the pain medication would be documented in a progress note. The surveyor then asked LPN #3 what the process was for administering a pain medication that was ordered with a specific pain level parameter. LPN #3 stated that if a pain medication was ordered for a pain level of 4-6 and a resident had a pain level of 5, then she would administer that medication. She then stated that if the resident had a pain level that was lower than a 4 that she would offer the medication that was ordered for that pain level, probably Tylenol. If the resident did not have another order or did not want the other medication, she would tell the charge nurse or call the physician for a one-time order.
At 8:43 AM, during the surveyor interview, UM #3 stated that if a resident's pain level is not within the parameters of the medication order, then the staff should offer another medication that is ordered. She further stated that if the resident did not have an order for another medication that the staff would call the physician. UM, #3 could not speak to why the nurses had administered and documented the administration of the Percocet not in accordance with the physician's order.
On 6/21/21, during the surveyor interview, the DON stated that staff should follow a physician's order and not administer a pain medication outside the physician's ordered parameters. She then added that the staff should administer the pain medication ordered for the appropriate pain level. If the resident did not have an order, the staff should contact the physician and obtain another order.
A review of the undated facility-provided policy titled Administering Pain Medications included Follow the medication administration per physician order. The policy did not include information regarding administering pain medication if the pain level was outside the parameter of the physician's order.
NJAC: 8:39-11.2(b), 29.2(d)

Based on interview and facility document review, the facility failed to ensure staffing ratios were met for 66 of 84 shifts reviewed. There was no increase in the resident census for a period of nine consecutive shifts. This deficient practice has the potential to affect all residents.
Findings include:
Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021:
One Certified Nurse Aide (CNA) to every eight residents for the day shift.
One direct care staff member to every ten residents for the evening shift provided that no fewer than half of all staff members shall be CNAs and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and
One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties.
On 6/21/21, the surveyor reviewed the facility provided Nursing Home Resident Care Staffing Reports from 5/25/21 to 6/21/21 which included the following staff to resident ratio for each shift:
5/26/21-(Census-187) Day shift 1CNA:8.9 residents
5/27/21-(Census-185) Day shift 1 CNA:8.8 residents
5/28/21-(Census-187) Day shift 1 CNA:9.8 residents
5/29/21-(Census-186) Day shift 1 CNA:10.9 residents
5/30/21-(Census-188) Day shift 1 CNA:12.5 residents
5/31/21-(Census-188) Day shift 1 CNA:9 residents
6/1/21-(Census-188) Day shift 1 CNA:9.4 residents
6/3/21-(Census-187) Day shift 1 CNA:11 residents
6/4/21-(Census-187) Day shift 1 CNA:9.3 residents
6/5/21-(Census-185) Day shift 1 CNA:10.9 residents
6/6/21-(Census-183) Day shift 1 CNA:12.2 residents
6/7/21-(Census-183) Day shift 1 CNA:9.2 residents
6/8/21-(Census-184) Day shift 1 CNA:9.7 residents
6/9/21-(Census-186) Day shift 1 CNA:9.8 residents
6/11/21-(Census-188) Day shift 1 CNA:9.4 residents
6/12/21-(Census-191) Day shift 1 CNA:11.2 residents
6/13/21-(Census-191) Day shift 1 CNA:10.6 residents
6/14/21-(Census-191) Day shift 1 CNA:10.6 residents
6/17/21-(Census-192) Day shift 1 CNA:10.1 residents
6/18/21-(Census-193) Day shift 1 CNA:9.7 residents
6/19/21-(Census-190) Day shift 1 CNA:11.2 residents
6/20/21-(Census-190) Day shift 1 CNA:11.9 residents
6/21/21-(Census-190) Day shift 1 CNA:9.5 residents
23 of 28-day shifts did not meet the minimum required ratio of 1 CNA to 8 residents:
5/29/21-Evening shift 1 CNA:10.9 residents
5/30/21-Evening shift 1 CNA:12.5 residents
