Wiley Mission

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ172381 and NJ173377
Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for residents that had unwitnessed falls and sustained fractures. This deficient practice was identified for 2 (two) of 2 Residents (Resident #5 and #45) reviewed for fracture of unknown origin and was evidenced by the following:
1.) According to the quarterly Minimum Data Set, dated [DATE], an assessment that facilitates a resident's care, indicated that Resident #5 had the diagnoses that included but was not limited to cerebral vascular accident (stroke), disease (GERD) and hip fracture. The MDS also indicated that the resident was cognitively intact.
On 09/23/24 at 10:03 AM, Surveyor #1 reviewed the Facility Reportable Event (FRE) dated 03/25/24 which revealed that Resident #5 had an unwitnessed fall in the resident's room on 03/23/24. The FRE indicated that while Resident #5 was trying to get something in the nightstand, the wheelchair (w/c) got away from him/her and the resident fell. The resident complained of pain in the right hip and was sent 911 to the hospital where the resident was diagnosed with a right hip fracture.
On 09/23/24 at 10:05 AM during tour, Surveyor #1 interviewed Resident #5 who stated that on 03/23/24, he/she was trying to walk around the front of the bed and fell. Resident #5 stated that he/she was independent and did not ask for assistance at the time of the fall.
The surveyor reviewed Resident #5's electronic medical record (EMR) which revealed the following information:
The Nurse's note dated 3/23/2024 at 20:48 (08:48 PM), indicated that staff heard Resident #5 yelling for help from the resident's room. The nurse and 2 (two) Certified Nursing Assistance observed that Resident #5 was not in w/c and found the resident on the floor on his/her right side next to bed. The resident told the staff he/she was trying to get into the nightstand when he/she felt the wheelchair slip from under him/her. The staff observed the seat cushion to be halfway off w/c. The resident complained of right hip pain 7 out of 10 on the pain scale and the resident's right leg was internally rotated. The resident was transported to the hospital by emergency medical services (EMS) at 08:45pm.
On 09/24/24 at 09:56 AM, Surveyor #1 reviewed the FRE and fall investigation form, root cause analysis and the care plan which was updated with new interventions after the resident returned from the hospital. The FRE did not contain any statements from the staff the that observed the resident lying on the floor on 03/23/24.
On 09/25/24 at 09:55 AM, Surveyor #1 interviewed the Licensed Practical Nurse (LPN #1) who stated that she had been employed in the facility for 9 1/2 years. The LPN revealed that she was the nurse that had entered the resident's room after the resident had fallen. The LPN stated that she had filled out the incident event in the computer and admitted that she did not recall filling out a witness statement form. She also stated that she did not remember if the CNAs that entered the resident's room with her, filled out witness statements. The LPN also explained that the MDS Coordinator (MDSC) or someone in administration assured that the witness statements were completed when they reviewed the investigation.
On 09/25/24 at 10:07 AM, Surveyor #1 interviewed a Certified Nursing Assistant (CNA #1) who stated that she recalled that when Resident #5 was found on the floor, the resident indicated that he/she was trying get something out of the bedside drawer and slipped out of the w/c. She stated that a Registered Nurse (RN) on duty had her write a witness statement. She stated that after she wrote a statement, she brought it to the front desk and sat it on the desk and told the supervisor that the report was placed at the front desk.
On 09/25/24 at 10:24 AM, Surveyor #1 interviewed CNA #2 who stated that Resident #5 had called for help and was reaching for something on the table and scooched forward and fell. CNA #2 could not recall if she was asked to fill out a witness statement form.
On 09/25/24 at 10:30 AM, Surveyor #1 interviewed the Registered Nurse (RN #1) that CNA #1 stated had her write a witness statement. RN #1 stated that she was not present in the facility when Resident #5 fell. The RN explained the investigative process when a resident had an unwitnessed fall in the facility. She stated that an incident report, fall assessment, pain assessment, neuro-checks were all to be completed for an unwitnessed fall. She explained that all findings were documented in the medical record, progress, and incident (risk management) report. She stated that the supervisor's role was to assure the incident report was completed. She continued to add that the RN would complete the assessment and report to the Interdisciplinary Care Team (ICD) team in morning meeting. She stated that the IDC team was to assure that if the fall was unwitnessed, the nurse would be responsible to complete a witness statement and the CNAs involved would also complete a statement. RN #1 revealed that anyone involved in the incident would have to write a statement. She stated that a statement would be important to obtain so that that facility had all information regarding what, why, when, and how the fall might have occurred.
On 09/26/24 at 12:44 PM, Surveyor #1 interviewed the Director of Nursing (DON) who stated that the nurse on duty was to be notified of any resident fall that occurs. The DON explained that if a resident fell, the nurse performed an assessment of the resident and if the resident was cognitively intact, ask the resident what happened. She stated that the nurse was responsible to fill out the incident report. The DON stated a witness statement form was to be complete by the nurse. She stated that the nurse in charge was responsible to obtain a handwritten statement from the CNA who was involved. She stated that the facility goes back so many hours and obtain a statement from the nurse and the CNA who cared for the resident at that time. She stated that it was important to obtain statement to see what happened and if there was anything that needed to be addressed to prevent further reoccurrence or future falls.
On 09/27/24 at 10:48 AM, the DON admitted that the fall investigation was not completed due to lack of statements regarding the CNAs that were present in the residents room after the resident had fallen on 03/23/24.
A review of the Facility Reported Event (FRE) dated 1/6/24, revealed that Resident #45 sustained a fall that resulted in a hip fracture. Further review of the FRE did not include a thorough investigation that included staff statements and maintain documentation that the investigation was thoroughly investigation that included the progress notes of the sequence of events leading to the fall.
On 9/23/24 at 8:34 AM, Surveyor #2 observed Resident #45 in bed eating breakfast.
On 9/26/24 at 9:24 AM, Surveyor #2 attempted to speak with Resident #45 regarding the fall. When asked if they fell, Resident #45 stated, that's what they tell me. The resident was unable to recall the events leading up to or after the fall.
The surveyor reviewed the medical record for Resident #45.
A review of the admission Record revealed that Resident #45 had diagnoses which included, but were not limited to, fracture of unspecified part of neck of left femur and unspecified dementia.
A review of the quarterly MDS dated [DATE], included the resident had a Brief Interview for Mental Status score of 6 out of 15; which indicated a severely impaired cognition.
A review of Resident #45's Electronic Medical Record (EMR) Nursing Progress Note revealed an entry dated 1/6/24 at 10:30 AM that stated, Alerted by team nurse that resident had fallen in bathroom. Assist to [unknown] Ax3. Unable to move left leg and severe pain in left hip. Notified NP and daughter {name redacted} that resident will be evaluated at {name redacted}. EMS transfer. Another EMR Nursing Progress Note entry dated 1/6/24 at 11:08 AM revealed, Team nurse notified this nurse that resident was found on the floor in his bathroom. Ax3 to wheelchair. Resident unable to move his left leg and has 10/10 pain in left hip. NP and daughter notified of fall and possible left hip fracture. Sent to{name redacted} ER for evaluation.
Further review of the EMR Progress Notes identified an Interdisciplinary Care Team Note on 1/8/24 at 9:59 AM that revealed, Round up review of fall on 1/6 at 10:20 AM. Resident was found on the floor in his bathroom. Resident was combing his hair in front of sink and lost his balance. Reported 10/10 left hip pain, sent to ER and admitted with hip fracture. Will address care plan upon readmission.
A review of Resident #45's Risk Assessments did not reveal any assessments for the fall dated 1/6/24.
During an interview on 9/25/24 at 10:27 AM, Registered Nurse (RN #1) stated that fall residents are first assessed before being moved. RN #2 explained that an assessment included documentation of vital signs (blood pressure, heart rate, respirations, level of consciousness, pain, neurological check). The nurse should also document the range of motion of all extremities and how the resident was found in the room. RN #2 identified that a fall investigation should have a full investigation, which included a risk management assessment in the electronic medical record and a paper based incident assessment that would have a drawing and statements. RN #2 advised that the fall investigation are completed by the supervisor.
During an interview on 9/25/24 at 1:42 PM, the Certified Nursing Aide (CNA #3) confirmed that they were the CNA at the time of the Resident #45 fall on 1/6/24. CNA #3 stated that she found the resident on the floor and immediately got assistance. CNA #3 indicated that the registered nurse did an assessment and the resident was transferred to the hospital. When asked if they were required to write a full statement, CNA #3 responded that they only had to fill out a prompted questionnaire.
During an interview on 9/26/24 at 11:17 AM, the Licensed Nurse Practitioner (LPN #2) advised that the facility expectation for fall documentation is that a patient assessment should be completed, which included vital signs (respirations, pulse, pulse ox, blood pressure, pain), range of motion, level of consciousness and if the resident was stable, then could then be transferred to position of comfort. LPN #2 stated that a fall assessment contained two parts a risk assessment and then an incident investigation. LPN #2 reviewed the EMR nursing progress notes for the dates of Resident #45's fall. LPN #2 confirmed that the progress notes did not contain vital signs, pain, no description of the leg, how the resident was found, no orders. LPN #2 also confirmed that there was no Risk Assessment completed for the date of the fall on 1/6/24, which also should have been completed.
During an interview on 9/27/24 at 10:34 AM, the DON, in the presence of the survey team, confirmed that a thorough fall investigation was not completed based on the fact that statements were not obtained and documentation of the progress notes of how the patient was found, vital signs, and completion of the incident packet.
A review of the undated facility provided document titled, Fall Events Process directed that, 2. Supervisor or Team Leader must completed the Falls Investigation Form. This includes the Supervisor or Team Leader interviewing the staff involved, drawing a diagram of the scene, sequence of events, contributing factors and the root cause of the fall Why?? Did it happen .
On 9/27/24, the facility provided the following untitled documented dated 8/8/19 that directed, We will begin using a new Fall report form in PCC [point click care] starting next week crossed off and handwritten with 8/16/19] [ .] 6. You will choose either witnessed or unwitnessed fall [ .] In addition, the paper fall investigation form has been updated and must be completed .
A review of the undated facility provided document titled, RN and LPN Orientation with a Revision date 06/13 indicated that, incident reports [ .] get all witness statements immediately [ .] care of the falling resident (assessment & documentation) .
