Does ARISTACARE AT CHERRY HILL have any serious inspection findings?

Yes, ARISTACARE AT CHERRY HILL has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 45 total deficiencies from recent inspections.

What are the staffing levels at ARISTACARE AT CHERRY HILL?

ARISTACARE AT CHERRY HILL has a two-star staffing rating from CMS with 0.44 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is ARISTACARE AT CHERRY HILL located?

ARISTACARE AT CHERRY HILL is located in CHERRY HILL, NJ. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ARISTACARE AT CHERRY HILL have?

ARISTACARE AT CHERRY HILL has 140 certified beds.

Who owns ARISTACARE AT CHERRY HILL?

ARISTACARE AT CHERRY HILL is a for profit - corporation facility and is part of the ARISTACARE chain.

What questions should families ask when visiting ARISTACARE AT CHERRY HILL?

Families visiting ARISTACARE AT CHERRY HILL should ask about staff retention and training programs, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does ARISTACARE AT CHERRY HILL compare to other nursing homes?

ARISTACARE AT CHERRY HILL has a 1-star overall rating, which is below average compared to other nursing homes in NJ. Families should carefully review inspection findings and consider alternatives.

ARISTACARE AT CHERRY HILL

Name: ARISTACARE AT CHERRY HILL
Address: 1399 CHAPEL AVE WEST, CHERRY HILL, NJ, 08002, US
Telephone: (856) 663-9009
Rating: 1.0

1399 CHAPEL AVE WEST, CHERRY HILL, NJ 08002 · (856) 663-9009

For profit - Corporation 140 Beds ARISTACARE Data: November 2025 2 Immediate Jeopardy citations

Trust Grade

9/100

#307 of 344 in NJ

Share this report:

ARISTACARE AT CHERRY HILL nursing home in CHERRY HILL, NJ - Photo 1 of 5

ARISTACARE AT CHERRY HILL nursing home in CHERRY HILL, NJ - Photo 2 of 5

Photo by AristaCare at Cherry Hill

ARISTACARE AT CHERRY HILL nursing home in CHERRY HILL, NJ - Photo 3 of 5

Photo by AristaCare at Cherry Hill

ARISTACARE AT CHERRY HILL nursing home in CHERRY HILL, NJ - Photo 4 of 5

Photo by AristaCare at Cherry Hill

ARISTACARE AT CHERRY HILL nursing home in CHERRY HILL, NJ - Photo 5 of 5

1 / 5 photos

Last Inspection: March 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

AristaCare at Cherry Hill has received a Trust Grade of F, indicating significant concerns and a poor overall quality of care. It ranks #307 out of 344 facilities in New Jersey, placing it in the bottom half, and #17 out of 20 in Camden County, meaning there are only a few local options that are better. Although the facility's trend is improving, with issues decreasing from 25 in 2024 to 4 in 2025, serious problems have been identified, including a critical incident where a resident choked on food due to receiving the wrong diet and a delay in emergency treatment that could have led to death. Staffing is a concern, with a rating of 2 out of 5 stars and a high turnover rate of 60%, which is above the state average. Additionally, the facility has been fined $4,194, which is average, but it has less RN coverage than 76% of New Jersey facilities, potentially impacting the quality of care residents receive.

Trust Score: F
In New Jersey: #307/344
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $4,194 in fines. Lower than most New Jersey facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for New Jersey. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 45 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 25 issues

2025: 4 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

1-Star Overall Rating

Below New Jersey average (3.2)

Significant quality concerns identified by CMS

Staff Turnover: 60%

14pts above New Jersey avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $4,194

Below median ($33,413)

Minor penalties assessed

Chain: ARISTACARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (60%)

12 points above New Jersey average of 48%

The Ugly 45 deficiencies on record

2 life-threatening

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Complaint #: NJ185404 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 6/27/2025, it was determined that the facility failed to update the care plan (CP) with interventions for a resident (Resident #1) involved in a staff to resident abuse allegation. This deficient practice was identified in 1 of 7 residents reviewed for care plans and was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility in April 2025 with diagnoses which included but were not limited to: Diabetes, Major Depressive Disorder, and Hypertension. According to the admission Minimum Data Set (MDS), an assessment tool dated 4/12/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. According to the facility's Investigation, Summary and Conclusion dated 4/11/2025, revealed the social worker was doing rounds and the resident reported that his/her Certified Nursing Assistant (CNA) was rough with him/her. Resident #1 stated yesterday when she helped me into the bed, she didn't wait for me to try and move over, she just shoved me. The investigation further revealed that Resident #1 was trying to be more independent due to going back home. The CNA did not want the resident to fall and helped the resident into the bed. A review of Resident #1's CP revealed no new updates or interventions related to the abuse allegation on 4/10/2025. On 6/27/2025 at 3:09 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the resident's care plan was not updated after the abuse allegation on 4/10/2025. The DON stated all nursing staff were responsible for updating the care plan and that it should have been updated after the abuse allegation. The DON further stated it was important to update the care plan because it tells staff how to care for the residents. Review of the facility's undated policy titled Care Plans revealed under Policy Statement, An individualized care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Under Policy Interpretation and Implementation, 4. Care plans are revised as changes in the resident's condition may dictate. NJAC 8:39-11.2 (e) (1) (2)

Feb 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

COMPLAINT#: NJ00183319, NJ00184308 Based on interview, medical record review, and review of pertinent facility documentation on 2/11/25, 2/12/25, and 2/14/25, it was determined that the facility failed to: a.) implement a care plan intervention for a physical therapy (PT) consult and b.) provide a resident with a Physical Therapy/Occupational Therapy (PT/OT) assessment after a fall as recommended by the Interdisciplinary Team (IDT). This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed and was evidenced by the following: Resident #2 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: Huntington's Disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), severe protein-calorie malnutrition, and adult failure to thrive. Review of the admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 1/23/25 indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating that the resident's cognition was moderately impaired. Review of Resident #2's Order Summary Report indicated active orders as follows: -Occupational Therapy Evaluation as needed -Physical therapy evaluation as needed A review of Resident #2's care plan indicated a focus related to the resident having actual falls. Further review revealed the following intervention, [Physical Therapy] consult for strength and mobility, that was initiated on 1/8/25. Further review of the medical record did not indicate that a PT consult was completed after this date. A review of an Incident Report dated 1/16/25 revealed, under the Conclusion section, that the IDT met to discuss the unwitnessed fall and determined that, .PT/OT will assess resident . Further review of the medical record did not indicate that a PT/OT consult was completed after this date. A review of an Incident Report dated 1/30/25 revealed, under the Conclusion section, that the IDT met to discuss the unwitnessed fall and determined that, .PT/OT will assess resident . Further review of the medical record did not indicate that a PT/OT consult was completed after this date. On 2/14/25, at 1:42 P.M., the surveyor interviewed the Director of Rehabilitation Services who stated that she would expect that a resident who fell would have been referred for a PT/OT assessment to determine if the resident would benefit from additional skilled interventions. She further stated that her department relies on Nursing to refer a resident who needed an assessment. The Director further stated that her department did not receive a referral for Resident #2 for the 1/8/25, 1/16/25, or the 1/30/25 falls. On 2/14/25, at 2:55 P.M., the surveyor interviewed the Director of Nursing (DON). In the presence of the surveyor, the DON reviewed Resident #2's care plan and incident reports. When asked if the PT/OT referrals should have been made, she stated yes. When asked what the importance of completing an assessment was, the DON stated, To determine whether or not additional needs or improvements could be made for the resident. Review of the facility's undated Care Plans policy revealed under the Policy Interpretation and Implementation section that a comprehensive care plan was designed to .f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; and g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program . The section further revealed that, .Care plans are revised as changes in the resident's condition may dictate . N.J.A.C. 8:39-27.1(a); 37.1(b)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

COMPLAINT#: NJ00183319, NJ00184308 Based on interview, medical record review, and review of pertinent facility documentation on 2/11/25, 2/12/25, and 2/14/25, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted an initial comprehensive visit. This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed and was evidenced by the following: Resident #2 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record (AR) revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: Huntington's Disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), severe protein-calorie malnutrition, and adult failure to thrive. The AR further revealed the name of the resident's Attending Physician, who was also the facility's Medical Director. Review of the admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 1/23/25 indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating that the resident's cognition was moderately impaired. Further review of Resident #2's medical record revealed Nurse Practitioner (NP) assessments; however, the surveyor was not able to locate any physician assessments for Resident #2. On 2/13/25, at 2:22 P.M., the surveyor conducted a telephone interview with the Medical Director (MD), who stated that he was familiar with Resident #2. When asked if he conducted any documented assessments of the resident, he stated that he observed the resident on the unit and he discussed the resident's care in meetings. He also stated that he went to the facility weekly, and that the facility has two Nurse Practitioners and an additional physician who are in the building during the week. Additionally, he added that patients were to be seen at time of admission and every other month. On 2/14/25, at 5:06 P.M., the surveyor informed the Chief Clinical Nurse/Administrator and the Director of Nursing (DON) of the concern that Resident #2 did not have any documented physician visits or admission assessment. The surveyor did not receive any additional documentation regarding this concern. A review of the facility's undated Medical Director policy, under the Policy Interpretation and Implementation Section, revealed, 1. Physician services are under the general supervision of the Medical Director . The policy further indicated that the MD was responsible for, .Ensuring adequate and appropriate physician services . and that the MD functions included, .Helping assure that residents receive adequate services appropriate to meet their needs . The policy failed to identify who was responsible for conducting initial comprehensive visits for residents. NJAC 8:39-23.2(d); 27.1(a)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