5/31/21-Evening shift 1 CNA:11.1 residents
6/1/21-Evening shift 1 CNA:11.1 residents
6/6/21-Evening shift 1 CNA:11.4 residents
6/12/21-Evening shift 1 CNA:11.2 residents
6/13/21-Evening shift 1 CNA:11.2 residents
6/14/21-Evening shift 1 CNA:11.2 residents
6/15/21-(Census-191) Evening shift 1 CNA:11.2 residents
6/16/21-(Census-194) Evening shift 1 CNA:10.8 residents
6/17/21-Evening shift 1 CNA:10.7 residents
6/18/21-Evening shift 1 CNA:12.1 residents
6/19/21-Evening shift 1 CNA:12.7 residents
6/20/21-Evening shift 1 CNA:14.6 residents
6/21/21-Evening shift 1 CNA:10.6 residents
15 of 28 evening shifts did not meet the minimum required ratio of 1 CNA to 10 residents:
5/25/21-(Census-184) Night shift 1 CNA:15.3 residents
5/26/21-Night shift 1 CNA:17 residents
5/27/21-Night shift 1 CNA:15.4 residents
5/28/21-Night shift 1 CNA:15.6 residents
5/29/21-Night shift 1 CNA:18.6 residents
5/30/21-Night shift 1 CNA:17.1 residents
5/31/21-Night shift 1 CNA:15.7 residents
6/1/21-Nightshift 1 CNA:15.7 residents
6/2/21-(Census-186) Night shift 1 CNA:15.5 residents
6/3/21-Nightshift 1 CNA:17 residents
6/4/21-Nightshift 1 CNA:15.6 residents
6/5/21-Nightshift 1 CNA:18.5 residents
6/6/21-Nightshift 1 CNA:15.3 residents
6/7/21-Nightshift 1 CNA:15.3 residents
6/8/21-Nightshift 1 CNA:15.3 residents
6/9/21-Nightshift 1 CNA:15.5 residents
6/10/21-(Census-186) Night shift 1 CNA:15.5 residents
6/11/21-Night shift 1 CNA:17.1 residents
6/12/21-Night shift 1 CNA:21.2 residents
6/13/21-Night shift 1 CNA:15.9 residents
6/14/21-Night shift 1 CNA:15.9 residents
6/15/21-Night shift 1 CNA:15.9 residents
6/16/21-Night shift 1 CNA:16.2 residents
6/17/21-Night shift 1 CNA:16 residents
6/18/21-Night shift 1 CNA:16.1 residents
6/19/21-Night shift 1 CNA:17.3 residents
6/20/21-Night shift 1 CNA:17.3 residents
6/21/21-Night shift 1 CNA:15.8 residents
28 of 28-night shifts did not meet the minimum required ratio of 1 CNA to 14 residents.
On 6/21/21 at 10:28 AM, during the surveyor interview, the Director of Nursing (DON) stated that the facility did not currently have a staffing coordinator. She added that she was performing the duties of staffing the facility. The surveyor then asked if she was aware of the minimum direct care staff to resident ratio, which became effective 2/1/21, in which she stated that she was aware. She then said that she sends an email twice a day to staffing agencies to acquire staff to meet the ratio.
At 10:39 AM, during the surveyor interview, the Administrator stated that the facility utilizes a few different staffing agencies but that sometimes there are last-minute call-outs from the agency. He further noted the facility was doing everything they could and that the nursing supervisors would provide additional support to staff and would be given an assignment if needed. The facility did not provide documentation as to which dates and shifts a nursing supervisor was designated an assignment of residents to provide care.
A review of the facility provided document titled Facility Assessment Tool, updated April 2021, included the following:
Under Staffing Plan. This chart describes our approach to ensure sufficient staffing based on our resident population and their needs for care. Average Staffing for 7-3 Shift: Position-Nurse aides. Total Number Needed or Average or Range-1:8.
NJAC: 8:39-5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident (Resident #169) who had a physician's order for continuous oxygen was properly identified, assessed, re-assessed, and monitored for smoking after the resident was noted to be smoking in the bathroom on three separate occasions on 4/18/21, 4/30/21 and 6/11/21. Further, the facility failed to address the smoking violations in accordance with their smoking policy and revise the resident's care plan to ensure safe smoking practices.
The facility's failure to revise and implement a care plan to avoid a smoking accident while the resident had a physician's order for continuous oxygen and was found to be smoking in the bathroom on the three occasions created an unsafe environment for serious injury, combustion, and fire.