A review of the facility provided policy titled, Charting with a revision date of 6/2010, revealed under, Policy that all services provided to the resident or any changes in the resident condition shall be recorded in the resident's medical record. The policy further revealed under Procedure that, All treatments must be signed out on Treatment Administration Record .
NJAC 8:39-9.4(f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00171237
Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to accurately assess the status of a resident in the Minimum Data Set (MDS). This deficient practice was identified for 1 of 22 sampled residents, (Resident #37) and was evidenced by the following:
On 6/11/2021 at 9:34 AM, the surveyor observed Resident #11 in the hallway with a wander guard/elopement bracelet on his/her left ankle.
On 09/23/24 at 08:53 AM, the surveyor observed Resident #37 in the room. The surveyor did not observe an elopement device.
According to the admission Record, Resident #37 was admitted with diagnoses including but not limited to Parkinson's Disease (a disease effecting the central nervous system).
A review of the Order Summary Report with active orders as of 02/05/2024 for Resident #37, did not include a physician's order for an elopement alarm.
A review of the February 2024 Treatment Administration Record for Resident # 37 did not include a physician's order for an elopement alarm.
A review of the Quarterly MDS dated [DATE] for Resident # 37, indicated under Section P0200 for alarms was coded as 2 indicating there was a wander/elopement alarm used daily.
During an interview on 09/25/24 12:24 PM, the MDS Coordinator stated that the elopement alarm for Resident #37 was discontinued when resident went to the hospital on 2/3/24. The MDS Coordinator stated the Quarterly MDS dated [DATE] was coded incorrectly.
NJAC 8:39-11.1

**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 develop and implement a comprehensive interdiciplinary care plan that a.) specified a resident's preferences for care and; b.) meets the medical needs identified on the comprehensive assessment for 2 (two) of 17 residents reviewed for comprehensive interdiciplinary care plans, (Resident #40 and #48).
This deficient practice was evidenced by the following:
1.) According to the admission Record (AR), Resident #40 was admitted to the facility with the diagnoses which included but was not limited to; compression fracture, fusion of the spine and osteomyelitis (infection in a bone). The quarterly Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 08/03/2024, indicated that Resident #40 had moderate cognitive impairment and did not experience inattention or disorganized thinking.
On 09/23/24 at 09:02 AM during tour, Surveyor #1 interviewed Resident #40 who appeared alert and oriented and was able to express his/her needs and wants. The resident stated that he/she was exhausted and tired daily. The resident stated, Look I have bags under my eyes and had made complaints multiple time regarding getting no sleep due to staff members coming into his/her room throughout the night waking him/her up. Resident #40 stated that the staff told him/her that they are waking him up at night due to safety, however he/she felt that the staff could just observe him/her without moving and adjusting the bed. The resident also stated that the staff continue to leave the door open at night after they leave. He stated that he/her did not think that the staff communicated his/her needs to have privacy at night and that due to different staff members, all staff don't know that he/she did not want to be woken up constantly at night.
The surveyor reviewed Resident #40's comprehensive Interdisciplinary Care Plan (ICP) and there was no indication in the ICP that the resident's preference was not to be disturbed or woken up at night.
The Interdisciplinary Team Note (IDC) dated 08/15/2024 at 13:43 (01:43 PM), did not indicated that the IDC team were aware of the resident's preference that he or she did not want to be disturbed or woken up at night.
Surveyor #1 reviewed the Social Service Note dated 08/9/2024 at 17:24 (05:24 PM) did not reflect that the Social Worker (SW) was aware of Resident #40's preference not to be disturbed or woken up at night.
On 09/25/24 at 12:44 PM, Surveyor #1 interviewed the residents Registered Nurse (RN) who stated that Resident #40 had mentioned it Monday (09/23/24) to her that staff had been coming into his/her room during sleeping hours and waking him/her up. The RN stated that she explained to the resident that the nurses conducted one-hour rounds and were responsible to check on him/her. The RN stated that she did not report this resident's concern to anyone or document the resident's concern in the medical record.
On 09/25/24 at 12:49 PM, Surveyor #1 interviewed the day shift RN Supervisor who stated that Resident #40 was confused however the resident had been complaining about the staff waking him up since admission to the facility. She stated that staff were aware and that the night shift was aware, but she did not work at night and was not sure what they were doing about it. She stated that Resident #40 was occasionally incontinent, and the staff were required to change the resident at night. The RN supervisor stated, Am I wrong, or should we not change him/her at night. The surveyor explained that the resident should be able to make the decision if he wanted the staff to wake him/her up for changing. The surveyor asked the RN supervisor if a conversation was had with the resident concerning his/her preference and if he/she wanted to be woken up and changed when incontinent. The RN supervisor did not know if the staff had a conversation with the resident regarding the residents' preferences not to be woken up at night. The RN stated that the resident was confused and continued to repeat the same story repeatedly. The RN then admitted that the resident did not have a Care Plan developed according to his preferences regarding not to be woken up at night.
On 09/25/24 at 01:18 PM, Surveyor #1 interviewed the Social Worker (SW) who stated that the resident had no complaint regarding the staff waking him/her up at night a not being able to get a good night's sleep. The SW stated that if this was a concern for the resident and the staff knew about it then it should have been brought to her attention so that the resident and the staff could come up with ideas to help make sure the resident got a good night's sleep. The SW also stated that it would be important to include this preference in the resident's ICP.
On 09/25/24 at 01:43 PM, Surveyor #1 interviewed a Certified Nursing Assistant (CNA) who stated that Resident #40 was slightly confused, however he/she was able to communicate his/hers needs and wants. The CNA stated that the resident was occasionally incontinent however utilized the bathroom independently during the day and would let the staff know if he/she had an accident. She stated that the resident was continent of bowel. The CNA stated that Resident #40 only required supervision with activities of daily living (ADLs) and propelled self around the facility independently. She stated that he/she utilized his/her call bell appropriately. The CNA stated that the resident did not have any complaints to her regarding the staff waking him/her up at night. She stated that she was not the resident's regular CNA but that the resident did not complain to her today while under her care.
On 09/26/24 at 01:02 PM, Surveyor #1 interviewed the Director of Nursing (DON) who stated that it would have been importance that the staff had a meeting regarding the resident's preferences. She stated that resident's preferences should have been documented on the resident's Care Plan and on the 24-hour report so that all shifts were aware that the resident did not want to be disturbed at night.
2. A review of Resident # 48's AR revealed that, Resident # 48 was admitted with but not limited to Neuromuscular Dysfunction of Bladder ( a condition caused by the nerves along the pathway between the bladder and the brain not working properly), Retention of Bladder,( Retention of Bladder (a condition where the bladder doesn't empty all the way or at all when urinating), and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms ( enlarged prostate).
A review of the Resident #48's admission MDS dated [DATE] revealed under section H that the resident had an indwelling catheter (tube inserted in the bladder to drain urine).
A review of the current ICP for Resident #48 did not include documentation of a ICP focus area or interventions for the care of indwelling catheters.
During an interview on 09/26/2024 at 09:53 AM, Surveyor #2 interviewed the Licensed Practical Nurse (LPN) who stated, how and when to clean , any precautions, when the catheter needs to be changed, and that there should be a privacy bag, when asked what should be on the CP for a resident with an indwelling catheter. When asked if there should be a focus on the indwelling catheter on the resident's baseline CP, LPN #3 replied. yes.
During an interview on 09/26/2024 at 12:30 PM with Surveyor #2, the DON stated, that they have a catheter, what care needs to be done, and how often it is to be changed, when asked what should be on the ICP for a resident with an indwelling catheter. When asked if there should be a focus on the indwelling catheter on the resident's baseline ICP, The DON replied, yes.
A review of a facility provided policy titled Resident Assessment and Care Planning revealed under section Policy that, Dependent upon the assessment, the care plan is developed or updated in order to meet the resident's needs.
NJAC 8:39-27.1(a)

Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to a.) follow physician's order to remove a left hand appliance during the day and b.) ensure that there was an active order for a right hand appliance for 1 of 17 residents reviewed for accuracy of physician's orders (Resident #8) c.) supervise the administration of medications for 1 of 4 residents (Resident #27) reviewed for medications and evidenced by the following:
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical 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 state: 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 deficient practice was evidenced by the following:
On 9/23/2024 at 8:20 AM, during initial tour, the surveyor observed Resident #8 in the area of the nursing wing with a hand appliance on both right and left hand.
On 9/24/2024 at 12:26 PM, the surveyor observed Resident #8 in the main dining room with hand appliance on both the right and left hand.
On 9/25/2024 at 9:11 AM, the surveyor observed Resident #8 in the television area of the nursing wing with the hand appliance on both right and left hand.
The surveyor reviewed Resident #8's medical Record:
A review of the admission Record revealed that Resident #8 had diagnoses which included, but were not limited to, Parkinsonism (a set of movements associated with Parkinson's disease and other disorders that include slow movements plus one or more of the following: stiffness, walking difficulties, balance problems, tremor), and Chronic Inflammatory Demyelinating Polyneuritis (autoimmune condition that affects the myelin sheath around your peripheral nerves).
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 8/9/2024, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact.
A review of Resident #8's Order Summary Report identified the following active physician's order (PO): Left Hand Splint every evening shift ON AT BEDTIME, OFF IN MORNING. Upon review of the October Treatment Administration Record (TAR) the PO was located with a check mark and initials.
A review of the individualized comprehensive care plan (ICCP) included a focus area area dated 2/16/2023 for decline in [activities in daily living] related to advancing Parkinson's Disease [ .]. Interventions included: left hand splint on at bedtime, off in morning. The Care Plan did not specify any treatment for the right hand.
A review of Resident #8 Nurse's Aide Information Care Plan revealed an entry under section titled Adaptive Equipment: Splint: Left Hand Bedtime-On; Morning-Off. The Nurse's Aide Care Plan did not specify any treatment for the right hand.