COMPLAINT#: NJ00181569 Based on observation, interview and review of medical records and other pertinent facility documents it was determined that the facility failed to maintain an accurately documented and complete medical records in accordance with acceptable standards and practice. This deficient practice was identified for 1 of 6 residents (Resident #4) reviewed and was evidenced by the following: Resident #4 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the admission Record revealed that Resident #4 was admitted to the facility with diagnoses that included but were not limited to: seizures, severe protein-calorie malnutrition, and COPD. Review of the admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 12/18/24 indicated that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that the resident's cognition was intact. Review of Resident #4's Order Summary Report indicated an order as follows: -Clonazepam [Klonopin] Oral Tablet 2 MG: Give 1 tablet by mouth three times a day for anxiety Review of Resident #4's Controlled Drug Administration Record Tablet, revealed that a Clonazepam 2 mg tablet was signed out on 12/13/24 at 9 P.M. A review of Resident #4's December 2024 Medication Administration Record (MAR) revealed a blank box for the above medication on 12/13/24 at 9 P.M. The surveyor reviewed a grievance that was reported on 12/17/24, by Resident #4, and revealed the following: Grievance Details - Resident stated not receiving the scheduled Klonopin on 12/13/24. Summary of Actions Taken - Indicated that the Supervisor reviewed the MAR and that no discrepancy was noted. On 2/14/25, at 10:04 A.M., the surveyor attempted to reach the Licensed Practical Nurse (LPN) that was assigned to Resident #4 on 12/13/24 during the evening shift, via telephone. The number provided by the facility was not in service and no alternate number was provided at the time of the survey. On 2/14/25, at 2:26 P.M., the surveyor interviewed the Director of Quality Experience (DQE), who reviewed the aforementioned grievance. The DQE stated that considered the grievance resolved on 1/23/25. She explained that her primary role is dealing with customer service issues. She stated that when she received information related to a grievance, she placed all information in the electronic system and then she would forward it to the Unit Manager (UM) responsible. She further added that she would then meet in-person with the UM who would inform her on what actions were taken and what the findings were and input that into the system. She would then follow-up with the resident and ensure that they were satisfied with the outcome, if they were not, she would file another grievance. The DQE stated that she recalled interacting with Resident #4 regarding this incident and she stated that the resident did not express any additional concerns, or she would have filed another grievance, which is what she would do if a resident expressed dissatisfaction with the outcome. On 2/14/25, at 2:55 P.M., the surveyor interviewed the Director of Nursing (DON). In the presence of the surveyor, the DON reviewed Resident #4's aforementioned grievance and the corresponding MAR. The DON stated that the UM was not available for interview, however, she recalled the resident. She stated that nurses are to sign the MAR after each medication is administered to reflect that this was done. She stated that although the UM verified the bingo card, and the narcotic count, she expected that the UM would have followed up with the assigned nurse regarding why the MAR was not signed. N.J.A.C. 8:39-27.1(a); 29.2(d)