This posed a serious and immediate threat to the safety and well-being of all the residents in the facility residing on 4 of 4 resident care units (Cedar, Maple, Oak, and [NAME] unit) which resulted in an Immediate Jeopardy (IJ) situation. The facility Administration was notified of the Immediate Jeopardy situation on 6/15/21 at 2:14 PM. The IJ began on 4/30/21 upon the second smoking violation incident and continued until 6/16/21, when the facility alleged complete implementation of the elements in their IJ Removal Plan, accepted on 6/16/21 at 4:00 PM and verified by the survey team on 6/16/21 and throughout the remainder of the Recertification Survey.
The evidence was as follows:
On 6/8/21, between 10:27 AM, the surveyor conducted an Entrance Conference with the Licensed Nursing Home Administrator (LNHA), Assistant Administrator, and the Director of Nursing (DON). Included as part of the Entrance Conference, the surveyor requested a copy of a list of residents who smoked at the facility.
The surveyor reviewed the list of residents identified to be smokers provided by the LNHA. The list of smokers did not include Resident
#169.
On 6/8/21 at 11:33 AM, during the initial tour of the facility, the surveyor observed Resident #169 in their semi-private room with no assigned roommate. The surveyor observed an oxygen concentrator (a device that supplies oxygen for supplemental use) in the room, and it was turned to the off position. The surveyor interviewed Resident #169, who stated that they used the oxygen once in a while.
On 6/11/21 at 9:29 AM and 6/14/21 at 11:21 AM, the surveyor observed that Resident #169 was not using the supplemental oxygen, and the oxygen concentrator was turned to the off position.
The surveyor reviewed the medical record for Resident #169.
A review of the admission Record face sheet (an admission summary) revealed that Resident #169 was admitted with diagnoses that included: shortness of breath (SOB), chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), pleural effusion (a build-up of fluid between the tissues that line the lungs and chest) and end-stage renal disease.
A review of an initial Smoking Safety Screen dated 7/29/20 reflected that the resident smoked 1-2 cigarettes per day in the morning but could not light their cigarette and required supervision with smoking. The note on the smoking screen indicated that the resident had subsequently, quit smoking.
A review of the admission comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/4/20 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating that the resident had an intact cognition with some forgetfulness. The MDS assessment further revealed that the section used to assess if the resident was a smoker reflected that they were not a current tobacco user.
A review of the most recent MDS dated [DATE] reflected that the resident had BIMS score of 15 out of 15, indicating the resident had a fully intact cognition.
A review of the resident's individualized comprehensive care plan initiated on 8/13/20, reflected that Resident #169 was a former smoker and not interested in smoking at this time. It further reflected that the resident had quit smoking. The goal indicated that the resident would be smoke-free through the next review date, with a single intervention to provide check-in visits to see how they were doing. The care plan further reflected that the resident was on oxygen therapy related to a respiratory illness of COPD initiated 7/29/20. Interventions included to administer the oxygen at 2 liters per minute via nasal cannula.
A review of the physician's order sheet (POS) reflected that the resident had a physician's order (PO) dated 8/26/20 for a nicotine patch discontinued upon hospitalization on 9/6/20. The nicotine patch was re-ordered by the physician on 9/23/20 and discontinued on 9/26/20. There were no other subsequent physician orders for a nicotine patch.
Further review of the POS reflected a physician order dated 2/16/21 to administer two liters of supplemental oxygen continuously every shift via the nares using a nasal cannula for shortness of breath (SOB).
The surveyor reviewed the electronic Progress Notes (ePN) for April, May, and June 2021, which reflected that the resident had three incidents of smoking in the bathroom. The Behavior Notes written within the ePN reflected the following:
An ePN dated 4/18/2021 at 2:53 PM included that the Resident was smoking in the bathroom. The Licensed Practical Nurse (LPN) documented that she asked the resident why they were smoking in the bathroom, but the resident denied doing it. No other details were documented in the ePN regarding the smoking paraphernalia, notification to the physician or chain of command, and the resident's use of oxygen during the alleged incident.
A review of the electronic Medication Administration Record (eMAR) for April 2021 reflected the PO dated 2/16/21 to continuously administer supplemental oxygen at 2 liters per minute. The eMAR was signed to reflect that the resident received the supplemental oxygen continuously via nasal cannula every shift on 4/18/21.