During an interview with the surveyor on 9/25/2024 at 9:54 AM, the Certified Nursing Aide (CNA #1) stated that every resident has a resident care plan that can be viewed in their wardrobe. This care plan would identify their preferences and care needs. When asked about care needs and specialized adaptions, CNA #1 indicated that nursing was responsible for putting on and taking off any specialized equipment and ensuring specialized equipment is in use after therapy provides training and instruction. CNA #1 stated that the resident has a left palm guard that is on during the day and is off when sleeping.
During an interview with the surveyor on 9/25/2024 at 12:10 PM, the Director of Rehabilitation (DOR) informed the surveyor they were familiar with the resident and that the physician's order incorrectly identifies the resident's hand appliances and splints, which I really don't like because are palm guards. The DOR confirmed that there is only an order for the left hand and that would make more sense for me because that hand is more contracted. The DOR further stated that the right hand would not have an appliance since that hand has functional use.
During an interview with the survyeor on 9/25/2024 at 12:38 PM, the surveyor requested Registered Nurse (RN #1) to visit the room of Resident #8. At this time, RN#1 confirmed that right and left palm guards were on the resident. Upon reviewing the physicians orders, RN #1 acknowledged that the order was identified for a left palm splint that should have been removed. RN #1 further identified that there was no order for a right palm guard.
During an interview with the surveyor on 9/26/2024 at 11:14 AM, the surveyor requested Licensed Nurse Practitioner (LPN #1) to visit the main dining room where Resident #8 was engaged in activities. LPN #1 confirmed that Resident #8 was wearing right and left palm guards. LPN #1 confirmed that based on the physician order, the left palm guard should not be on and that there should not be a palm guard on the right since there was not a physician's order. LPN #1 confirmed that this appliance was not a splint and that it should have been clarified by nurses.
During an interview with the surveyor on 9/27/2024 at 9:34 AM, the Director of Nursing and Licensed Nursing Home Administration, in the presence of the survey team, confirmed that the right appliance was being applied without an order and that the left hand was not being taken off during the day.
A review of the facility provided policy titled, Physicians Orders with an unknown revision date revealed under, Procedure that, Medications, diets, therapy, or any other treatment may not be administered to the resident without the written approval from the attending physician /nurse practitioner .
A review of the facility provided policy titled, Charting with a revision date of 6/2010, revealed under, Policy that all services provided to the resident or any changes in the resident condition shall be recorded in the resident's medical record. The policy further revealed under Procedure that, All treatments must be signed out on Treatment Administration Record .
2.) On 09/24/2024 at 7:40 AM, during medication administration surveyor # 2 observed the Registered Nurse (RN #1) prepare an omeprazole capsule 40 milligram (mg) (reduce stomach acid), acidophilus capsule (probiotic supplement), glipizide tablet 10 mg (lowers blood sugar), and preservision capsule (eye supplement) to Resident #27 in a disposal paper cup. Resident #27 said to RN #1 that he/she did not want to take the acidophilus capsule and preservision capsule right now. Resident #27 swallowed the glipizide tablet 10 mg and omeprazole capsule 40 mg. Resident #27 kept the disposal paper cup with the acidophilus capsule and preservision capsule inside placing it on his/her bedside table. The RN #1 walked out of Resident #27 bedroom to the medication cart leaving the medications in the disposal paper cup in Resident #27's room on the bedside table. Surveyor #2 asked RN #1 does she always leave medications at residents' bedside, RN #1 stated, I will come back in 10 minutes as the resident does this all the time. RN #1 then went back into Resident # 27's bedroom and removed the medications from the bedside table.
During an interview with surveyor #2 on 09/24/2024 at 09:17 AM, he Director of Nursing (DON) said Resident #27 should not have medications left in the bedroom on the bedside table.
During an interview with surveyor #2 on 09/24/2024 at 1:27 PM, the Registered Nurse Charge Nurse (RNCN #1) said medications should not be left in a resident's room.
A reviewed of the facility policy and procedure on oral medication administration under special considerations number 10 revealed, Administer medication and remain with resident after medication swallowed. a.) Never leave a medication in a resident's room, except for residents with bedside storage and self-administer orders.
NJAC 8:39-29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that an indwelling urinary catheter (tube inserted in the bladder to drain urine) drainage bag was secured in a manner to prevent contamination for 1 of 1 resident reviewed for a urinary catheter, (Resident #48).
The deficient practice was evidenced by the following:
During the initial tour of the unit on 09/23/2024 at 08:44 AM, Resident #48 was in bed with a urinary catheter drainage bag in contact with the floor, with no privacy bag, and visible from the hallway. It was not secured to the bed frame.
A review of Resident # 48's admissions record revealed that, Resident # 48 was admitted with but not limited to Neuromuscular Dysfunction of Bladder ( a condition caused by the nerves along the pathway between the bladder and the brain not working properly), Retention of Bladder (a condition where the bladder doesn't empty all the way or at all during urination), and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms (enlarged prostate).
A review of the Resident #48's admission Minimum Data Set (MDS) dated [DATE] revealed under section H that the resident had an indwelling catheter.
During an interview on 09/25/2024 at 12:51 PM with the surveyor, the Infection Prevention (IP) nurse stated, Catheters should be hung below the hip or bottom rail of the bed so they don't touch the floor. When asked if there should be a privacy bag, the IP replied, in their rooms we don't have privacy bags, when out of the room they do.
During an interview on 09/25/2024 at 01:12 PM with the surveyor, the Director of Nursing (DON) stated, the foley bags should be hung on the side, never on the floor and should have privacy bags at all times.
A review of a facility policy title Using Urinary Catheter Leg Drainage Bags revealed under In Changing Leg Bag to Foley Bag that, All foley drainage bags will be covered and positioned off the floor.
N.J.A.C. 8:39-19.4(a)

Based on interview and record review, it was determined that the facility failed to ensure that appropriate assistive devices were provided to residents (Resident #8) to maintain and improve their ability to drink independently for 1 of 3 residents reviewed for activities of daily living.
The deficient practice was evidenced by the following:
On 9/23/2024 at 8:20 AM, during initial tour, the surveyor observed Resident #8 with adapted water bottle attached to the right side of resident's chair. The long flexible straw of the bottle was observed to be coiled around itself and the tip was not located near the resident's mouth, leaving the resident unable independently drink.
On 9/24/2024 at 12:22 PM, the surveyor observed Resident #8 in the main dining room being assisted during lunch. The resident's water bottle was not observed attached to the resident's chair. A staff member approached holding a new bottle and asked what the resident would like. At 12:41 PM, the resident was observed being removed from the main dining room to their room with no water bottle.
On 9/25/2024 at 9:11 AM, the surveyor observed Resident #8 in the television area of the nursing wing. The resident's water bottle was not observed attached to the resident's chair.
A review of the admission Record revealed that Resident #8 had diagnoses which included, but were not limited to, Parkinsonism (a set of movements associated with Parkinson's disease and other disorders that include slow movements plus one or more of the following: stiffness, walking difficulties, balance problems, tremor), and Chronic Inflammatory Demyelinating Polyneuritis (autoimmune condition that affects the myelin sheath around your peripheral nerves).
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 8/9/2024, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact.
A review of the individualized comprehensive care plan (ICCP) included a focus area area dated 8/15/2024 for risk related [diagnosis] of Parkinson's disease, dysphagia, need for texture modified diet [ .] . Interventions included: specialized drinking cup attached to wheelchair for independent hydration [ .].
A review of Resident #8 Nurses Aide Information Care Plan revealed an entry under section titled Adaptive Equipment: Drinking cup with straw to [wheelchair]- position straw for independent drinking.
A review of the facility requested Occupational Notes revealed a note dated 7/16/2024 [ .] spoke to nursing regarding having pt's adapted cup within reach for self hydration [ .] modification to move cup within reach [ .].
A review of Resident #8's Electronic Medical Record (EMR) Nursing Progress Note revealed an entry dated 9/11/14 at 09:55 AM that stated, Discussed placement of water bottle and straw. Will add to the care plan to ensure straw is placed properly for independent drinking. Care Plan reviewed and updated.
During an interview on 9/25/2024 at 9:54 AM, the Certified Nursing Aide (CNA #1) stated that every resident has a resident care plan that can be viewed in their wardrobe. This care plan would identify their preferences and care needs. When asked about care needs and specialized adaptions, CNA #1 indicated that nursing was responsible for putting on and taking off any specialized equipment and ensuring specialized equipment is in use after therapy provides training and instruction. The surveyor inquired if CNA #1 was familiar with Resident #8, CNA #1 confirmed and stated that they have a water adaptor bottle with a snake straw that should be positioned by the resident's head so that they can turn and sip. CNA #1 specified that Resident #8 does not like the straw in front of them, but rather to the side.
During an interview on 9/25/2024 at 12:10 PM, the Director of Rehabilitation (DOR) informed the surveyor that based on a previously held Interdisciplinary Team Meeting, Resident #8's cup should be at their side at level of head as it allowed the resident to independently increase hydration. The DOR confirmed that nursing should have been made aware of this intervention. When asked if it should be available at mealtimes, the DOR stated that it should absolutely be there during meals so that they can drink at will.
During an interview on 9/25/2024 at 12:38 PM, the surveyor requested Registered Nurse (RN #1) to visit the room of Resident #8. At this time, RN#1 confirmed that the water bottle is not on the chair and that it is the responsibility of the nursing staff to ensure that it is on the chair and that the resident has accessibility to drink.
During an interview on 9/26/2024 at 11:09 AM, the Licensed Nurse Practitioner (LPN #1) confirmed that Resident #8's water bottle should be available at their preference. The surveyor explained that on 9/24/2024, a staff member approached the resident to inquire about the water bottle but it was never given to them and the resident was brought to their room without the water bottle. LPN #1 indicated that Resident #8 does enjoy having access to their water bottle and that she recalled the resident asking for the bottle on Tuesday and it should have been given to them right away.
A review of the facility provided policy titled, Accommodation of needs and preferences and homelike environment with an unknown revision date of 7/22/2023 revealed under, Procedure that [the facility] will assess and interview [the] resident to make reasonable accommodations such as: [ .] adaptive devices necessary to maintain/restore resident at their highest level of functioning .
During an interview on 9/27/2024 at 9:34 AM, the Director of Nursing and Licensed Nursing Home Administration, in the presence of the survey team, acknowleged that the water bottle should be accessible at all times.