Mar 2024 25 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure residents were served their meals in a dignified manner during meal services. This deficient practice was identified on 1 of 3 nursing units (Second-Floor), and was evidenced by the following: On 2/27/24 from 12:18 PM to 12:49 AM, the surveyor made the following meal observations in the Second- Floor dining room: On 2/27/24 at 12:19 PM, the food truck arrived to the Second-Floor nursing unit. There were sixteen residents observed seated in the dining room at five different tables. The Certified Nursing Aide (CNA #1) placed a tray in front of Resident #30 and walked away. Resident #30's tablemate proceeded to take Resident #30's tray and removed the dome from the tray. The surveyor observed that CNA #2 from the opposite side of the dining room addressed the resident in a raised voice stating, Leave it alone [Resident's name] [he/she] is feeder. On 2/27/24 at 12:29 PM, the surveyor observed the staff did not serve residents by tables. The surveyor observed sixteen residents were sitting in the dayroom for lunch. Seven out of the sixteen residents received their meal trays and were eating lunch. The other nine residents sat at the tables and watched their tablemate's eat. The LPN/UM stated that the other residents' meal trays were on a separate truck. At that time, the surveyor observed the LPN/UM yell out to the staff who were in the dayroom that Resident #30 was a feeder. At 12:31 PM, the surveyor observed CNA #3 spoke in a raised voice as she informed staff in the dayroom that Resident #30 was a feeder and that someone needed to feed him/her. At that time, CNA #3 stated that she would feed Resident #30. The surveyor observed that CNA #3 fed Resident #30 at a table where the other residents were feeding themselves. At 12:37 PM, the second food truck arrived on the Second-Floor nursing unit. The surveyor observed staff deliver the trays to residents in their rooms and other residents who ate in the dining room. The surveyor observed that meals were being served to both residents in the dining room and in their rooms from both dining carts. The last resident in the dining room was served at 12:42 PM. On 2/28/24 at 12:11 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated that the residents should be served by tables; staff should not refer to a resident as a feeder and that residents dependent on staff for feeding should be seated separately from residents who were independent with their meals. On 3/4/24 at 12:01 PM, the surveyor interviewed CNA #3 who acknowledged she should not have used a raised voice when she informed other staff that Resident #30 needed to be fed as it was a dignity issue. CNA #3 further acknowledged that Resident #30 should have been seated at a table where other residents also needed feeding assistance and that residents should be served by tables but that the trays don't come up that way. A review of the Mealtimes list provided by the Licensed Nursing Home Administrator (LNHA) from the entrance conference reflected that lunch on the Second-Floor nursing unit was served at 11:55 AM; 12:15 PM, and 12:30 PM. The paper indicated the delivery of meals may be fifteen minutes early or fifteen minutes late. On 3/7/24 at 11:15 AM, the LNHA acknowledged that residents should be served by tables, staff should not have discussed a resident's status publicly in the dining room where other residents and visitors were within hearing distance, and that residents who were dependent on staff should not have been seated at the same table as residents who were able to feed themselves. A review of the facility's undated Serving of Food policy included residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. A review of the facility's undated Resident Rights policy included the facility must care for you in a manner that enhances your quality of life; the facility will treat you with dignity and respect in full recognition of your individuality . N.J.A.C. 8:39-27.1(a)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Complaint #NJ160540 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) provide a wheelchair for resident use when out of bed(Resident #43); b.) maintain the call bell within reach of the resident (Resident #58); and c.) accommodate a resident whose preference was to smoke without getting wet during inclement weather (Resident #31). This deficient practice was identified for 3 of 28 residents reviewed for accommodation of needs (Resident #31, #43, and #58), and was evidenced by the following: 1. On 2/28/24 at 9:15 AM, the surveyor observed Resident #43 in bed and there was no wheelchair observed in the room. On 2/29/24 at 12:04 PM, the surveyor observed the resident in bed with head of bed elevated, eyes closed. The resident did not respond to surveyor inquiry. There was no observed wheelchair noted in the room. On 2/29/24 at 12:09 PM, the surveyor interviewed the resident's primary Certified Nurse Aide (CNA #1), who stated the resident needed complete care and she wanted to get the resident out of bed, but she did not have a wheelchair. CNA #1 stated she borrowed a wheelchair from other residents to get the resident out of bed, that it had been a month since she was able to get the resident out of bed with their own wheelchair. At this time, the CNA reported that the resident's skin was intact. On 2/29/24 at 12:23 PM, the surveyor interviewed the resident's Licensed Practical Nurse #1 (LPN #1) who stated this was the third time she was taking care of Resident #43, but to her knowledge the resident did not have a wheelchair; that they were usually kept by the resident's bed, and she had not seen one. On 2/29/24 at 12:32 PM, the surveyor interviewed the Unit Manager/LPN (UM/LPN) who stated all residents should have a way to get out of bed and that Resident #43 would need a reclining wheelchair instead of a traditional wheelchair to do so. LPN/UM #1 further stated she had been the UM/LPN on the Second-Floor nursing unit for a week, and had not once seen the resident out of bed and acknowledged she had not observed a reclining wheelchair in the resident's room. On 3/4/24 at 11:41 AM, the surveyor observed Resident #43 dressed and well-groomed in a reclining wheelchair being wheeled into the Second-Floor dayroom. The surveyor observed the chair had been labeled with the resident's name. At that time CNA #1 stated to the surveyor they got [him/her their] own chair smiling. On 3/5/24 at 11:48 AM, the surveyor interviewed the Director of Rehabilitation Services (DRS) who stated every resident should have a chair, either a wheelchair, or reclining chair unless they refused to get out of bed. The DRS stated the resident was last evaluated on 2/29/24, as a result she had been initiated for therapy services for sitting tolerance. DRS explained that sitting tolerance was getting a resident into a wheelchair to see how they tolerated sitting, and if any positioning devices were needed for support. The surevyor reviewed the medical record for Resident #44. A review of the admission Record face sheet reflected the resident was admitted to the facility with diagnoses which included dementia, hypertension, and dysphagia (difficulty swallowing). A review of the most recent quarterly Minimum Data Set (MDS), assessment tool, reflected the resident had a brief interview of mental status (BIMS) score of 00; which indicated severely impaired cognition. According to section GG Functional Abilities and Goals, the resident had functional limitations in range of motion including impairment on both sides of their upper extremities and impairment on one side of their lower extremities. For mobility devices used in the last seven days, it was indicated none of the above, meaning the resident did not use a cane/crutch, walker, wheelchair, or limb prosthesis for mobility. On 3/6/24 at 10:46 AM, the surveyor interviewed the Regional Director of Nursing (RDON) who stated each resident should have a chair in their room based on functional ability and based on therapy approval would expect the facility to provide the resident with a reclining wheelchair. 2. On 2/27/24 at 10:55 AM, the surveyor observed Resident #58 in bed with their eyes closed; the resident did not respond to the surveyor's greeting. The surveyor observed the resident's call bell (bell used to summon staff for assistance) wrapped around the circadian alert circuit (a system used to monitor resident vital signs and movement). The call bell was affixed to the top of the wall near the ceiling and was not within Resident #58's reach. On 2/28/24 at 11:52 AM, the surveyor observed Resident #58 in their bed with the call bell wrapped around the circadian alert system, not within Resident #58's reach. On 2/28/24 at 12:04 PM, the surveyor interviewed LPN #2 who stated that she had no idea what the circle on the wall was (the circadian alert system), but acknowledged that the call bell should not have been tied around it. On 2/28/24 at 12:11 PM, the surveyor accompanied by the UM/LPN entered Resident #58's room, and they observed the call bell wrapped around the circadian alert system, not within Resident #58's reach. The UM/LPN stated that the circadian alert system was used to monitor the resident's vital signs and that the call bell should not have been tied around the circadian alert system. The UM/LPN further stated that she needed to get someone taller who could reach up the wall to unwrap the call bell from the circadian alert unit. The surveyor reviewed the medical record for Resident #58. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses which included but were not limited to cardiac arrest, seizures, hypoxic-ischemic encephalopathy (a type of brain damage caused by a lack of oxygen to the brain), chronic respiratory failure, tracheostomy status (a surgical opening in the neck to the windpipe to allow air to fill the lungs) and gastrostomy status (a surgical opening into the stomach used for feeding). A review of the most recent quarterly Minimum Data Set indicated the resident had severe cognitive impairment, and was dependent on staff for all activities of daily living (ADLs). On 3/7/24 at 11:52 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the RDON, Clinical Chief Officer, and survey team acknowledged call bells should be within reach of all residents in their rooms. 