A review of the comprehensive individualized care plan initiated 8/13/20 reflected that the care plan for smoking was not updated after the alleged smoking violation incident on 4/18/21 until nine days later on 4/27/21, which indicated to educate resident as needed on the dangers of smoking while being on O2 [oxygen].
There was no documented evidence in the medical record that reflected that the resident received the education on the dangers of smoking while being on oxygen and how they responded to the education since the first alleged incident on 4/18/21.
The surveyor reviewed the second smoking violation incident documented in the ePN dated 4/30/21 at 2:21 PM. The note indicated that the same LPN wrote the following Behavior Note: Resident was smoking in the room, oxygen in use, resident denied, social worker, informed.
There was no subsequent re-assessment for smoking for Resident #169 after the first smoking violation.
A review of the ePN dated 4/30/21 at 3:08 PM, reflected that the Social Worker (SW) wrote that two social workers performed a room search and confiscated a full pack of cigarettes and matches. The Behavior Note indicated that the resident denied smoking in the room and stated they go outside to smoke. The SW continued, Writer re-educated the resident on the smoking policy, and at this time, there is no smoking. The SW concluded the note by documenting that the resident was aware of all the above.
A review of the eMAR for April 2021 reflected the PO dated 2/16/21 to continuously administer supplemental oxygen at 2 liters per minute. The eMAR was signed to reflect that the resident received the supplemental oxygen continuously via nasal cannula every shift on 4/30/21.
A review of the comprehensive individualized care plan initiated on 8/13/20 reflected that the care plan for smoking was not updated after the alleged smoking violation incident on 4/30/21 until nearly a month later on 5/26/21, which indicated a new intervention to offer the resident a Nicotine patch.
The eMAR for April 2021 and May 2021 was signed every shift that the resident continued on supplemental oxygen continuously on 4/30/21. There was no documented evidence that the resident had a physician's order or received a Nicotine Patch.
A review of a Care Plan Meeting Note within the ePN dated 5/26/21 and authored by the Activities Director (AD) reflected that the Resident was unable to attend care planning meeting as [Resident #169] was in the shower. The AD also documented in this progress note that, Resident is a smoker, has not smoked the last few months d/t [due to] Covid -19 restrictions and guidelines. The resident had one violation of smoking in [their] room and was educated. Resident is non-compliant with medical advice.
The surveyor reviewed that a third smoking violation incident occurred on 6/11/2021 when an SW wrote a Behavior Note in the ePN timed at 4:09 PM for Resident #169. The note reflected: Writer received a call smoke smelled coming from room. Myself and Admin [Administrator] conducted a room search with resident present. The SW quoted the resident, who stated, I just lit it in the bathroom and put it out in the toilet. The Behavior Note concluded that the resident handed over a lighter willingly. No other smoking materials found after search completed.
The eMAR for April, May, and June 2021 was signed every shift that the resident continued to receive supplemental oxygen at 2 liters per minute via nasal cannula continuously in accordance with the physician's order, including on the date of the third smoking violation on 6/11/21.
A review of an ePN Behavior Note dated 6/11/2021 at 4:51 PM reflected that the Director of Nursing (DON) documented that Daily room checks will be done over the weekend to ensure no smoking paraphernalia is found.
A review of the comprehensive individualized care plan initiated on 8/13/20 reflected that the care plan for smoking was not updated until 6/14/21, after the alleged smoking violation on 6/11/21.