NJAC 8:39-27.5(b)

Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness.
This deficient practice was evidenced by the following:
On 09/23/2024 from 07:57 AM to 08:27 AM the surveyor, accompanied by the Dietary Clerk (DC), observed the following in the kitchen:
1. The surveyor observed a dietary worker walking around the kitchen with a full beard and no beard guard.
2. In refrigerator #1 an unopened package of hot dogs with a use- by-date of 09/18/2024. There was also a large metal tray of raw salmon covered with plastic wrap that was not labeled or dated. The DC removed and discarded items.
3. In refrigerator # 9 there was a plastic container of hard-boiled eggs, a plastic container of feta cheese, a plastic container of mozzarella cheese, and a plastic container of grilled chicken all with the use by date of 09/21/2024. There was also an open carton of potato salad in a plastic bag with no date. There was also a plastic container or peeled mandarin oranges with a use by date of 09/22/2024. The DC removed and discarded all items.
4. In refrigerator # 7 there were 2 tray metal trays of raw chicken wrapped in plastic labeled 9/14-12/14. When asked what those dates meant the DC stated, I am not sure what that means and removed and discarded the trays. Also found was a large plastic bin of sliced ham with a metal pan of chunks of ham inside of it all wrapped in plastic with no label or date. The DC said the ham was prepped yesterday and should have been labeled. There were also 3 crates of milk cartons directly on the floor.
5. In the walk-in freezer there was an opened bag of pepperoni slices wrapped in plastic with no label or date. The DC removed and discarded the items.
During an interview on 09/23/2024 at 11:09 AM with the surveyor, the Food Service Director (FSD) stated, Everything in the fridge and freezer should be labeled and removed after the use-by-dates. When asked if staff with beards should be wearing beard guards in the kitchen, the FSD replied, yes. When asked about milk cartons being directly on the ground the FSD replied No they shouldn't be on the ground.
During an interview on 09/25/2024 at 12:49 PM with the surveyor the Infection Preventionist (IP) stated, In the kitchen I go in early and look for anything on the floors, check the fridge temps, hairnets, that they are washing their hands. when asked what the process for surveilling the kitchen was. When asked if staff with beards should be wearing a beard guard, the IP replied Yes.
A review of an undated facility provided policy titled Employee Sanitary Practices, revealed under Procedure that All employes will: 1. Wear restraints (hairnet, hat and or beard restraint) to prevent hair from contacting exposed food.
A review of an undated facility provided policy titled Food Storage revealed under Procedure: that 10. Food should be stored at a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall with adequate space on all sides of stored items to permit ventilation . 13. Refrigerated food storage: f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. 14. Frozen foods: c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.
N.J.A.C. 8:39-17.2(g)

Based on interview and record review, it was determined that the facility failed to ensure that the pneumococcal vaccination was offered to all residents upon admission to the facility to prevent incidence of pneumonia for 2 of 5 residents (Resident #4, Resident #32) reviewed for immunization administration.
This deficient practice was evidenced by the following:
1. On 9/23/2024 at 8:38 AM, during the initial tour of the facility, the surveyor observed Resident #4 sleeping in bed in their room.
A review of Resident #4's admission Record revealed that the resident was admitted to the facility with diagnosis which included, but were not limited to, presence of unspecified artificial hip joint and encounter for other specified surgical aftercare.
A review of Resident #4's Electronic Medical Record (EMR) could not provide documentation that the resident received or declined the pneumococcal vaccination.
On 9/24/2024 at 12:26 PM, the facility provided Resident #4's computer generated immunization record that did not identify a pneumonia vaccination date. The facility also provided Resident #4's New Admission/ readmission Chart Review for Infections which indicated under Pneumovax: Yes but a ? under Date. In addition the consent boxes were not checked and the documented in electronic records were not checked.
On 9/26/2024 at 10:08 AM, during an interview with Surveyor #1, the Infection Preventionist (IP) advised that Resident #4's family could not provide any documentation that they received the Pneumovax. The IP confirmed that it is facility policy to offer the Pneumovax, which was not offered and a declination was not signed. The IP also acknowledged that it was their responsibility to ensure that their policy is followed.
On 9/12/2024 at 11:22 AM in the presence of the survey team, the Director of Nursing and Licensed Nursing Home Administrator confirmed that there was no proof on Pneumovax administration for Resident #4 and moving forward we will put it in the chart.
NJAC 8:39-19.4 (h) (i)
2. On 09/23/2024 at 8:38 AM, during the initial tour of the facility, the surveyor observed Resident #32 dressed sitting in bed reading a paper.
A review of Resident #32's admission Record revealed that the resident was admitted to the facility with diagnosis which included, but were not limited to, Myelodysplastic Syndrome (a type of rare blood cancer where you don't have enough healthy blood cells), Neutropenia (a condition where you have low levels of neutrophils, a type of white blood cell that fights infections), and Pancytopenia (a condition that lowers all three types of blood cells: red, white and platelets).
A review of Resident #32's Electronic Medical Record (EMR) could not provide documentation that the resident received or declined the pneumococcal vaccination.
On 09/24/2024 at 09:33 AM, the facility provided Resident #32's New Admission/ readmission Chart Review for Infections which indicated under Influenza and Pneumovax: NO. In addition, the consent boxes were not checked and the documented in electronic records were not checked.
During an interview on 09/25/2024 at 09:45 AM with Surveyor #2, the Infection Preventionist (IP) said that Resident #32 refuses all vaccines.
When asked if there was a declination form that the resident signed, the IP stated, No we don't have a form if they decline When asked how refusals are documented the IP replied, there is no documentations on refusals, I am not sure why.
During an interview on 09/25/2024 at 01:12 PM with Surveyor #2, The Director of Nursing (DON) stated, we don't document that at this time, I think the IP sometimes writes it on the admission check off sheet if they refuse when asked where refusals of vaccines were documented. When asked if refusals should be documented the DON stated, yes, from here on out they will be.
A review of the facility provided Immunization of Residents Policy, with a Version date of April 15, 2015, revealed under the title Procedure that, 2. All new residents (Health Care Center and Residential Health Care) must be assessed for influenza and pneumococcal vaccine upon admission: 3. Because long-term care residents are prone to developing serious complications when they contact the flu, all residents receive a flu vaccination during the fall of each year, unless otherwise ordered by the residents attending physician or the resident refuses: 5. The original consents are filed in the resident's medical record.
NJAC 8:39-19.4 (h) (i)

**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.) identify the medical symptom that warranted the use of restraints; b.) perform an assessment and evaluation for restraint use; c.) obtain a consent with disclosure of risk versus benefits for use the of a restraint; d.) conduct on-going evaluations for the continued use of the restraints; e.) monitor the residents during the use of the restraints; f.) document interventions to decrease and/or discontinue the use of the restraints and; g.) release the restraints during supervised activities. This deficient practice was identified in 1 (one) of 1 (one) residents reviewed for restraints (Residents #19) and was evidenced by the following:
Review of the admission Record indicated that Resident #19 was admitted to the facility with the diagnoses which included but was not limited to: dementia without behavior disturbance, mood disturbance and anxiety, repeated falls, and metabolic encephalopathy (a neurological disorder that occurs when a chemical imbalance in the blood affects the brain). The significant change of status Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 06/25/24, reflected that Resident #19 had severe cognitive deficits. The MDS also indicated that the resident required substantial/maximum assistance with dressing and transfers, dependent with toileting and showering. The MDS did not reflect that the resident utilized a truck restraint when in the chair or out of bed.
On 09/23/24 09:14 AM, during tour, the surveyor observed Resident #19 sitting up in the wheelchair (w/c), at the activities wearing a blue velcro seat belt. The surveyor asked the resident if he/she could remove the belt independently and the resident stated, I can't remove it. The resident was very confused and could not explain to the surveyor what the purpose of the seat belt was.
The surveyor reviewed the resident's electronic medical records (EMRs) which revealed the following:
The physician's orders dated 04/28/24 reflected a PO for a self-releasing seat belt, apply every shift while in the w/c and to check for placement every shift.
The EMR reflected that the resident was admitted to the hospital on [DATE] for a urinary tract infection and was readmitted to the facility on [DATE].
The PO dated 06/18/24 contained a PO for a self-releasing seat belt, apply every shift while in the w/c and to check for placement every shift.
A review of Resident #19's comprehensive Interdisciplinary Care Plan (CP) indicated that the resident had the self-releasing seat belt was applied on 04/29/24. There was no documentation that the resident was assessed that he could self-release the seat belt on request at the time the seat belt was applied. There was no supporting clinical documentation or medical symptom being treated or ordered for the use of the specific type of restraint. There was no evidence that ongoing reevaluation or documentation of the medical symptoms and use of the restraint for the least amount of time possible found in the medical record, and there was no documentation that the restraint could be released during supervised activities.
The Certified Nursing Assistant CP (CNACP) indicated that the resident had a seat belt applied on 04/29/24. There was no documentation on the CNACP that the seat belt could be released at intervals or during supervised activities.
The surveyor could not find any documentation in the progress notes any assessments or evaluations for the use of restraint, the medical symptom that warranted the use of restraint, a consent with disclosure of risk versus benefits for use the of a restraint, documentation of on-going evaluations for the continued use of the restraints, documentation that the resident was monitored during the use of the restraints, documentation of interventions to decrease and/or discontinue the use of the restraints or that the restraint was released during supervised activities
The Fall Assessment (FA) dated 06/18/24, indicated that the resident was a high risk for falls, however the intervention section of the FA did not indicate that the facility applied the self-releasing seat belt even though the facility received a physician's order dated 06/18/24 to apply a self-releasing seat belt every shift while the resident was in the wheelchair.
On 09/23/24 at 11:27 AM, the surveyor interviewed the resident's Certified Nursing Assistant (CNA) who stated that she did not know the last time Resident #19 had fallen. The CNA stated that Resident #19 had a seat belt on for safety. The CNA stated that the resident was able to get up and could possibly fall so therefore the seat belt prevents the resident from being able to get up on his own. The CNA stated that she believed that the resident was able to remove the belt on his/her own with instructions. The CNA accompanied the surveyor to observe Resident #19 who was sitting at the activity table wearing a velcro seat belt. The CNA asked the resident if he could remove the velcro seat belt and the resident responded that he was not able to remove the device on his/her own. Resident #19 stated, I don't think so, and no I can't take it off. When the surveyor asked the CNA if the seat belt was removed throughout the day, the CNA stated that the seat belt remained intact when the resident was OOB and that the seat belt was not removed as long as the resident was out of bed. The CNA stated that there should be a consent from the family or responsible party for the use of the seatbelt but did not know where in the medical record it could be found.