3. On 2/28/24 at 9:33 AM, the surveyor observed Resident #31 seated in an electric wheelchair outside in the facility's designated smoking area. At this time, the surveyor interviewed the Activity Assistant who stated that the residents complained that there was not enough room in the designated smoking area to allow them to smoke during a rain storm without getting wet. On 2/28/24 at 9:53 AM, the surveyor interviewed Resident #31 in their room. The resident stated that the designated smoking area did not accomidate the resident to smoke while it was raining outside without getting wet. On 3/1/24 at 9:40 AM, the surveyor interviewed the Director of Activities (DOA) who stated that it was the Activity departments responsibility to monitor the residents in the designated smoking area to ensure they were smoking safely and responsibly. The DOA stated that the residents often complain that when it rained, there was not enough room for them to smoke without getting wet. On 3/7/24 at 11:52 AM, the LNHA in the presence of the RDON, Chief Clinical Officer, and survey team stated that the designated smoking area use to accomidate all the residents to smoke in inclement weather without getting wet because there was only two or three residents who smoked. The LNHA stated there was now twenty resident who went out at one time during the designated smoking times, so residents were getting wet during inclement weather. A review of the facility's undated Resident Rights policy included the facility must care for you in a manner that enhances your quality of life; treat you with dignity and respect in full recognition of your individuality; you have the right as a resident to receive services with reasonable accommodations to individual needs and preferences . A review of the facility's undated Smoking Policy included .it is the policy to provide a safe environment for our residents, staff and visitors by defining and enforcing safe smoking practices . NJAC 8:39- 31.8 (c)(9)(10)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident was free of exploitation and misappropriation of resident property. The deficient practice was identified for 1 of 6 residents reviewed for abuse (Resident #47), and was evidenced by the following: On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide would ask the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. The resident stated he/she transferred the money using money applications (app) on their phone, and CNA #1 owed him/her around $330 that was never paid back. The resident stated the facility's Director of Quality Experience (DQE) and current Licensed Nursing Home Administrator (LNHA) spoke to the resident and took pictures of the transactions on the money app, but the DQE and LNHA never did anything further. The resident stated that CNA #1 no longer worked at the facility. On 2/29/24 at 10:00 AM, a request was made to the LNHA to provide all investigations and grievances for Resident #47. On 3/4/24 at 9:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated allegations of abuse were immediately investigated. On 3/4/24 at 12:16 PM, the LNHA confirmed the surveyor had all the investigations for the resident. A review of the investigations did not include the abuse allegation made by the resident. On 3/5/24 at 11:50 AM, the surveyor interviewed the Director of Nursing (DON) and asked if the resident ever informed the facility he/she was missing anything. The DON stated there was a time there was missing money or a cell phone that she could not speak to that involved CNA #1 who no longer worked here. On 3/5/24 at 12:27 PM, the surveyor interviewed the LNHA who stated there was money exchanged with a former employee (CNA #1), and CNA #1 had not paid back Resident #47 per the resident. The LNHA stated the facility only completed a grievance since the resident was alert and oriented. The surveyor requested the grievance form. A review of the facility's undated Abuse Policy & Procedure included when an incident or suspected incident of resident abuse, neglect, misappropriation of resident property, or injury of unknown source is reported, the Administrator/Director of Nursing will immediately be notified. They will appoint a staff member to investigate the incident .The investigation shall consist of: a review of the complete Resident Abuse form for facility and F.R.I.D.A.Y. and Reportable Event Record Report for Department of Health [DOH]; interviews with the person(s) reporting the incident; interviews with any witnesses to the incident; an interview with the resident; an interview with staff members (on all shifts) having contact with the resident during the period of alleged incident; interviews with resident's roommate, family members, and visitors if applicable; interviews with other residents to which the accused employee provided care or services (if applicable); a review of circumstances surrounding the incident; review of pertinent emails. Witness statements shall be in writing. Witness will be required to sign and date such statements. A review of the Grievance Summaries dated reported 10/13/23 and resolved 10/17/23, included the following: Grievance details: resident stated [he/she] had been exchanging money via a [money] app for personal items with [CNA #1]; resident states that [he/she] has not seen the CNA, she was not responding to calls or messages and the CNA owes [him/her] money. Summary of investigation: resident reported that [he/she] had been exchanging money with an employee for them to purchase [him/her] personal items and that the employee was not responding to [his/her] calls or texts. Summary findings: resident was alert and oriented and has been sending money to now a former employee to buy [him/her] things. According to the resident, the individual owes [him/her] money and was no longer responding to [his/her] calls or texts. Summary of actions taken: Administration reached out to the former employee via phone who stated she did not owe the resident any money or items and confirmed [Resident #47] had been sending her money. She also stated when she was not able to get [him/her] the item, she would give the money back to the resident. Resident was made aware of the conversation with the employee and resident stated [he/she] made their attorney aware. The grievance did not include any witness statements from the resident, employee, other staff members, and residents; as well as no facility completed Resident Abuse Form per facility policy. The surveyor reviewed the medical record for Resident #47. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included multiple sclerosis, major depressive disorder, insomnia, and anxiety. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/20/24, reflected the resident had a brief interview for mental status score of a 15 out of 15; which indicated a fully intact cognition. A review of the individual comprehensive care plan included a focus area dated initiated 9/28/21, I sometimes lend my money to other residents despite education against it. Interventions included to educate resident not to lend money to other residents and to encourage resident to inform staff if [he/she] feels pressured to give someone money. The care plan did not include the resident gave money to staff. A review of the Progress Notes did not include any documentation on the incident. On 3/6/24 at 8:51 AM, the surveyor re-interviewed Resident #47 who stated he/she loaned CNA #1 money for the aide's personal use; that CNA #1 had never nor was ever asked to purchase the resident personal items. The resident further stated CNA #1 would take his/her personal items like shampoo and hair gel to give to other residents. The resident continued that CNA #1 told the resident the facility did not have direct deposit for their paychecks so when she needed money and did not have her paycheck yet, she would borrow money from the resident that she was at one point paying the resident back. The resident stated he/she asked CNA #1 for the money owed, and CNA #1 kept saying tomorrow. The resident stated CNA #1 used to take good care of me doing personal grooming that other aides would not, and the resident stated they felt that if [he/she] did not give CNA #1 the money, they would no longer go above and beyond with care. The resident stated that the Director of Social Services (DSS) informed him/her that staff should be giving him/her that care, and the resident should never have to give staff money for that level of care. On 3/6/24 at 9:59 AM, the surveyor interviewed the DSS and asked if she had spoken to the resident regarding any grievances with staff, and the DSS stated the only issue she recalled was from this past January where the resident and a staff member shared a phone plan, and the staff owed the resident money. The DSS stated she thought the incident involved CNA #1 who was no longer at the facility, but the LNHA, DON, and law enforcement were aware. On 3/6/24 10:19 AM, the surveyor interviewed the DQE who stated she was the person residents made their complaints to; and then she communicated it to the LNHA and DON. The DQE stated back in October or November, Resident #47 reported that a CNA (CNA #1) owed them money; and I reported it to the LNHA and DON. The DQE stated she did no investigations. On 3/6/24 at 10:46 AM, the surveyor interviewed the LNHA who stated the types of abuse were physical, verbal, mental, financial, emotional, and that all residents were at risk for abuse in the facility. On 3/6/24 at 2:29 PM, the surveyor re-interviewed the LNHA who stated since Resident #47 was alert and oriented and gave CNA #1 the money, the facility did not investigate it as abuse since we did not feel it was misappropriation of funds. The LNHA confirmed it was not facility policy for staff to accept money from residents; it would be inappropriate. The LNHA stated CNA #1 was terminated from the facility not for accepting the resident's money, but for refusing to come into the facility to provide a statement on the incident. The LNHA stated that CNA #2 had a cell phone that Resident #47 paid the bill for that the aide stopped paying the resident for, but the resident reported this to staff in January of 2024, and CNA #2 stopped working for the facility in February of 2023. The LNHA stated law enforcement was called, but CNA #2 was no longer their employee at the time of the complaint. On 3/6/24 at 3:53 PM, the surveyor asked Resident #47 who purchased their personal belongings, and the resident stated their family member; that the facility never purchased personal items for them. On 3/6/24 at 3:48 PM, the surveyor interviewed the Activities Director (AD), who stated if a resident needed personal items purchased, the resident made an individual request, and the resident's social worker received consent from the business office who released the resident's funds. The items were then purchased, and the business office was given a receipt to track the purchase. The AD continued that staff was not allowed to purchased personal items for residents; that it was against facility policy and to avoid financial issues which would be considered exploitation. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer, and survey team confirmed the incident was never investigated. The LNHA also stated that the activities staff and social worker were the staff who purchased resident's personal needs if their families could not. A review of the facility's undated Abuse Policy and Procedure policy included all reports of resident abuse, neglect, misappropriation of resident property, and injuries of unknown source shall be promptly and thoroughly investigated . NJAC 8:39-4.1(a)5