The surveyor continued to conduct interviews with facility staff. The following was revealed:
On 6/14/21 at 1:49 PM, two surveyors interviewed the SW regarding her responsibility with residents who smoke. The SW stated that her only involvement regarding residents who smoke was to provide smoking counseling and conduct a room search. The SW added that she would offer counseling regarding issues with smoking and reiterate to the resident the facility's rules and smoking requirements. The surveyor inquired if incident reports or any type of investigation were conducted for any smoking violations. She replied that the incident report would be filled out if needed if there was a smoking violation. She stated that she completed incident reports within the electronic medical record, specifically in the electronic Progress Note section. The SW said that the ePN would get attached to a 24-hour report (a shift-to-shift nursing report to communicate incidents or changes in resident condition). The SW continued that nursing staff would then know by reading the 24-hour report that they would have to go by the resident's room to make sure they didn't smell anything unusual like smoke. She stated that they would conduct a room search if necessary. The SW added that the smoking privileges would be taken away for 24 hours after the first offense. After the second offense, they would lose their privileges for a few days. The SW further stated that the consequences were spelled out in the smoking policy, which was given to all residents who smoke. She then stated, We all know what the rules are. She explained that the Recreation Department was in charge of the smoking program. The SW explained that the Activities Director (AD) distributed the list of smokers to all the nursing units. Resident #169 was taken off the list because he/she was on continuous oxygen. The SW clarified that as of recently, the resident no longer needed continuous oxygen, and therefore they were allowed to smoke. She stated that the resident's name was subsequently put back on the facility list of residents who smoke.
On 6/14/21 at 2:11 PM, the surveyor interviewed the AD, who indicated that Resident #169 was not on the smoking list because they weren't cleared to smoke until today (upon surveyor inquiry). She stated that they just reached out to the Attending Physician to add Resident #169 to the smoking list because they were cleared to smoke. When asked if there had been any violations during smoking, the AD was unaware whether-or-not Resident #169 had violated any smoking rules. The AD stated that nursing did an initial smoking screen upon admission and that the resident would need a further smoking assessment before being placed on the smoking program. She further stated that Physical Therapist would complete a safety screen for residents who qualified and wanted to smoke. She stated that she also did an initial assessment that was activity-based. The AD added that residents would sign their names in a book outside when smoking in addition to signing a smoking contract.
The AD stated that Resident #169 was not in the smoking program because he/she did not qualify. She explained that the resident kept saying that they did not smoke, and so he/she was not on the smoking list. The AD stated that Resident #169 always stated to her that he/she previously quit but had now just re-started smoking.
When asked about smoking violations and consequences, the AD explained that the first violation would result in resident education and warning. She stated that if the resident was not on the smoking list and had a smoking violation anyway, the resident could still get consequences if necessary. The AD continued that for the second violation, the resident would lose privileges for one day, and for the third violation, privileges would be lost for three days.
The AD concluded that Resident #169 now has a smoking contract. She stated that the resident was not smoking in April 2021 and had just started [smoking] today, on 6/14/21.
On 6/15/21 at 9:02 AM, a second surveyor observed five residents with the Recreation Aide (RA) outside on the patio area where smoking was permitted. The surveyor interviewed the RA, who stated that he had a binder with smoking instructions for each resident, and each resident signed a Smoking Sign Off Sheet when taking a cigarette for the date and time. The RA added that smoking times were only at 9:00 AM and 1:00 PM because several activity programs were being done in the afternoon. The surveyor interviewed a resident (Resident #109) who was present smoking and stated that there had been additional smoking times in the past, but now the times were only 9:00 AM and 1:00 PM daily.
On 6/15/21 at 9:30 AM, the surveyor conducted a second interview with the AD, who stated that she thought that the facility had stopped the smoking program in November or December 2020. She said that if staff smelled smoke in a resident room in a location not approved for smoking, they would contact the SW, who would counsel the resident and conduct a room search. When asked if she had any smoking violations on Resident #169, the AD just stated that the social worker would do a room search and an investigation. The AD did not answer the question regarding if Resident #169 had any smoking violations.
The AD provided a copy of the facility's undated Smoking Policy which included the following:
Due to the safety-related to non-compliance with the smoking policy, the following consequences will be enforced. Violations will include but are not limited to: Smoking in areas not designated for smoking, maintaining supplies/lighting materials that should be locked up, and/or smoking without supervision when assessment indicates otherwise.
1st violation-resident will be educated and given a warning.
2nd violation-resident will lose smoking privileges for one day.
3rd violation-resident will lose smoking privileges for three days.
4th violation-resident will lose smoking privileges for seven days.
5th violation-resident will lose smoking privileges in this facility.
6th violation-resident will have possible discharge from the facility.
The surveyor reviewed that the Smoking Policy was signed by Resident #169 on 6/14/21. There was no documentation provided that revealed that Resident #169 signed a Smoking Policy or other smoking contract prior to 6/14/21.