On 09/23/24 at 11:40 AM, the surveyor interviewed the Registered Nurse (RN) who stated that she had been employed in the facility for approximately one (1) year. The RN explained that Resident #19 was very confused and could not follow commands or make his/her own decisions. The RN continued to explain that the resident used to be combative however his behavior had improved since he had been treated for a urinary tract infection (UTI). She stated that Resident #19 had not had any behavior issues since then. The RN stated that the resident's family was very support and visited daily. She continued to explain that the resident had no skin issues and was incontinent of bladder and bowel. She stated that the resident had the current fall prevention interventions; bed alarm, w/c alarm, self-releasing seat belt, assist of two with transfers, and had a blue bolster in the bed and that the bed was positioned in low position. The RN stated that she thought that to use the seat belt that the facility would need consent from the family because it would be considered a restraint. She stated that the resident had cognition issues and did not even realize the seat belt was in place. She stated that the only physician order documented in the Medication Administration Record (MAR) was for the nurse to sign out that the seat belt was in place. No other physician orders were required.
The surveyor reviewed the MAR and there was an order for a self-releasing seat belt, apply every shift while in the w/c and to check for placement every shift, however there was no diagnoses for the use of the seat belt, nor were the staff documenting that the seat belt was being routinely released.
On 09/23/24 at 11:56 AM, the surveyor interviewed the RN Supervisor (RNS) who explained that self-releasing seat belts were utilized as fall prevention interventions and as long as the resident was able to release the device, it would not be considered a restraint. She stated that there must be documentation in the resident's medical record that the resident was able to release it. She stated that there would be documentation in the nurses note on the day the seat belt was applied that the resident was assessed and was able to remove the device. The RNS reviewed the residents medical record in the presence of the surveyor and admitted that there was no documentation that the resident could remove the seat belt on request and there was no assessment completed when the device was applied on 04/28/24. The RNS revealed that that facility did not need consent from the family, however the nurses let the family know verbally. The RNS reviewed Resident #19's medical record in the presence of the surveyor and admitted that the self-releasing seat belt was applied 04/28/24 and put on the resident's CP on 04/29/24. The RNS stated that she was the nurse that added the self-releasing seat belt to the resident's CP on 04/29/24.
On 09/24/24 at 10:24 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she had been employed in the facility for 26 years and the MDS Coordinator (MDSC) regarding seat belt use. The DON stated that self-releasing seat belts were utilized as positioning devices, for trunk control or for a cognitive assistance device which is a gentle reminder on not to get up without assistance. The DON explained that before application the interdisciplinary team evaluated the fall to determine the best intervention to prevent the falls. The process for application of self-releasing seat belt would be determined if the resident could demonstrate self-release at the time of application. She stated that this was determined because the resident continued to release the seat belt and continued to stand in April when it was applied but has since readmission to the facility on [DATE] had not tried to stand and get out of the w/c. She stated that at the time the seat belt was applied the nurse should have assessed and documented that the resident had demonstrated that he/she could release the seat belt. The MDS Coordinator stated that the CP interventions were reviewed each quarter to determine if the CP goals and interventions were still appropriate. The MDS coordinator stated that the nurses did not get verbal or written consent from the family because when the beat belt was applied it was not being used as a restraint.
The DON admitted that there was no clinical documentation to determine why the restraint was being used. The MDSC reviewed the residents medical record in the presence of the surveyor and a physician's order was obtained 04/28/26, discontinued on 06/13/24 when the resident was discharged to the hospital and then reordered when the resident returned from the hospital on [DATE]. The MDSC coordinator stated that a fall assessment should have been completed on 04/28/24 when an PO was received to apply the self-releasing seat belt. The MDSC and DON both admitted that the resident should have had continued assessment for the continued use of the restraint and that since it was brought to their attention that the seat belt was discontinued.
On 09/27/24 at 10:00 AM, the DON and Licensed Nursing Home Administrator (LNHA) did not provide any additional information.
According to the facility policy titled, Restraints-Physical dated 04/23/19 indicated that restraints shall only be used for safety and well-being of a resident after all other alternatives have been utilized. Prior to use of any restraint, except emergencies, it was the facility policy to inform the resident and/or representative of the behaviors creating a risk of injury; describe alternatives that have been employed to address the risk and their lack of success and advise on the risk and benefits of such devices and interventions and request consent for their use. A restraint would only be used as it is medically necessary and with a physician's order. The restraint would be least restrictive for the least amount of time with ongoing evaluation of need for use. The restraint would only be used when other alternatives fail and were documented. Medical symptoms or problems that can't be controlled must be documented in the medical record and on the Care Plan. Verbal or written consent must be obtained. The potential or risk were to be explained. The policy also indicated that the facility should attempt to remediate the resident's condition or lessen the need for the restraint and if the use of restraints is needed beyond 1 (one) week the following should be done:
-The need for the continued use of restraints should be implemented only as part of the physician's medical care plan.
-Every resident in restraints should be assessed by a RN at least every 48 hours for continued use of restraints.
-Interdisciplinary review of the record of any resident whose assessment indicated the need for continued use of restraint. This should occur within 30 days of the initiation to the use of restraints.
-Recommendation will be documented on the IDCT restraint review form.
-At regular interval and as needed the nursing staff were responsible to release restraints at least every two hours to assess for circulation, perform skin care, provide an opportunity to perform range of motion exercises, assess the need for toileting or incontinence care, ensuring adequate fluid intake, adequate nutrition, assisting with bathing and ambulation if feasible.
Review of the facility RN and LPN orientation dated 06/13, indicated that restraints such a seat belts may be ordered for upper trunk control support and should be removed during meals and activities with supervision.
NJAC 8:39-19.4(h), (i), (j)

Based on observation and interview, the facility failed to promote a home-like dining atmosphere for 1 of 1 facility dining rooms. This deficient practice was evidenced by the following:
1. On 07/13/2023 at 12:21 PM, the surveyor observed the lunch meal in the facility main dining room. The surveyor observed 30 residents present at the lunch meal. All 30 residents received their meal on a tray.
2. On 07/14/2023 at 11:55 AM, the surveyor observed the lunch meal in the facility main dining room. 25 residents were observed in the dining room. 25 residents received their lunch meal served on a tray.
3. On 07/17/2023 at 12:25 PM, the surveyor observed the lunch meal in the main dining room. There were 29 resident's present in the main dining room for the lunch meal. 29 of 29 resident's received their lunch meal on a tray.
4. On 07/18/2023 at 12:05 PM, the surveyor observed the lunch meal in the main dining room. 28 residents were present at 7 tables in the dining room. 28 residents received the lunch meal on a tray.
5. On 07/19/2023 at 12:25 PM, the surveyor observed the lunch meal in the MDR. There were 25 residents present in the dining room at the lunch meal. 25 residents were observed to receive the lunch meal on at tray.
On 07/20/2023 at 01:58 PM, the surveyor conducted an interview with the facility Licensed Nursing Home Administrator (LNHA) and the facility Director of Nursing (DON). The surveyor pointed out the facility dining practice of serving residents meals on plastic trays. The facility LNHA stated that the facility had previously not used trays to serve meals in the main dining room prior to COVID. However, once communal dining was restarted the facility had been serving meals on trays. The LNHA agreed that residents should not be served on trays as it did not create a home-like environment.
The facility did not provide a policy for home-like environment during meals.
NJAC 8:39.4(a)(12)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C/O # NJ 161082
Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to follow a physician order and care plan for the use of an abductor pillow (a device that will hold your hip in one position and help it heal) for 1 of 24 sampled residents, Resident #41. This deficient practice was evidenced by the following:
During the initial tour of the facility on 07/13/2023 at 10:25 AM, Resident #41 said he/she had a fractured arm and also fell and fractured their hip. The Resident was out of bed sitting in a wheelchair.
According to the admission Record, Resident #41 was admitted to the facility with diagnoses including but not limited to: displaced fracture of surgical neck of right humerus, Parkinson's disease, fracture left femur.
According to the Minimum Data Set, dated [DATE], an assessment tool used to facilitate care, revealed a Brief Interview for Mental Status of 12/15 indicating moderately impaired cognition. Section G indicated the resident required extensive staff assistance for bed mobility and transfers.
A review of the Order Recap Report dated 01/01/2023-01/31/2023 revealed a physician order with a order date of 01/28/2023, for Abduction Pillow every shift for L(left) hip fracture Use small pillow when out of bed and large pillow while in bed.
A review of the Order Recap Review also revealed a physician order for Acetaminophen Oral Tablet 500 milligram give 2 tablets by mouth three times a day related to unspecified fracture of the shaft of left femur, subsequent encounter for closed with routine fracture healing Two tabs=1000 milligrams.
A review of the Treatment Administration Record (TAR) revealed that the abductor pillow was signed as having been in place when in bed on 01/30/2023.
A review of the care plan revealed a Problem of ADL's: (Activities of Daily Living) Decline in ADL's related to generalized weakness readmitted with left hip fracture. Under the interventions included, the Resident has 2 abductor pillows. Smaller pillow to be utilized when out of bed. Large pillow in place while in bed.
A review of the Progress Notes revealed the following:
On 1/28/23 timed at 15:08 (3:08 PM) resident was readmitted to the facility and admission weight was taken with Hoyer lift with bed abductor pillow and both heel boots on 107.8
On 1/29/23 timed at 07:40 AM revealed resident complained of left leg pain and medicated with prn (as needed) Tylenol at 5am which was effective.
On 1/31/2023 timed at 11:36 (AM) revealed Left hip internally rotated and unable to straighten left leg. NP (Nurse Practioner) aware. Xray of left hip/femur ordered.
On 1/31/2023 timed at 18:30 (6:30 PM) revealed Xray of left hip/femur done. Impression displaced arthroplasty of left hip. NP aware. Xray faxed to MD . Will send to ER per MD. EMS arrived at 4:45pm for transport.