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop an abuse policy that was in accordance with regulatory guidelines and b.) implement their abuse policy for an allegation of misappropriation of resident property. This deficient practice was identified for 1 of 6 residents reviewed for abuse (Resident #47), and was evidenced by the following: During entrance conference on 2/27/24 at 10:13 AM, the surveyor requested and provided the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) with the Centers for Medicare & Medicaid Services (CMS) Entrance Conference Worksheet which indicated in section 32. Abuse Prohibition Policy and Procedures to be provided to the surveyor for the next day. On 2/28/24 at 9:00 AM, the surveyor reviewed the facility's undated Abuse Policy and Procedure which did not include how the facility would protect residents from abuse through screening, training, preventing, identification, and protecting. The policy included investigation and reporting. The reporting indicated that the facility had one business day to report to the New Jersey State Department of Health any suspected allegation of abuse, which was not in accordance with the regulation of two hours. On 2/28/24 at 10:00 AM, the surveyor asked the LNHA if the facility had any additional abuse policies, and the LNHA stated she would check. On 2/28/24 at 10:40 AM, the LNHA provided the surveyor with the facility's undated Abuse Investigations policy, and stated she believed the two abuse policies provided was all the facility had. On 2/28/24 at 1:51 PM, the LNHA provided the surveyor with the facility's undated Abuse - Identifying policy, and stated the facility had three abuse policies that were provided by the facility. On 3/4/24 at 9:08 AM, the surveyor asked the DON if she could confirm that the survey team had all the facility's abuse policies, and the DON stated she would find out. On 3/4/24 at 12:16 PM, the LNHA confirmed the facility had three abuse policies and they were all provided to the surveyor. On 3/5/24 at 10:52 AM, the surveyor interviewed the LNHA regarding how the facility prevented abuse, and the LNHA responded by educating staff; and performing background checks for any history of abuse. The surveyor asked the LNHA if she reviewed all the facility's policies including the abuse policy and the LNHA confirmed she had. The surveyor asked the LNHA if she knew the components that needed to be included in the abuse policy and she stated break down of abuse the physical emotional, financial. reporting. At this time the surveyor produced the facility's Abuse Policy and Procedure provided to the survey team, and the LNHA confirmed it was the facility's abuse policy. The surveyor asked the LNHA to identify the screening section, and the LNHA stated this policy was the in-house policy so it would not be included in there. The surveyor asked for the training portion and the LNHA confirmed was not included. The surveyor asked for the prevention section and the LNHA confirmed it was s not there. The LNHA confirmed the identification of abuse was a separate policy that was already provided to the surveyor. The LNHA stated she was aware all those elements should be in the abuse policy, and the survey team had the main abuse policy, but the facility also had additional policies. On 3/6/24 at 10:46 AM, the surveyor reviewed the facility's abuse policy with the LNHA which indicated the facility had one business day to notify the DOH of abuse, and the LNHA confirmed the facility had one day to notify. On 3/6/24 at 2:45 PM, the LNHA provided the surveyor with the facility's Abuse Prevention - Policy & Procedure Manual which included a Key Components of Systemic Approach to Prevent Abuse and Neglect which included the seven components the abuse policy needed to contain. The policy and procedure manual indicated the facility had to report allegations of abuse to the NJDOH immediately. On 3/7/24 at 10:30 AM, the LNHA stated the Abuse Prevention - Policy & Procedure Manual was used to in-service staff on abuse. 2. On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide would ask the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. The resident stated he/she transferred the money using money applications (app) on their phone, and CNA #1 owed him/her around $330 that was never paid back. The resident stated the facility's Director of Quality Experience (DQE) and current Licensed Nursing Home Administrator (LNHA) spoke to the resident and took pictures of the transactions on the money app, but the DQE and LNHA never did anything further. The resident stated that CNA #1 no longer worked at the facility. On 3/5/24 at 11:50 AM, the surveyor interviewed the Director of Nursing (DON) and asked if the resident ever informed the facility he/she was missing anything. The DON stated there was a time there was missing money or a cell phone that she could not speak to that involved CNA #1 who no longer worked at the facility. On 3/5/24 at 12:27 PM, the surveyor interviewed the LNHA who stated there was money exchanged with a former employee (CNA #1), and CNA #1 had not paid back Resident #47 per the resident. The LNHA stated the facility only completed a grievance form since the resident was alert and oriented. The surveyor requested the grievance form. A review of the facility's undated Abuse Policy & Procedure included when an incident or suspected incident of resident abuse, neglect, misappropriation of resident property, or injury of unknown source is reported, the Administrator/Director of Nursing will immediately be notified. They will appoint a staff member to investigate the incident .The investigation shall consist of: a review of the complete Resident Abuse form for facility and F.R.I.D.A.Y . A review of the Grievance Summaries dated reported 10/13/23 and resolved 10/17/23, included the following: Grievance details: resident stated [he/she] had been exchanging money via a [money] app for personal items with [CNA #1]; resident states that [he/she] has not seen the CNA, she was not responding to calls or messages and the CNA owes [him/her] money. Summary of investigation: resident reported that [he/she] had been exchanging money with an employee for them to purchase [him/her] personal items and that the employee was not responding to [his/her] calls or texts. Summary findings: resident was alert and oriented and has been sending money to now a former employee to buy [him/her] things. According to the resident, the individual owes [him/her] money and was no longer responding to [his/her] calls or texts. Summary of actions taken: Administration reached out to the former employee via phone who stated she did not owe the resident any money or items and confirmed [Resident #47] had been sending her money. She also stated when she was not able to get [him/her] the item, she would give the money back to the resident. Resident was made aware of the conversation with the employee and resident stated [he/she] made their attorney aware. The grievance did not include any witness statements from the resident, employee, other staff members, and residents; as well as no facility completed Resident Abuse Form per facility policy. On 3/6/24 at 8:51 AM, re-interviewed Resident #47 who stated he/she loaned CNA #1 money for the aide's personal use; that CNA #1 had never nor was ever asked to purchase the resident personal items. The resident continued that CNA #1 told the resident the facility did not have direct deposit for their paychecks so when she needed money and did not have her paycheck yet, she borrowed money from the resident. Resident #47 stated CNA #1 was paying back the borrowed money, but then the aide stopped paying back the resident. The resident stated he/she asked CNA #1 for the money owed, and CNA #1 who tell the resident Tomorrow. The resident stated CNA #1 used to take good care of me doing personal grooming that other aides would not, and the resident felt that he/she did not give CNA #1 the money, they would no longer go above and beyond with care. On 3/6/24 at 10:46 AM, the surveyor asked the LNHA what the types of abuse were, and the LNHA responded physical, verbal, mental, financial, emotional. The surveyor asked the LNHA who was susceptible to abuse in the facility and the LNHA stated all residents were at risk for abuse in the facility. The LNHA stated at first Resident #47's complaint was CNA #1 would not return his/her phone calls, and then the facility was informed CNA #1 owed the resident money. The LNHA sated CNA #1 refused to come in to provide a statement, so she was terminated, and the grievance was the resident's statement. On 3/6/24 at 11:33 AM, the surveyor requested a copy of the facility's Resident Abuse Form from the facility's abuse policy, and the LNHA stated the facility did not have that form. The surveyor asked about the F.R.I.D.A.Y. in the abuse policy, and the LNHA stated that was a state form that the facility reported to. On 3/6/24 at 2:29 PM, the surveyor re-interviewed the LNHA who stated since Resident #47 was alert and oriented and gave CNA #1 the money, the facility did not investigate it as abuse since we did not feel it was misappropriation of funds. The LNHA confirmed it was not facility policy for staff to accept money from residents; it would be inappropriate. The LNHA stated CNA #1 was terminated from the facility not for accepting the resident's money, but for refusing to come into the facility to provide a statement. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer, and survey team confirmed the incident was never investigated, and the incident was not reported to any state agencies. The LNHA also stated that the activities staff and social worker were the staff who purchased residents' personal needs if their families could not. Refer F602; F609; F610 NJAC 8:39-4.1(a)5