On 6/15/21 at 10:11 AM, two surveyors interviewed the DON and the LNHA. The DON explained that a smoking assessment was performed and documented on the Nursing admission Summary. She stated that if the resident answered yes that they were a smoker, the facility would initiate screening, and a smoking assessment would be done, and the AD would further complete the smoking assessment. The DON also stated that the Therapy department would be incorporated into the assessment to determine if the resident could safely hold a cigarette.
At that time, the LNHA stated, There was a period of time that we weren't allowing smoking due to the COVID-19 pandemic and the risk for the spread of infection, and instead were offering Nicotine patches. The LNHA elaborated that some residents had a desire to quit smoking.
When asked specifically about Resident #169, the DON stated that he/she wasn't medically cleared to smoke. She continued that the resident denied smoking on the Nurse's Assessment. The DON then referenced the incident that occurred on 6/11/21: The incident last Friday. I physically smelled the cigarette. [Resident #169] lit it quickly and threw it away . This is why we're trying to get to the bottom of this.
The LNHA concluded that they spoke to the nurse who wrote the note on 4/30/2021 and that the nurse did not see the resident smoking that day. He stated that his understanding was that cigarettes were only found and confiscated. The LNHA said, I was not aware that [Resident #169] was smoking in the room. We're trying to find out now. He then stated that as far as physically seeing the resident smoking .No one saw.
On 6/15/21 at 10:30 AM, the DON presented the facility's investigations for Resident #169 since 4/1/21; The surveyor had requested these files on 6/14/2021. There was no investigation or report related to the Behavior Note dated 4/18/21 regarding the resident smoking in the bathroom. One new Interdisciplinary Care Plan Intervention was added on 4/27/21 to Educate resident as needed on the dangers of smoking while being on O2. This intervention was added nine days after the actual, alleged incident.
The folder provided regarding the 4/30/21 incident contained two papers: one was a copy of the Behavior Note from the medical record written by the SW on that date. The other was an Employee Concern Report completed by the Assistant Administrator and signed by the LNHA on 4/30/21. The Detail of Concern was that cigarettes were found in Resident #169's room. Findings and Disposition: Removed smoking materials and complete room check done. Follow Up/If Applicable: Resident verbally educated that residents cannot have smoking materials in room as per our smoking policy. There were no other details provided within the investigation. There were no written statements from the LPN who discovered the resident smoking in the room while supplemental oxygen was in use or statements from any potential witnesses, including the resident. There was no investigation regarding where the resident may have obtained the smoking materials. The only intervention added to the resident's Care Plan was to Offer Nicotine Patch. This intervention was not initiated until 5/26/21, 26 days after the incident occurred. The only evidence in the medical record that the nicotine patch was offered to Resident #169 was dated ten months prior, on 8/25/20. The Care Plan Meeting Note dated 5/26/21 authored by the AD did not address that the resident was offered or refused a Nicotine Patch. It reflected that the resident was a smoker and has not smoked the last few months d/t [due to] Covid -19 restrictions and guidelines.
The investigation of the third smoking violation incident on 6/11/21, which occurred within the dates of the Recertification Survey, included statements from witnesses including the DON, LNHA, SW, and AD. The resident's Interdisciplinary Plan of Care was revised regarding smoking on 6/14/21. There was a signed daily check of the resident's room for lighters, dated 6/12/21, 6/13/21, and 6/14/21. There was a smoking policy signed by the resident, dated 6/14/21. The Smoking Violation Review, dated 6/11/21, revealed that the facility considered this incident as the resident's Level 1: First Offense, requiring a Warning with education. There was no documentation that a first or second offense was issued for either the 4/18/21 or 4/30/21 incidents.
On 6/15/21 at 11:10 AM, the surveyor attempted to conduct a phone interview with the LPN who wrote the Behavior Notes regarding Resident #169 smoking in the bathroom on 4/18/21 and 4/30/21. A message was left on the LPN's phone to contact the surveyor at the facility, but the LPN did not respond.
On 6/15/21 at 11:15 AM, the LNHA presented a timeline regarding Resident #169, which included the following information:
7/29/2020: Smoking - Safety Screen completed. Resident quit smoking.
7/30/2020: Nurse Practitioner (NP) Progress Note: History of smoking not current [sic] smoking due to medical condition.