On 1/31/2023 timed at 22:36 (10:36 PM) Resident admitted to hospital dx (diagnosis): dislocation of left hip
A review of the facility reportable event dated 01/31/2023 revealed the Resident had an injury. Resident found that morning without the abductor pillow place between his/her legs. The Resident was complaining of left hip pain. An x-ray was done and showed left hip arthroplasty with superolateral dislocation. Resident sent to ER (emergency room) for evaluation. Under 2. prior to event was care plan developed that addressed this issue and were planned interventions in place when the event occurred. Yes care plan in place indicating that resident is to have abductor pillows in place when not in bed.
A review of the facility Post Investigation/Conclusion signed and dated by the Director of Nursing (DON) dated 2/3/23 revealed the following:
daughter reported to nursing that she entered the resident's room and found her parent in bed with right leg over the right side of the bed and his/her left leg next to it. The resident c/o pain. X-ray was done and showed left hip arthroplasty with superolateral dislocation. Was admitted and had closed reduction in the hospital under anesthesia on 2/1/23.
Spoke with 7am-3pm Certified Nursing Assistant (CNA) who stated that she entered residents room at 8am on 1/31/23 with residents breakfast ray. At this time resident was in bed and both his/her legs were in the middle of the bed. When asked about the abduction pillow the CNA said that she didn't check for it. RW was reeducated about reading the residents care plan and following it.
Interview with NA 3PM-11PM shift on 1/30/21 (clarified with DON 1/30/23) who said he didn't know the resident needed it. NA was counseled and reeducated on reading care plan on resident's door.
Interview with CNA who had the resident on 11PM-7AM shift 1/30/23. CNA stated she thought the abductor pillow was not being used anymore because it was not on the resident when she came on and the nurse who assisted her with positioning the resident never said anything about the pillow. CNA was reeducated on reading the residents care plan on the closet door and following it.
Interview with RN (Registered Nurse) who worked 7PM-7AM 1/30/23. RN stated he did not check for the abduction pillow to be in place. RN documented it was in place. He stated he completely forgot. RN was disciplined and will be meeting with staff education nurse regarding documentation.
In conclusion, resident's care plan did state that the resident was to have abduction pillow on while in bed. Orders were in place. The nurse did not follow the care plan and the 3 CNA's did not follow the care plan which was on residents closet door in the room.
All nursing staff are being reeducated on abduction pillows and following care plans.
During an interview with the surveyor on 07/19/2023 at 11:23 AM, the DON said Resident #41 did not have the abductor pillow in place. The daughter walked in the room and the abductor pillow was not in place and I started an investigation. The Resident c/o (complained of) pain and did the x-ray right then. The Resident had thrown his/her right leg over the side of bed and left leg (fractured and surgically repaired leg) was on the bed next to the right leg and I could tell by looking at it that the leg was dislocated. The resident was sent to the hospital. I determined that the nurse signed that the abductor pillow was in place and it wasn't. One aide said they thought if the nurse didn't have the abductor pillow in place, it was discontinued. The DON also said she determined staff needed a lot of in-services. The care plan did say the abductor pillow was to be in place. The DON said they in-serviced all staff and therapy was involved. The Resident's room had pictures of how the staff was supposed to have pillows placed in the chair and in the bed. Therapy assisted with all shift in-services as well. Therapy thought the foot brace to keep her knee immobilized may have played a part as it was very heavy. The DON confirmed the care plan wasn't followed. The DON said the Resident is very frail and I can't say that not using the abductor pillow caused the dislocation.
A review of a facility policy titled Resident Assessment and Care Planning with revised date of 10/25/22 revealed under the Policy section ., the care plan is developed or updated in order to meet the residents need.
NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to follow their own facility policy for weights for 1 of 3 residents (Resident #28) reviewed for nutrition. This deficient practice was evidenced by the following:
On 07/13/2023 at 10:29 AM, the surveyor observed Resident#28 at an activity group. Resident #28 had a soft cervical collar around their neck and appeared thin and cachectic.
According to the face sheet, Resident #28 was admitted to the facility with the following but not limited to diagnoses: rhabdomyolysis (a condition in which damaged skeletal muscle breaks down rapidly), dysphagia, oropharyngeal phase (difficulty swallowing), protein-calorie malnutrition, dementia, and muscle weakness.
According to the July 7th, 2023, quarterly Minimum Data Set, an assessment tool, Resident #28 had a Brief Interview for Mental Status score of 3/15, indicating severe cognitive impairment. Section G revealed Resident #28 required limited assistance with eating and Section K revealed that Resident #28 had weight loss and was not on a physician-prescribed weight loss program.
A review of the Order Summary Sheet dated July 21, 2023, revealed Resident #28 had the following physician orders: CHECK WEIGHT MONTHLY ON BATH DAY every evening shift every 4 weeks on Thursday. Use same scale & wheelchair (without footrests) if applicable. Compare to previous months weight. Document amount gained/lost in Amount box. If +/- 5LBS OBTAIN REWEIGHT WITHIN 24H (hours) IF WEIGHT REMAINS +/- 5LBS, NOTIFY NP. DOCUMENT IN 24H & DIETICIAN.
A review of the Medication Administration Record dated 7/1/2023-7/31/2023 revealed that Resident #28 had a monthly weight completed on 7/20/2023 and Resident #28 was measured at 133.7lbs
A review of the comprehensive care plan for Resident #28 revealed a care plan for nutrition. Review of the care plan revealed under Interventions/Tasks Monitor weights, meal completion, labs and skin. The care plan was undated.
On 7/18/2023 at 9:16 AM, the surveyor reviewed the medical record (MR) for Resident #28. Included in the MR was the weight record for Resident #28. The weight record revealed that Resident #28 had a documented weight of 130.1 on 5/11/2023 measured via mechanical lift. On 5/25/2023 Resident #28 had a weight of 130.1#, indicating a 9.9# weight decline. The weight on 5/25/2023 was measured via shower chair and not the mechanical lift that Resident#28 was measured by on 5/11/2023. On 6/1/2023 Resident #28 had a weight of 142.3, no scale was indicated for this weight. On 6/8/2023 Resident #28 had a weight of 129.4 measured via shower chair. This represented a weight decline of 12.9 pounds over a seven-day period. According to the physician order for weights Resident #28 should have been reweighed within 24 hours because they had a weight change that exceeded +/- 5 pounds. The next weight for Resident #28 was completed on 6/15/2023, 9 days after the weight change of +/- 5 pounds occurred.
On 07/21/2023 at 09:39 AM, the facility Director of Nursing told the surveyor, Staff has been in-serviced on our weight policy and we have ordered 2 new lift scales and we are not going to use the wheelchair and shower scales anymore.
The surveyor reviewed the facility policy titled WEIGHT POLICY, revised 11/22/11 and effective date: [DATE]. The following was revealed under the heading PROCEDURE:
1. Upon admission, all Healthcare Residents will be weighed weekly for 4 weeks. All Healthcare Center residents will be weighed the first week of each month on their bath day. All residents must be weighed on the same shift, on their bath day, using the same scale. The team leaders and supervisors are responsible for reviewing previous and current weight for all residents weekly. Trends and changes are to be documented and followed according to this policy. All weights must be recorded in the supervisor's book and in the IMAR.
2. If a weight change of +/- five (5) pounds from the previous weight occurs, the resident will be re-weighed in 48 hours. The supervisor will meet with the dietician weekly to evaluate the need for weekly weights and other interventions.
N.J.A.C. 8:39-27.1(a)

Based on observation, interview, record review, and review of other facility documentation it was determined that the facility failed to ensure that a resident received care and services for the provision of parenteral fluids (intravenous) consistent with professional standards of practice, specifically by failing to label and date, as appropriate, infusion fluids and lines for 1 of 1 resident (Resident #21) identified for Parenteral/IV Fluids.
This deficient practice was evidenced by the following:
On 7/13/2023 at 10:21 AM, during the initial tour of the facility, the surveyor observed an intravenous (IV) bag of Normal Saline Solution (NSS; fluid used for hydration) hanging from a pole in Resident #21's room. The bag had no label identifying the resident, dose, or order, and the tubing had no date on it showing when it was initiated. At that time, the NSS was not connected to the resident.
On 7/18/2023 at 9:06 AM, the surveyor observed Resident #21 in bed. At that time, the surveyor observed the bag of NSS hanging from a pole, connected to Resident #21 via peripherally inserted central catheter (PICC) located on his/her right arm. The bag of NSS had no label on it.
A review of Resident #21's quarterly Minimum Data Set (an assessment tool) dated 6/16/2023, revealed that he/she was receiving intravenous fluid while a resident in the facility.
A review of Resident #21's physician's orders revealed an ordered for Sodium Chloride External Solution 0.9% to be intravenously infused at 70 milliliters (mL) at bedtime for Acute Kidney Failure (failure of the kidneys to keep the right balance of fluid in the body).
A review of Resident #21's Care Plan with a revision date of 3/31/2023 revealed an intervention to give IV fluids as ordered, 1 liter of sodium chloride at 70mL per hour during hours of sleep.
On 7/19/2023 at 12:32 PM, during an interview with the surveyor, the Registered Nurse #1 stated that IV bags should be labeled when used.
On 7/20/2023 at 1:35 PM, during an interview with the surveyor, the Director of Nursing stated, In a semi-private room, it (IV Bag) should be labeled and the tubing dated. She further said that the label on the bag should contain the name of the resident and dosing.
The facility was unable to provide a policy referencing the labeling of IV fluids.
NJAC 8:39-25.2 (c) 5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) During the initial tour of the Healthcare Unit on 07/13/2023 at 10:46 AM, Resident #12 was observed in bed with head of the bed elevated approximately 65 degrees. Resident #12 had nasal oxygen in use via concentrator with humidification bottle in place on 2 liters per minute. The tubing was undated. Resident #12 said he/she just started with oxygen due to lung problem.
On 07/14/2023 at 08:41 AM, Resident #12 was observed sitting up in bed nasal oxygen in use 2 liters per minute with humidifier in use. The oxygen tubing was undated.