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 5 residents reviewed for unnecessary medications (Resident #80), and was evidenced by the following: On 2/29/24 at 11:50 AM, the surveyor observed Resident #80 in a wheelchair in the hallway self-propelling using their feet. The surveyor reviewed the medical record for Resident #80. A review of the admission Record face sheet (an admission summary) reflected that Resident #80 was admitted to the facility with diagnoses that included schizophrenia, bipolar disorder, cerebral infarction (stroke- parts of the brain become damaged or die). A review of the Psychiatric Progress Noted dated 2/12/24 included under diagnosis and plan that the resident had a current diagnosis of schizoaffective disorder- depressed type, insomnia, and Post Traumatic Stress Disorder (PTSD). A review of the resident's most recent comprehensive MDS, an assessment tool dated 12/6/23, reflected a brief interview for mental status (BIMS) score of 15 out of 15; which indicated a fully intact cognition. A further review in Section I- Active Diagnoses did not include PTSD. On 3/6/24 at 9:32 AM, the surveyor interviewed the MDS Coordinator who stated she gathered information to complete the assessments from interviews with the resident and family, review of the resident's medical record including physician's progress. At that time, the surveyor reviewed with the MDS Coordinator the Physician Progress Note dated 2/12/24, that included the diagnosis of PTSD and the most recent MDS dated [DATE]. The MDS Coordinator acknowledged the MDS should have included the PTSD diagnosis in Active Diagnoses, and that she needed to modify the MDS to include the diagnosis. On 3/6/24 at 12:41 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who acknowledged the MDS Coordinator had just updated the MDS to include the diagnosis of PTSD, but should have been included on the most recent comprehensive MDS. A review of the facility's undated MDS submission Timeframes policy did not include the process for completing a MDS assessment. NJAC 8:39-33.2 (d)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified services to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. This deficient practice was identified for 3 of 28 residents reviewed for comprehensive care plans (Resident #45, #80, and #102), and was evidenced by the following: 1. On 2/28/24 at 10:18 AM, the surveyor observed Resident #45 sleeping in bed on his/her right side. The surveyor reviewed the medical record for Resident #45. A review of the admission Record face sheet (an admission summary), Resident #45 was admitted to the facility with diagnoses including, but not limited to, osteomyelitis (infection of the bone) of left femur, pressure ulcer (Stage 4) left hip, and heart failure. A review of the admission Minimum Data Set (MDS), an assessment tool reflected that the resident was not able to complete the brief interview for mental status (BIMS). A further review of Section M Skin Conditions identified that the resident was admitted with one stage 4 pressure ulcer (wound that extends past the fat layer into deep tissues including muscle, tendon, and ligament). A review of the Order Summary Report identified the following active physician's order (PO): Monitor Resident for urine output [every] shift. Notify [doctor] if no urine output [over] eight hours for urinary retention; document in progress notes how many wet briefs resident has per shift with a start date of 1/24/24. A review of the corresponding February 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) the PO was located, and the nurses signed with a check mark and their initials. A Further review of the TAR identified wound treatment orders. A review of individualized comprehensive care plan did not include the interventions regarding the monitoring of urine output; documentation of wet diapers; or the stage 4 wound care orders. On 3/5/24 at 12:58 PM, the surveyor interviewed LPN #2, who stated that a care plan should promote resident's current health status and dictated their overall care. LPN #2 confirmed that the resident's intervention for urinary retention, along with the wound and its intervention, should be identified on the care plan. On 3/6/24 at 9:48 AM, the surveyor spoke with Unit Manager/Licensed Practical Nurse (UM/LPN #1) who confirmed that the resident's interventions, including regarding the documentation of wet diapers and contact the physician regarding urinary retention, should be identified on the care plan. UM/LPN #1 further acknowledged that the resident's wound and its treatments should be identified on the care plan. Upon review of Resident #45's care plan, UM/LPN #1 verified that these focus areas were not included. On 3/7/24 at 11:32 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), in the presence of Regional Director of Nursing (RDON) and Chief Clinical Officer, who acknowledged that a care plan should be updated as needed to include relevant interventions. 2. On 2/29/24 at 11:50 AM, the surveyor observed Resident #80 in a wheelchair in the hallway self-propelling using their feet. The surveyor reviewed the medical record for Resident #80 A review of the admission Record face sheet reflected the resident was admitted to the facility with diagnoses that included schizophrenia, bipolar disorder, cerebral infarction (stroke- parts of the brain become damaged or die). A review of the Psychiatric Progress Noted dated 2/12/24, included under diagnosis and plan a current diagnosis of schizoaffective disorder- depressed type, insomnia, and Post Traumatic Stress Disorder (PTSD). A review of the resident's most recent comprehensive MDS dated [DATE], reflected a BIMS score of 15 out of 15; which indicated a fully intact cognition. A further review in Section I- Active Diagnoses, PTSD was not indicated. A review of the individual comprehensive care plan did not include any focuses, goals or interventions related to the resident's diagnosis of PTSD. On 3/6/24 at 9:32 AM, the surveyor interviewed the MDS Coordinator who stated she gathered information to complete the assessments from interviews with the resident and family and review of the resident's medical record including physician's progress notes. At this time, the surveyor reviewed with the MDS Coordinator the Physician Progress Note dated 2/12/24, that included the diagnosis of PTSD and the most recent MDS dated [DATE]. The MDS Coordinator acknowledged the MDS should have reflected the PTSD diagnosis and that she would need to modify the MDS. On 3/06/24 at 10:36 AM, the surveyor reviewed with the Regional Director of Nursing (RDON) the resident's current diagnoses, which now included PTSD. The RDON stated she expected that PTSD would be addressed in the care plan, since the purpose of the care plan was to share information to take the best care of the patient possible. The surveyor and the RDON then reviewed the resident's current care plan, and she acknowledged it did not include a focus, goal or intervention to address resident's PTSD diagnosis. On 3/6/24 at 12:41 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who acknowledged the care plan should have included the resident's diagnosis of PTSD. A review of the facility provided Baseline Care Plan Completion and Ongoing Care Plan Updates policy, dated 11/17/17, included .The comprehensive care plan will described the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing .Nursing staff will update the care plan related to physician's orders and/or changes in care needs follow a uniform process for the comprehensive care plan upon Care Area Assessment(CAA) completion, and ensuring care plans are updated to reflect the resident's status . Ongoing updates to care plans: nursing staff will update the care plan related to physician's orders and/or changes in care needs . update acute care plans for the resident as they are warranted. A review of the facility provided undated LPN Nurse Job Position document included .Review care plans daily to ensure that appropriate care is being rendered. Inform the Nursing Supervisor of any changes that need to be made on care plan. Ensure that your nurses' notes reflect that the care plan is being followed when administering care or treatment .Ensure that your assigned [CNAs] are aware of the resident care plans. Ensure that the CNA's refer to the resident's care plan prior to administering daily care to the resident . A review of the facility provided undated Unit Manager Nurse Job Position document included .Adjusts care plan when indicated. Care plans can and should be updated by the Unit Manager as situations present. NJAC 8:39-11.2(e) thru (i); 27.1(a),(d)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide asked the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. The resident stated he/she transferred the money using money applications (app) on their phone, and CNA #1 owed him/her around $330 that was never paid back. The resident stated the facility's Director of Quality Experience (DQE) and current Licensed Nursing Home Administrator (LNHA) spoke to the resident and took pictures of the transactions on the money app, but the DQE and LNHA never did anything further. The resident stated that CNA #1 no longer worked at the facility. On 3/5/24 at 11:50 AM, the surveyor interviewed the Director of Nursing (DON) and asked if the resident ever informed the facility he/she was missing anything. The DON stated there was a time there was missing money or a cell phone that she could not speak to that involved CNA #1 who no longer worked here. On 3/5/24 at 12:27 PM, the surveyor interviewed the LNHA who stated there was money exchanged with a former employee (CNA #1), and CNA #1 had not paid back Resident #47 per the resident. The LNHA stated the facility only completed a grievance since the resident was alert and oriented. The surveyor requested the grievance form. A review of the Grievance Summaries dated reported 10/13/23 and resolved 10/17/23, included the following: Grievance details: resident stated [he/she] had been exchanging money via a [money] app for personal items with [CNA #1]; resident states that [he/she] has not seen the CNA, she was not responding to calls or messages and the CNA owes [him/her] money. Summary of investigation: resident reported that [he/she] had been exchanging money with an employee for them to purchase [him/her] personal items and that the employee was not responding to [his/her] calls or texts. Summary findings: resident was alert and oriented and has been sending money to now a former employee to buy [him/her] things. According to the resident, the individual owes [him/her] money and was no longer responding to [his/her] calls or texts. Summary of actions taken: Administration reached out to the former employee via phone who stated she did not owe the resident any money or items and confirmed [Resident #47] had been sending her money. She also stated when she was not able to get [him/her] the item, she would give the money back to the resident. Resident was made aware of the conversation with the employee and resident stated [he/she] made their attorney aware. The surveyor reviewed the medical record for Resident #47. A review of the admission Record face sheet reflected the resident was admitted to the facility with diagnoses which included multiple sclerosis, major depressive disorder, insomnia, and anxiety. A review of the most recent comprehensive MDS dated [DATE], reflected the resident had a brief interview for mental status score of a 15 out of 15; which indicated a fully intact cognition. A review of the individual comprehensive care plan included a focus area dated initiated 9/28/21, I sometimes lend my money to other residents despite education against it. Interventions included to educate resident not to lend money to other residents and to encourage resident to inform staff if [he/she] feels pressured to give someone money. The care plan did not include the resident gave money to staff. On 3/7/24 at 9:00 AM, the surveyor interviewed UM/LPN #2 who stated care plans were completed by nursing staff as needed, upon admission, and quarterly upon review. UM/LPN #2 continued care plans included diagnoses, medications, behaviors, treatments, and anything pertinent to that resident. UM/LPN #2 confirmed after an investigation care plans were updated; as well as any time a new intervention needed to be added. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer, and survey team confirmed the resident's care plan was not updated to reflect giving money to staff as well, and it should have been. The LNHA stated care plans were updated by the nurse, but usually by the unit managers. A review of the undated facility's Baseline Care Plan Completion and Ongoing Care Plan Updates policy included ongoing updates to care plans nursing staff will update the care plan related to physician's orders and/or changes in care needs; the nursing staff will initiate and/or update acute care plans for the resident as they are warranted. NJAC 8:39-11.2(e-i); 27.1(a);(d) Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to a.) revise a comprehensive care plan and for pressure wounds and b.) revise a care plan to include a resident gave staff money. This deficient practice was identified for 2 of 27 residents reviewed for care plans revisions (Resident #47 & Resident #79) and was evidenced by the following: 1. On 2/28/24 at 11:50 AM, the surveyor observed the resident seated in a high-back wheelchair with foot pedals. The surveyor reviewed the medical record for Resident #79. A review of the admission Record face sheet (an admission summary) reflected that the resident had a diagnosis that included but was not limited to anemia, fracture of the right femur, and hypertension. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/6/24, reflected the resident had a cognitive mental status of memory problems with severe impairment. Further review revealed the resident had a stage III pressure ulcer and an unstageable pressure wound. A review of the Progress Note included a Skin/Wound Note dated 1/19/24 at 11:32 AM, which indicated the resident had a stage III pressure ulcer. New treatment was ordered, and the resident would be seen by the wound Nurse Practitioner (NP). A review of the Progress Note included a Nutrition/Dietary Note indicating an unstageable pressure ulcer to coccyx and stage III pressure ulcer to sacrum. A review of Resident #79's individual comprehensive care plan (ICCP) included a focus area dated 11/12/21, for skin integrity with no updated focus area and interventions to address two developed pressure ulcers. On 3/7/24 at 10:30 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN #1), who stated that it would be the unit manager that updated care plans to reflect the wounds. She further noted that a care plan reflected goals with interventions to prevent wounds from happening again, but the actual wounds should have been care planned.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) assist a resident out of bed daily with the use of a hoyer lift as ordered by the physician. This deficient practice was identified for 1 of 28 residents reviewed for quality of care (Resident #102), and was evidenced by the following: On 2/29/24 at 12:00 PM, the surveyor observed Resident #102 in bed. The resident stated that he/she was waiting for their lunch meal and that he/she needed assistance getting out of bed and wished that the staff would get him/her out of bed. Resident #102 stated that he/she had not been out of bed for over a week. On 3/1/24 at 12:45 PM, the surveyor observed Resident #102 in bed eating their lunch. Resident #102 stated that he/she still had not been assisted out of bed. The surveyor reviewed the medical record for Resident #102. A review of admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to peripheral vascular disease, obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed flow of urine), and muscle weakness. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/23/23, reflected the resident had a brief interview for mental status score of 15 out of 15; which indicated a fully intact cognition. A review of the Physician Order Summary Report (POS) reflected an active order dated 12/8/23, for the patient to be hoyered daily at 11:00 AM, to the geriatric chair (geri chair; a large padded chair with wheeled bases). On 3/6/24 at 12:20 PM, the surveyor interviewed Resident #102's Certified Nursing Aide (CNA #1) who stated that the resident only got out of bed three times per week on Mondays, Wednesdays, and Fridays and that she would not be transferring the resident from the bed to their chair today. The surveyor asked the CNA why not if today was Wednesday, and the CNA did not answer. The surveyor then asked where the resident's geri chair was stored, and CNA #1 replied that therapy took the resident's chair back to the therapy room. Another CNA (CNA #2) overheard the conversation, and instructed CNA #1 to check the shower room. At that time, the surveyor accompanied by CNA #1 went to the shower room and observed Resident #102's geri chair there. On 3/6/24 at 12:37 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated that the resident, gets out of bed whenever [he/she] wants to. The surveyor asked the UM/LPN where their geri chair was stored as it had not been observed in Resident #102's room throughout the entire survey. The UM/LPN replied that the geri chair was broken. The surveyor asked the UM/LPN if she had informed the rehab department or maintenance about the chair being broken, and the UM/LPN responded, maybe it's not broken, I don't know. At that time, the surveyor reviewed the POS with the UM/LPN which reflected a PO to hoyer lift the resident out of bed every day at 11:00 AM. The UM/LPN then stated, I guess [he/she] should be gotten out of bed every if he wants to. The surveyor stated that the resident has expressed that he/she would like to be assisted out of bed daily as per the physician's order. On 3/6/24 at 12:58 PM, the surveyor interviewed the Director of Rehabilitation (DOR) who stated that she had not been informed that Resident #102's geri chair had been broken and if she had been notified, she would have ordered a temporary replacement until the chair was repaired. The DOR stated that it would take one to two days for the rental chair to be delivered to the facility. The DOR stated that the geri chair should be stored in the resident's room or just outside in the hallway for easy access. At that time, the DOR stated that Resident #102 received rehab from 12/8/23-1/5/24 and then was discharged to the Restorative Nursing Program. The DOR provided the surveyor with a copy of the Physical Therapy Recommendations To Restorative Nursing which reflected that Resident #102 was discharged from therapy with the recommendations .to be hoyer lifted daily to the geri chair. The DOR further stated that she made two copies of the form and provided one to the Director of Nursing and one to the Certified Nursing Assistant who provided care to the resident. A review of the facility provided undated Certified Nursing Assistant Job Position document, included .Perform restorative and rehabilitative procedures as instructed . On 3/6/24 at 4:02 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Regional Director of Nursing and discussed the above observations and concerns. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional Director of Nursing, Clinical Chief Officer, and survey team acknowledged that the resident should have been out of bed daily per the physician's order, and if the geri chair was broken, the DOR should have been notified. NJAC 8:39-27.1 (a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident with limited range of motion of the right hand received appropriate services to prevent further decrease in range of motion. This deficient practice was identified for 1 of 3 residents reviewed for positioning/mobility (Resident #6), and was evidenced by the following: On 2/27/24 at 12:44 PM, the surveyor interviewed Resident #6 who stated that they had a contracture to the right hand. When asked if he/she was supposed to wear a brace, the resident opened their dresser drawer to show the surveyor a brace. Resident #6 stated that they do not wear it because it hurts. The resident stated that he/she had told the nursing staff, but nothing had been done. On 2/29/24 at 11:21 AM, the surveyor observed Resident #6 dressed and seated in their wheelchair. The resident did not have the brace applied. On 3/4/24 at 10:53 AM, the surveyor observed Resident #6 dressed and seated in their wheelchair. The resident did not have the brace applied. The surveyor reviewed the medical record for Resident #6. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses including, but not limited to, rhabdomyolysis (breakdown of skeletal muscle) and acute respiratory failure. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15; which indicated a fully intact cognition. A review of the Order Summary Report identified the following active physician's orders (PO): right resting hand splint with a start date of 9/20/23. A review of the corresponding February 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) the order could not be identified. A review of the Resident's Occupational Therapy Encounter notes included the following: On 9/20/23 at 6:10 PM, spoke with physician regarding script for resting hand splint and called orthotic company to order. On 9/21/23 at 2:39 PM, resting hand splint applied to right hand; trained nursing staff on donning (putting on)/doffing (taking off) and skin checks: optimal position is obtained and patient with no [complaints of] pain. A review of Resident #6 individualized comprehensive care plan did not include the resident's right-hand contracture or the PO for the splint. On 3/5/24 at 10:40 AM, the surveyor interviewed Certified Nursing Aide (CNA #1) who identified that he/she was familiar with Resident #6. When asked if they were responsible for applying any splints, CNA #1 denied. CNA #1 stated that Physical Therapy (PT) or Occupational Therapy (OT) was responsible for applying braces to residents according to physician's orders. The surveyor asked CNA #1 how a brace should fit a resident, the CNA confirmed that it should never hurt and if a resident reported pain, the CNA would let the nurse know who entered a referral to PT/OT. The surveyor asked the process for patient refusals, and CNA #1 advised that all refusals should be documented and not just for braces or splints but every time a patient refuses. CNA #1 reported that they notified the nurse about the refusal who documented in the chart. On 2/29/24 at 12:57 PM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who advised that there was not one specific person who was responsible for entering PO and both the physicians and nursing could enter an order. LPN #1 confirmed that nursing was responsible for ensuring that the PO was accurate and correctly entered into the system. LPN #1 confirmed that contractures, along with the interventions like braces, should be identified on the care plan. When asked why that was important to identify, LPN #1 stated that care plans promoted independence and health but also directed resident care. LPN #1 confirmed that an orthotic should never be painful and if he/she were notified that a resident was complaining of pain while wearing an orthotic, they would let the unit manager know. The surveyor inquired about how the nursing staff was aware of residents that required orthotics, and LPN #1 responded that it would be identified on the MAR/TAR and therapy communicated that with nursing. When asked who was responsible for ensuring that residents were wearing their orthotics, LPN #1 responded, nursing. The surveyor directly inquired about Resident #6, and LPN #1 was not aware that she/he was ordered to wear a brace. LPN #1 reviewed the PO and confirmed the active order. LPN #1 proceeded to Resident #6's MAR/TAR and could not locate the order. When asked if Resident #6 should be wearing the orthotic, LPN #1 confirmed. When asked if the order should be identified on the MAR/TAR, LPN #1 confirmed. LPN #1 further agreed that Resident #6's refusal of wearing the splint and its corresponding pain should be documented and supervisor made aware. On 3/6/24 at 9:48 AM, the surveyor spoke with Unit Manager/Licensed Practical Nurse (UM/LPN) who confirmed care plans should be updated as needed and with special interventions. Upon review of Resident #6's PO, the UM/LPN confirmed the active order for the right hand splint. The UM/LPN agreed that the resident's contracture and interventions for the splint should be identified on the care plan. The UM/LPN indicated that if the resident complained of pain from the splint, the facility should have tried to find out why it hurt. The UM/LPN indicated that she would have consulted therapy and requested a PT evaluation. On 3/6/24 at 12:25 PM, the surveyor interviewed the Director of Rehabilitation (DOR) who confirmed that any issues regarding pain while wearing an orthotic would be reported to PT/OT for further evaluation. At this time, the DOR was unaware of any issues or concerns with Resident #6's orthotic. The DOR confirmed, based upon their documentation, that the resident was wearing the orthotic for up to five hours while in therapy without concerns. The DOR further advised that her expectation would be that Resident #6 continued wear the orthotic on regular a basis. When the DOR reviewed the current active order, the DOR stated that this was an incomplete order since it did not specify when or how long the orthotic was to be worn. On 3/7/24 at 11:32 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), in the presence of Regional Director of Nursing (RDON) and Chief Clinical Officer, who acknowledged that Resident #6 was not wearing the brace, lack of documentation regarding the resident's refusal to wear the brace, and that the care plan did not identify the resident's contracture and interventions. Furthermore, the LNHA confirmed that the resident should have been referred to PT/OT. A review of the facility provided undated Certified Nursing Assistant Job Position document included .Perform restorative and rehabilitative procedures as instructed . A review of the facility provided undated LPN Nurse Job Position document included .Review care plans daily to ensure that appropriate care is being rendered. Inform the Nursing Supervisor of any changes that need to be made on care plan. Ensure that your nurses' notes reflect that the care plan is being followed when administering care or treatment .Ensure that your assigned [CNAs] are aware of the resident care plans. Ensure that the CNA's refer to the resident's care plan prior to administering daily care to the resident . Review the resident's chart for specific treatments, medication order, diets, etc, as necessary .Implement and maintain established nursing objectives and standards .Ensure that your nurses' notes reflect that the care plan is being followed when administering care or treatment. A review of the facility provided undated Unit Manager