8/13/2020: Resident told recreation that [he/she] had quit smoking and donated [his/her] cigarettes . to another resident.
8/25/2020: Resident went outside during smoke times to smoke a cigarette. Recreation staff spoke with resident about smoking. Clinically smoking is not recommended. Resident agreed to nicotine patch.
8/27/2020: NP Note: Discussed smoking cessation program.
10/8/2020: NP Note: No current smoking.
11/15/2020: Covid outbreak-Smoking put on hold.
2/26/2021: Reviewed smoking changes due to Covid- Resident states [he/she] does not have cigarettes and does not ask for any.
4/18/2021: Resident found smoking in the bathroom. Resident denied.
4/30/2021: Resident found smoking in room -social worker informed.
4/30/2021: Social worker performed room search and confiscated full pack of cigarettes and matches. [Resident #169] denied smoking in the room and states [he/she] goes outside when [he/she] wants to smoke. Resident was re-educated on policy.
5/25/2021: Resident Council - Discussed re-implementing smoking.
5/26/2021: Recreation note summarizing smoking violation.
6/11/2021: Smelled smoke from room. Room search completed. Resident educated. Daily checks put into place for residents [sic] room for smoking paraphernalia.
6/14/2021: Restarted smoking and Smoking -Safety Screen updated.
On 6/15/21 at 1:00 PM, the LNHA provided a written statement regarding a phone interview with the LPN who wrote the Behavior Notes for Resident #169. The statement revealed the following conversation that the LNHA had with the LPN:
In the 4/18/21 Behavior Note statement, the LPN stated that she had smelled a strong air freshener smell and possibly smoke when in the resident's room. She asked the resident if they were smoking. Resident
#169 denied smoking at the time. The statement did not indicate that a chain of command at the facility was made aware of the incident.
In the statement for the 4/30/21 Behavior Note, the LPN stated that she smelled smoke from the resident's room. She found the resident in the bathroom, where she believed Resident #169 might have been smoking. The resident denied smoking. The oxygen concentrator was on in the room away from the bathroom. The Supervisor and Social Services were made aware.
On 6/15/21 at 1:01 PM, the surveyor interviewed the Registered Nurse (RN), who stated that Resident #169 used supplemental oxygen when in the facility's lobby. She noted that the resident sometimes used the oxygen concentrator when in their room.
On 6/15/21 at 1:10 PM, the surveyor interviewed Resident #169, who was observed smoking in the courtyard. The resident was not receiving supplemental oxygen at that time. The resident stated that he/she was offered a nicotine patch in the past and that he/she refused it, because it didn't work.
The facility was notified of the Immediate Jeopardy (IJ) situation on 6/15/21 at 2:14 PM. The facility's LNHA and DON were informed that the facility's failure to ensure Resident #169, who had a physician's order for continuous oxygen, was properly identified, assessed, re-assessed, and monitored for smoking after the resident was allegedly noted to be smoking in the bathroom on three separate occasions on 4/18/21, 4/30/21 and 6/11/21. Further, the failure to address each of the smoking violations in accordance with their smoking policy, and revise the resident's care plan in a timely manner to ensure safe smoking practices, posed a serious and immediate threat to the safety and wellbeing of all the residents in the facility. The Removal Plan was accepted on 6/16/21 at 4:00 PM. The immediacy was removed on 6/16/21 based on the accepted implemented elements of the Removal Plan verified by the survey team on 6/16/21.
The plan included the following:
Removal Plan and Completion Date 6/16/21
On 6/11/21, members of the Interdisciplinary Team met with Resident
#169 to review the smoking violation and conduct a room search. With the resident's permission, measures were initiated on 6/11/21 and documented on a log sheet. The Unit Manager/Nursing Supervisor was charged with overseeing the log for compliance.
During the public health emergency, the smoking program was put on hold. Residents were offered smoking cessation alternatives. Smoking was reinitiated on 6/14/21.
The nursing department increased random room checks to three times per day on 6/15/21 for the resident. In-service was initiated for all front desk receptionists regarding checking packages delivered to Resident
#169. A new smoking evaluation was conducted, revealing that Resident #169 was safe to smoke with supervision. Smoking times were increased from twice daily to four times a day. The dialysis center and ambulance transport company were notified that they should not provide smoking materials to Resident #169 or any of the residents from the facility.