A review of the admission Record revealed Resident #12 was admitted with diagnoses including but not limited to: Pneumonia and Pulmonary Fibrosis (fibrosis means thickening or scarring of the tissue of the lungs).
A review of a significant change MDS dated [DATE] revealed a BIMS score of 12/15 indicating moderately impaired cognition. Section O indicated Resident #12 used oxygen when a resident.
A review of the Order Summary Report (OSR) with active Orders as of 07/20/2023 revealed OXYGEN 2 L every shift O2 @ __2__LPM. DOCUMENT PULSE OX. The OSR also indicated OXYGEN: CLEANING every night shift every Fri ALL NASAL CANNULAS, HUMIDIFIERS AND MASKS/OXYGEN TUBING MUST BE REPLACED EVERY FRIDAY 11-7 SHIFT.
During an interview with Surveyor #2 on 07/14/2023 at 11:53 AM, Licensed Practical Nurse (LPN #1) the assigned nurse revealed If on continuous oxygen the physician goes over orders and tells us if a resident needs oxygen to be continued. Yes, we still need physician order. LPN #1 went on to say tubing changes weekly every Friday 11-7 shift. tubing and humidifier bottle. usually have little piece of tape with nurses initials who changed it and the date.
On 07/14/2023 at 11:57 AM, LPN #1 accompanied Surveyor #2 to Resident #12's room and Surveyor #2 asked LPN #1 to show them the date on the tubing. LPN #1 said I actually don't see a date, tape is usually at the end by the concentrator. Resident #12 was interviewed at that time and said the staff changes the tubing every Friday night on 11-7 shift.
4.) During the initial tour of the Healthcare Unit on 07/13/2023 at 10:12 AM, Resident # 23 was observed sitting in his/her wheelchair (w/c) in their room. Surveyor #2 observed an oxygen cylinder on back of the w/c, turned off/not in use. The oxygen tubing was hanging over the cylinder undated, uncovered and exposed. Resident #23 said he/she does not use oxygen and doesn't become short of breath.
On 07/14/2023 at 08:38 AM, Resident #23 was observed by Surveyor #2, sitting in their w/c with the oxygen cylinder on the back of the w/c. The tubing was hanging over the cylinder, undated, uncovered and exposed.
A review of the admission Record revealed Resident #23 was admitted to the facility with diagnoses including but not limited to: Angina Pectoris (a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart).
A review of a significant change MDS dated [DATE] revealed a BIMS score of 11/15 indicating moderately impaired cognition. Section O did not include documentation of Resident #23 using oxygen while a resident.
A review of the Order Summary Report dated 04/01/2023-04/30/2023 did not include a physician order for oxygen. A review of the discontinued physician orders revealed OXYGEN VIA N/C 2-3L as needed for as needed for SOB (shortness of breath), angina with a start date of 03/25/2023 and discontinued date of 04/25/2023.
A review of Resident #23's care plan revealed a focus area of O2 (oxygen) use with an initiated date of 11/01/2022 and revised on 04/14/2023. Under the Goal Resident #23 will have no signs and symptoms of poor oxygen absorption through the review date. Interventions included: OXYGEN SETTINGS: O2 via nasal cannula at 2 l/min (2 liters/minute) As ordered.
During an interview with Surveyor #2 on 07/14/2023 at 11:53 AM, LPN #1 said Yes, we need a physician order for oxygen.
On 07/14/2023 at 11:59 AM, Surveyor #2 accompanied by LPN #1 went to Resident #23's room. LPN #1 said Resident #23 is not on oxygen any more. the LPN and surveyor observed oxygen cylinder and LPN said no tubing not to be like that. She said if oxygen tubing is not in use fold up the tubing and put tape around the end when not in use. Surveyor clarified with LPN that the tape went around the nasal cannula and she replied yes. I know sometimes the resident needs oxygen due to sob when walking with PT.
During an interview with Surveyor #2 on 07/20/2023 at 02:02 PM, the DON confirmed that a resident needs a physician order for oxygen use. The DON further explained that when oxygen therapy is discontinued, the concentrator or tank are removed from the room or wheelcahir, tubing is discarded and the concentrator is cleaned by housekeeping. Surveyor #2 questioned what is the process for updating care plans should a intervention be discontinued if no longer appropriate. The DON replied we discuss it at morning meeting and change it then. We then hang in the closet door. When Surveyor #2 asked why the oxygen was discontinued from Resident #23's care plan, the DON replied the intervention should have been discontinued.
A review of the facility policy titled, Oxygen/Nebulizer Equipment dated 2/25/2016 revealed under section, 2. Oxygen Tanks to, Replace humidifiers, masks, cannulas and oxygen tubing every 7 days by the 3-11 shift. Nurses initial and date tubing .
A review of a facility policy titled Resident Assessment and Care Planning with a revision date of 10/25/22 revealed under 11. The care plan is to be updated accordingly at the time of the MDS review and at any time changes occur in the residents status (i.e., goals are met, interventions are no longer appropropriate .).
8:39-27.1 (a)
Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to provide necessary respiratory care consistent with professional standards of practice specifically by leaving a continuous positive airway pressure (CPAP) mask exposed on top of a nightstand when not in use, failing to date nasal cannulas, and failing to appropriately store a nasal cannula when not in use and failed to update the care plan for 4 of 5 residents (Resident #1, Resident #12, Resident #21, Resident #23) investigated for Oxygen.
The deficient practice was evidenced by the following:
1.) On 7/13/2023 at 10:09 AM during the initial tour of the facility, Surveyor #1 observed Resident #1 in his/her room. At that time, Resident #1 was wearing a nasal cannula (tube used to deliver supplemental oxygen to a person). The tube did not reveal a date when it was replaced.
On 7/14/2023 at 12:24 PM during the dining observation, Surveyor #1 observed Resident #1 seated at a table in the dining room. The nasal cannula was connected to him/her. At that time, Surveyor #1 did not observe a date on the tube indicating when it was replaced. Surveyor #1 also observed some of the nasal cannula tubing in contact with the floor.
A review of Resident #1's Physician Orders located in the Electronic Medical Record (EMR) revealed an order for oxygen delivered at 2 liters per minute. The Physician Orders also revealed that nasal cannulas, humidifiers, and masks/oxygen tubing must be replaced every Friday 11-7 shift.
A review of Resident #1's Diagnosis located in the EMR revealed a diagnosis of Pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid).
A review of Resident #1's Care Plan with a revision date of 7/06/2023 located in the EMR revealed an intervention to administer oxygen as ordered.
On 7/19/2023 at 9:44 AM during an interview with Surveyor #1, the Infection Preventionist replied, No. when asked by the surveyor if tubing from a nasal cannula should ever be on the floor. She stated, Germs when asked by the surveyor why it would be important to not have the nasal cannula in contact with the floor.
On 7/20/2023 at 1:35 PM, during an interview with Surveyor #1, the Director of Nursing stated, In a plastic bag. Usually, they put it on the bedside table in the top drawer next to the bed. when asked by the surveyor how should a nasal cannula be stored when not in use. Further, the DON confirmed that a nasal cannula should never be in contact with the floor.
2.) On 7/13/2023 at 10:20 AM during the initial tour of the building while in Resident #21's room, Surveyor #1 observed a CPAP mask on the night stand next to the bed. The CPAP mask was not in a bag or stored.
On 7/18/2023 at 9:06 AM while in Resident #21's room, Surveyor #1 observed the CPAP mask on the bedside table. The CPAP mask was not in a bag or stored. At that time, during an interview with the surveyor, Resident #21 said he/she uses the CPAP every night.
A review of Resident #21's quarterly Minimum Data Set (MDS; an assessment tool) dated 6/16/2023 revealed that he/she had a Brief Interview for Mental Status score of 15, indicating that he/she was cognitively intact.
A review of Resident #21's Physician's Orders located in the Electronic Medical Record (EMR) revealed an order for him/her to use the CPAP at bedtime and to be removed in the morning. The Physician's Orders also revealed orders to clean the exterior of the CPAP surface, tubing, and to change the blue, disposable, ultra-fine filter in the CPAP.
A review of Resident #21's diagnosis located in the EMR revealed a diagnosis of Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts).
A review of Resident #21's Care Plan created on 3/21/2023 and located in the EMR revealed an intervention for Resident #21 to wear the CPAP while sleeping.
On 7/19/2023 at 12:31 PM, during an interview with Surveyor #1, Registered Nurse (RN) #1 stated that the CPAP should be stored in a bag in a drawer if possible.
On 07/21/2023 at 1:35 PM during an interview with the surveyor, the Director of Nursing replied, In a plastic bag. Usually, they put it on the bedside table in the top drawer next to the bed. when asked by the surveyor how a CPAP should be stored.

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:
On 7/13/2023 from 9:00 to 9:42 AM, the surveyor, accompanied by the Food Service Director (FSD) and Assistant Food Service Director (AFSD), observed the following in the kitchen:
1. In the dry storage room on a middle shelf an opened bag of breadcrumbs was stored inside a plastic bin. The bin was labeled Bread Crumbs and had a date of 3/3. The AFSD stated they are good for about a week after opening. We get these regularly, but the date wasn't changed. We date the bag, but this bag isn't dated. The AFSD removed the bread crumbs to the trash. On the same shelf, a clear plastic scoop used to access bulk foods was lying on the wire shelf uncovered and exposed to contamination. On the shelf directly above a stack of 3 Styrofoam bowls were not inverted and were not covered. The bowls were exposed to contamination.
2. In the cold prep area: on a metal shelf 4 stacks of cleaned and sanitized bowls were not inverted and were uncovered and exposed. The FSD stated, They probably just put them back here.
On 7/14/2023 at 12:13 PM, during the lunch meal in the main dining room the surveyors observed staff serve resident's pizza slices on the metal insert pellet with no plate on the pellet to 3 residents. One (1) resident had the pizza cut into pieces for him/her to eat. No plates were observed on the tray and staff placed the pizza slice directly onto the metal pellet insert that is utilized to keep food warm. The metal insert is not designed to be used as a surface to serve food to residents.
On 7/20/2023 at 01:58 PM, the surveyors conducted an interview with the facility Licensed Nursing Home Administrator (LNHA) and the facility Director of Nursing (DON). The surveyors asked the LNHA and DON if it was appropriate to serve pizza to residents on the metal pellet insert. The DON agreed that staff should not have served pizza on 7/14/2023 at the lunch meal on the metal pellet insert. The DON stated they had some issues with plates and staff should have waited for plates and not served the pizza on the metal pellet inserts.
On 7/17/2023 at 10:57 AM, the surveyor, accompanied by the Unit Secretary (US) and Registered Nurse (RN#2), observed the following on the health care unit pantry:
1. The surveyor observed the following foods on the shelf of the freezer door: A frozen breakfast sandwich in a plastic wrapper, appeared to be a sausage, egg, and cheese on a muffin. The sandwich had no dates and was covered with ice. An opened bag contained (2) frozen Eggo waffles. The bag was opened, and the waffles were exposed. The waffles had no dates. A plastic Zip Loc style bag contained what appeared to be a whole wheat waffle. The waffle was covered with ice and the bag was dated 5/27. On interview RN#2 stated, I think dietary is responsible for the maintenance of the pantry freezer and refrigerator. We will throw these in the trash. RN#2 and the US agreed that foods must be labeled and dated prior to storage in the freezer or refrigerator, according to facility policy.
The surveyor reviewed the facility policy titled Dry Storage Areas, undated. The following was revealed under the Procedure heading:
7. Staff will maintain care of the storeroom according to the following directions:
b. Canned and dry foods should be labeled with date of receipt so that they will be used within six months of delivery (or according to manufacturer's guidelines).
The surveyor reviewed the facility policy titled Handling Clean Equipment and Utensils, undated. The following was observed under the Procedure heading:
2. Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from splashes, dust, or other contamination. Stationary equipment will also be protected from contamination.
The surveyor reviewed the facility provided policy titled Policy & Procedure Manual, undated. The following was revealed at 4.:
a. Stored food is handled to prevent contamination and growth of pathogenic organisms. All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored.
When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food.
Leftovers are used within 72 hours (or discarded).
N.J.A.C. 8:39-17.2(g)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris. This deficient practice was evidenced by the following:
On 7/13/2023 from 9:00 to 9:42 AM, the surveyor observed the facility designated garbage area: The area consisted of what the Food Service Director (FSD) described as (4) comingled dumpster's for recyclables and (2) additional dumpster's that were designated for the facility garbage. The (4) co-mingled dumpster's for recyclables were observed to have their lids closed and no garbage was on the ground surrounding the co-mingled dumpster's. The surveyor them observed the garbage dumpster's. The facility had (2) red garbage dumpster's. One out of 2 lids on one dumpster were opened and the bagged garbage was exposed. (2) doors to access the 2nd dumpster were elevated at the top of the dumpster. The doors opened and closed by sliding them in a back-and-forth motion. Both slider doors were opened exposing the bagged garbage contents. The FSD stated that Dietary and housekeeping were responsible for maintaining the garbage area.
The surveyor reviewed the facility policy titled Waste Disposal, undated. The following was revealed under the heading Procedure:
2. Prior to disposal all waste shall be in leak-proof, non-absorbent, fireproof containers that are kept covered when not in use.
N.J.A.C. 8:39-19.3(c)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure staff implemented appropriate sanitary practice for resident care equipment, specifically by staff retrieving a nasal cannula from the floor and placing it onto 1 of 5 residents (Resident #1) investigated for Respiratory Care.
The deficient practice was evidenced by the following:
On 7/20/2023 at 10:51 AM, while inside Resident #1's room, the surveyor observed a nasal cannula (tube used to deliver supplemental oxygen to a person) on the floor behind the oxygen concentrator. Resident #1 was not in the room at this time.
A review of Resident #1's Diagnosis located in the EMR revealed a diagnosis of Pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid).
A review of Resident #1's Physician Orders located in the Electronic Medical Record (EMR) revealed an order for oxygen delivered at 2 liters per minute. The Physician Orders also revealed that nasal cannulas, humidifiers, and masks/oxygen tubing must be replaced every Friday 11-7 shift.
A review of Resident #1's Care Plan with a revision date of 7/06/2023, located in the EMR revealed an intervention to administer oxygen as ordered.
On the same date at 11:02 AM, while in the hallway, the surveyor observed Certified Nurses Aide (CNA) #1 returning Resident #1 back to his/her room. From the hallway outside the room, the surveyor observed CNA #1 retrieve the nasal cannula from the floor and place it back onto Resident #1 under his/her nostrils.
On the same date at 11:03 AM, during an interview with the surveyor, CNA #1 replied that he thinks the nasal cannula was on top of the oxygen concentrator but that he wasn't sure. He concluded his statement but saying, Honestly, I probably should have got a new one or told the nurse.
On the same date at 11:11 AM, during an interview with the surveyor, the Infection Preventionist replied, No when asked if a nasal cannula should be left on the floor attached to an oxygen concentrator. During the same interview, the Infection Preventionist replied, No when the surveyor asked if the nasal cannula should be put back onto the resident. She concluded the interview stating, There should be a bag on the side for that when the surveyor asked how the nasal cannula should be stored.
On 7/20/2023 at 1:35 PM, during an interview with the surveyor, the Director of Nursing replied, Absolutely not. when asked by the surveyor should a nasal cannula left on the floor be placed back onto a resident. She also replied, It (nasal cannula) should have been thrown out and replaced with a brand new one.
A review of the facility policy titled, Oxygen/Nebulizer Equipment with an effective date of 2/25/2016 revealed under Procedure number 7 that, All used humidifiers, tubing, masks, and cannulas must be discarded. The 3-11 team must document in the treatment record when humidifiers, tubing, masks, and cannulas are replaced. A sticker will be placed on all new tubing with the nurse's initials and date.
§ 8:39-19.4(a)

Based on observation, interview and record review it was determined the facility failed to accurately document the administration of controlled medication that ensured an accurate inventory of controlled medications. This deficient practice was identified on 1 of 2 medication carts (cart #3) reviewed and evidenced by the following:
On 11/15/21 at 11:27 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected cart #3 for LTC lounge 3 area. A review of the reconciliation of the narcotics located in the secured and locked narcotic box to the declining inventory sheet revealed that Resident #5's acetaminophen/codeine 300/30 milligram (mg), did not match the inventory. The blister pack contained 24 tablets and the declining inventory sheet indicated there should be 25 tablets remaining. The LPN stated that she had forgotten to sign the declining inventory sheet for the dose that she had administered that morning. She further acknowledged that she should have recorded on the declining inventory sheet immediately after she had administered the medication to the resident.
Further review of cart #3's narcotic reconciliation revealed Resident #11's tramadol 50 mg, did not match. The blister pack contained 67 tablets and the declining inventory sheet indicated there should be 68 tablets remaining. The LPN again stated that she had forgotten to sign the declining inventory sheet for the dose she had administered that morning. She stated that she was distracted that morning and had been trying to hurry to complete her tasks. She further acknowledged it was important to make sure to follow the process to ensure a medication was given and that the declining inventory sheet reflected an accurate count.
On 11/15/21 at 1:17 PM, the survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator LNHA). The DON stated the LPN should have signed the declining inventory sheet immediately after administering the medication and before moving on to the next resident.
On 11/18/21 at 9:25 AM, the surveyor interviewed the facility's consultant pharmacist (CP) who stated the nurse was to sign the declining inventory sheet immediately after the medication was administered to the resident. She further stated the declining inventory sheet was a legal document and that the nurse was to sign the declining inventory sheet and the electronic medication administration record (eMAR) at the same time.
A review of the facility's General Information for Medication Administration policy dated effective date 6/01/14, included that 16. The Medication Administration Record (MAR) and treatment record are to be maintained according to practice standards.
NJAC 8:39-29.7

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to a.) ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards and manufacturer's instructions and b.) maintain accurate records of medication refrigerator temperature logs. This deficient practice was identified for 1 of 1 facility medication rooms inspected and was evidenced by the following:
1. On [DATE] at 11:56 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the medication room located on the unit referred to as Health Care Area. Located in the medication refrigerator were two opened and undated liquid lorazepam bottles (a federally regulated medication used for anxiety). One bottle was prescribed for Resident #9 and the other was not for a designated resident but facility stock in an emergency. At that time, the LPN stated that the two lorazepam bottles in the refrigerator should have been dated when they were opened. The LPN stated that facility policy was the overnight shift nurse would check the expiration dates on all the medication stored in the medication room to ensure nothing was expired. The LPN further stated that a nurse should always check the expiration date before they administered any medication and should have noticed the lorazepam had not been dated when it was opened. The LPN then acknowledged that the manufacturer recommendation printed on the lorazepam box protect from light, store in refrigerator between 36-46 degrees Fahrenheit. Discard open bottle after 90 days.
At that same time, in the Health Care Area medication room, in the presence of the LPN, the surveyor reviewed the medication refrigerator temperature log. The log revealed on the following dates there were no signatures indicating that the refrigerator temperature was within the acceptable limits of 36-46 degrees Fahrenheit as required:
[DATE] PM, [DATE] AM, [DATE] PM, [DATE] PM, [DATE] PM, [DATE] PM, [DATE] PM.
The LPN stated that the medication refrigerator log should have been filled out daily at 7 AM and at 7 PM, with no blanks and that team one was responsible to check the refrigerator temperatures and recording them in the logbook.
On [DATE] at 1:17 PM, the survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The DON acknowledged the lorazepam bottles should have been dated when they were opened and the nurses knew they needed to date the lorazepam when they opened it, because they had to use it within a certain timeframe. At that same time, the DON confirmed that the medication refrigerator logs should be signed at 7 AM and 7 PM to ensure the temperature was maintained in the required range to ensure the integrity of the medications stored inside.
On [DATE] at 9:25 AM, the surveyor interviewed the facility's consultant pharmacist (CP). The CP stated that she inspects the medication rooms monthly. She further stated the medication room refrigerator should be checked at least twice a day and the logbooks should be signed as required. The CP also stated she provided the facility with a chart that listed medications with shortened expirations as a reference which included lorazepam liquid.
A review of the facility provided policy titled Storage of Medication did not address the refrigerator temperature log or the dating of medications upon opening.
NJAC 8:39-29.4 (h)