Staff were interviewed regarding the resident's smoking events since April 2021. Resident #169 was made aware that he/she would be searched upon return from all medical appointments. The resident was re-educated regarding the dangers of smoking with or near oxygen. All oxygen supplies were removed from the resident's room and chair, as the physician's order for the supplemental oxygen was changed from continuous to as needed.
The facility held a smoking program meeting on 6/15/21 with all residents who smoked. The facility revised the smoking evaluation and completed a new smoking evaluation on each resident that currently smokes or who formerly smoked within the past six months. An individualized care plan was completed for these residents.
The facility revised the smoking policy to include updates on violations.
Education was initiated with the direct care staff of Resident #169 to include expectations of random room checks related to smoking materials/violation of the smoking policy.
The survey team verified the Removal Plan from 6/16/21 to 6/21/21 during the remainder of this Recertification Survey.
The surveyors continued to interview facility staff and review pertinent facility documents regarding the three smoking violations.
The following was revealed:
On 6/16/21 at 11:59 AM, the surveyor interviewed the LPN who wrote the Behavior Notes on 4/18/21 and 4/30/21. The LPN stated that regarding the [second] smoking incident that occurred on 4/30/21, she had walked into the resident's room and asked if he/she was okay. The resident was in the bathroom, and as soon as they came out, the LPN stated that she could smell smoke. Even though she could smell the smoke, she asked the resident, and Resident #169 denied that he/she was smoking. The O2 concentrator was on in [his/her] room. I went to the desk to report it. Staff came upstairs right away and searched [Resident #169] room and found cigarettes and a lighter.
The surveyor reviewed the Statement Forms provided by the LNHA regarding Resident #169 in response to the surveyor's inquiry. There were two forms signed on 6/15/21 completed by a Certified Nursing Aide (CNA #1). CNA #1 wrote on one form that on 4/18/21, she smelled a special spray in the resident's bathroom, and she notified the nurse. The second Statement Form reflected that CNA #1 witnessed Resident #169 with a cigarette and called the nurse on 4/30/21.
The surveyor reviewed the eMARs for Resident #169 for April, May, and June 2021. The eMARs indicated that O2 was administered to Resident #169 continuously on every shift from 4/1/21 until the evening shift of 6/14/21, with the exception of 4/24/21 during the day shift, which documented that the resident refused the continuous oxygen that shift.
The three smoking violations and subsequent investigative reports provided to the surveyor did not include an examination of the eMAR and a determination if Resident #169 may have been using continuous oxygen on 4/18/21, 4/30/21, and 6/11/21, when the eMAR had been signed to reflect the resident was receiving the oxygen continuously every shift on those dates.
On 6/16/21 at 12:02 PM, the surveyor and the Licensed Practical Nurse/Unit Manager (LPN/UM) reviewed the current June 2021 eMAR regarding nurses' signatures for the physician's order for oxygen. The LPN/UM stated that the nurses were recording O2 saturations (O2 Sats) (a measure of the oxygen levels carried in the resident's blood) on the eMAR. Further review of the eMAR had indicated that the O2 Sats corresponded with the physician's order for O2 at 2 liters via N/C (nasal cannula) Continuous every shift for SOB. The LPN/UM added that he thought the nurses were signing for the O2 Sats and that they were not signing that they had administered O2 continuously to Resident #169.
On 6/16/21 at 12:03 PM, the surveyor interviewed LPN #1, whose signature appeared numerous times on the eMAR. LPN #1 stated that she had documented the O2 saturation levels on the dates indicated on the eMAR. LPN #1 added that she did not think that she was signing for continuous O2 administration for Resident #169.
On 6/16/21 at 1:13 PM, the surveyor interviewed the DON regarding the resident's eMAR. She stated that her understanding of the nurses signing and checking the eMAR for an order on the left-hand side stating O2 at 2 liters via N/C Continuous every shift for SOB meant that the O2 was administered as ordered.
The surveyor reviewed the Facility assessment dated [DATE]. This document included that Services and Care [are] Offered Based on our Resident's Needs. Within this section of the Assessment, the document reflected that the facility would Provide person-centered/[TRUNCATED]