Nurse Job Position document included .Adjusts care plan when indicated. Care plans can and should be updated by the Unit Manager as situations present . Responsible for the proper transcription and executing of physician's orders, accurate documentation, maintenance of the clinical record completeness [ .] Directly supervises staff nurses to ensure their completion of duties as well as the direct supervision of CNAs. A review of the facility provided Baseline Care Plan Completion and Ongoing Care Plan Updates policy, dated 11/17/17, included .the comprehensive care plan will describe the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being .nursing staff will update the care plan related to physician's orders and/or changes in care needs . A review of the facility's undated Charting and Documentation document included .all observations, medications administered, services performed, etc., must be documented in the resident's clinical record . A review of the facility's undated Splinting document included .Once the wearing schedule is established, the physician's clarification order should specify the type of splint, where it is to be applied, and the wearing schedule. Written instructions should be left available to the nursing staff. This may be placed in the medical record per the facility policy, on the nursing unit, or other designated area. A review of the facility's undated Refusal of Medications and Treatments, Documentation of document included .If a resident refuses his or her medications and/or treatments, nursing staff will document such refusal in the resident's medical record .Repeated refusals shall be reported to the Director of Nursing Services and Attending Physician after 3 continued refusals . NJAC 8.39-27.1(a); 27.2(m)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident was assessed and the comprehensive care plan was updated post fall with safety interventions for a resident with a history of falls. This deficient practice was identified for 1 of 7 residents reviewed for falls (Resident #79), and was evidenced by the following: On 2/28/24 at 11:50 AM, the surveyor observed the resident seated in a high-back wheelchair with foot pedals in the dining area. The surveyor reviewed the medical records for Resident # 79. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses that included anemia, fracture of the right femur, and hypertension. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/6/24, reflected a cognitive mental status of memory problems with severe impairment. Further review of Section I Active Diagnoses reflected a fall diagnosis. A review of the Progress Note included a Health Status Note dated 11/26/23 at 3:40 PM, which indicated that the resident had a fall in activities. The writer notified the Nurse Practitioner to assess the resident, who ordered an x-ray of the right knee, hip, and leg. A review of the Progress Note included a Health Status Note dated 11/26/23 at 9:30 PM, that indicated the x-ray result of the right femur and right hip was acute right femoral neck fracture: age-indeterminate inferior pubic ramus fracture, two screws fixating right hemipelvis, and osteopenia. The physician was notified and ordered to be sent to the hospital. A review of the incident report provided by the Director of Nursing (DON) for a fall that occurred on 11/26/23, included that the resident was seated in a wheelchair while attending activities and fell onto the floor. A review of the Certified Nursing Aide's (CNA) statement included the resident was in activities and slipped out of wheelchair. Further review of the Individual Statement Forms from Activity Aides revealed that the resident was watching a movie in their wheelchair; and the Activity Aides heard a noise, and the resident was observed on the floor. Further review of a Post Fall Huddle revealed the safety interventions in place: any resident who uses footrests on their wheelchairs should have them on the wheelchair. A review of Resident #79's individual comprehensive care plan (ICCP) dated 11/19/21, included a focus areas that the resident was at risk for falls with regards to gait/balance problems with actual falls on 4/26/22, 5/6/23, and a witness fall on 11/26/23. Interventions included to anticipate and meet the resident's needs; to educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair; follow facility fall protocol; resident requires supervision in the dayroom; resident needs activities to minimize the potential for falls while providing diversion and distraction. No further interventions were updated at that time to address the prevention of a fall using footrests. On 2/28/24 at 12:20 PM, the surveyor interviewed the Certified Nursing Assistant (CNA #1), who stated she was the resident's permanent day shift CNA. She further stated that the resident had fallen from the wheelchair in the activity room on a day that she was not working and fractured her leg. On 2/29/24 at 11:26 AM, the surveyor interviewed the Director of Rehabilitation (DOR), who stated that when the resident returned to the facility, they were evaluated for hip fracture and seen by the Physical Therapist. On 2/29/24 at 11:40 AM, the surveyor interviewed the Physical Therapist (PT), who stated she evaluated the resident after returning from the hospital. Since the resident was the same as their baseline and dependent on staff, no further services were needed. On 3/5/24 at 9:45 AM, the surveyor interviewed the Recreation Aid (RA), who stated that when Resident #79 fell, the resident was seated in a wheelchair with no footrests next to him. The RA continued that he turned to assist another resident and heard a noise, and when he turned, the resident was on the floor. He stated that he and another recreation aide lifted the resident back into the wheelchair and brought the resident to the nurse. The RA stated that he knew he should not have picked the resident up off the floor, but he reacted and felt that he had to get the resident off the floor. On 3/5/24 at 10:20 AM, the surveyor interviewed the Director of Nursing (DON), who stated that when a fall occurred, the unit managers completed and summarized the conclusions on the interdisciplinary team (IDT) notes. The DON stated that all activity staff were educated not to move a resident when they fell. On 3/5/24 at 12:45 PM, the Licensed Nursing Home Administrator (LNHA) stated that when there was a fall, there was an IDT meeting, and they discussed and documented it in the electronic medical records or on the incident report. The LNHA further stated that the root cause of the fall was not having footrests on the wheelchair, so the facility added the intervention of a footrest post fall. On 3/6/24 at 10:45 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated that if a resident was required to have footrests when in a wheelchair, it should be care planned. On 3/7/24 at 10:30 AM, the surveyor interviewed the UM/LPN, who stated that the unit manager would update care plans to reflect the wounds and fall interventions. She further noted that a care plan reflects goals with interventions to prevent further falls from happening again. A review of the facility's undated Assessing Falls and Their Causes policy included that after a fall, the nursing staff will evaluate for possible injuries before moving the resident . perform post-fall evaluation .apply new interventions . NJAC 8:39-27.1(a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to accurately document the administration of a controlled medication for 1 sampled resident (Resident #171) identified upon inspection of 1 of 3 medication carts (low-cart Second-Floor), and was evidenced by the following: On 3/4/24 at 10:47 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the Second-Floor nursing unit low-side medication cart. A review of the narcotics located in the secured and locked narcotic box and reconciled to the controlled drug administration record, a declining inventory sheet, revealed Resident #171's tramadol 50 milligram (mg) tablet, a medication used to relieve pain, did not match. The blister packs contained 36 tablets and the declining inventory sheet indicated there should be 37 tablets remaining. The LPN stated she had administered the medication earlier and she had forgotten to sign the declining inventory sheet for the dose she had administered. The LPN further stated the declining inventory sheet should be signed when the medication was removed from the packaging. On 3/4/24 at 11:43 AM, the surveyor interviewed the Second-Floor nursing unit's Unit Manager/LPN (UM/LPN). The UM/LPN acknowledged the LPN should have signed the declining inventory sheet immediately after removing the medication from the packaging. She further acknowledged this was the process to ensure the accurate inventory of all controlled medications. On 3/6/24 at 10:50 AM, the surveyor interviewed the Regional Director of Nursing (RDON), in the absence of the facility's DON who stated as soon as medication was removed from the packaging, the nurse must sign the declination sheet. This was the process to ensure accountability and ensure the medication counts were correct. A review of the undated facility Controlled Substance policy revealed AristaCare at Cherry Hill shall comply with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled medications . A review of the facility's undated Administering Medications policy did not include the process for documenting administration of controlled medications using a declining inventory sheet. NJAC 8:39- 29.2(d), 29.7(c)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure safe and appetizing temperatures of food for 2 of 2 regular texture meals observed during 1 of 1 meal observations (lunch) on 1 of 3 nursing units (Second-Floor). This deficient practice was evidenced by the following: On 2/29/24 at 10:33 AM, the surveyor conducted a Resident Council meeting which included five residents (Resident #18, #19, #51, #65, and #73). Four of the five residents informed the surveyor during the meeting that the meals served at the facility were cold; room temperature if lucky. On 3/1/24 at 11:22 AM, the surveyor informed the Director of Dietary (DD) they wanted to observe the lunch meal for the day including food temperatures. The surveyor asked the DD to calibrate the facility's digital thin probe thermometer in their presence; which the DD completed using an ice bath, and the thermometer reached 33 degrees Fahrenheit (F). The surveyor completed the same process, and their thermometer reached 32 F. On 3/1/24 at 11:40 AM, the surveyor asked the DD what the minimum temperatures hot and cold food should be served at, and the DD responded 135 F and 41 F respectively. At this time the DD obtained the following food temperatures for the regular texture meal (fish cake, sweet potato, squash) and the alternate regular texture meal (beef tips, chopped carrots, and squash) which were as follows: Fish cake 191 F Sweet potato 172 F Squash 190 F Beef tips 171 F Chopped carrots 203 F On 3/1/24 at 11:45 AM, the [NAME] started plating the first meal cart. The surveyor observed the facility utilized a plate warmer, a device used to heat the plates prior to serving, and plastic insulated domes and bases. On 3/1/24 at 12:36 PM, the surveyor observed the [NAME] start plating the fourth dining cart. At this time, the surveyor requested test trays of the regular texture meal and the alternate regular meal texture to be plated first. On 3/1/24 at 12:46 PM, the surveyor observed the [NAME] plate the last resident tray for the fourth cart, and at 12:48 PM, the Dietary Aide left the kitchen with the cart headed to the Second-Floor nursing unit. On 3/1/24 at 12:50 PM, the dining cart arrived to the Second-Floor nursing unit, and the nurse checked the trays to ensure accuracy. On 3/1/24 at 12:52 PM, the DD tested the temperatures of the test trays utilizing the thermometer calibrated to 32 F, and obtained the following temperatures below 135 F: Regular texture meal: Fish cake 131 F Squash 124 F Sweet potato 127 F Regular alternate texture meal: Beef tips 119 F Chopped carrots 123 F Squash 123 F At the time of the observation, the DD confirmed that the hot food should be at 135 F, and acknowledged none of the food on the test trays was at that temperature. On 3/1/24 form 1:00 PM to 1:16 PM, the surveyor interviewed sampled residents from the Second-Floor nursing unit to see if their lunch meal was hot and received the following responses: At 1:00 PM, Resident #104 stated that his/her beef was warm at best and preferred it to be hot; breakfast was always cold. At 1:10 PM, Resident #102 stated that his/her fish was cold At 1:14 PM, Resident #31 stated the beef was warm, but he/she preferred it to be hot. At 1:16 PM, Resident #18 stated beef tips were warm, but he/she preferred it hot and coffee was semi-warm. On 3/7/24 at 11:52 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Regional Director of Nursing, Chief Clinical Officer, and survey team acknowledged the cold food temperatures. NJAC 8:39-17.4(a)(2)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health within two hours for a.) an allegation of exploitation and misappropriation of resident property and b.) an allegation of verbal abuse. This deficient practice was identified for 2 of 4 incidents of abuse reviewed (Resident #47), and was evidenced by the following: 1. On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide asked the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. The resident stated he/she transferred the money using money applications (app) on their phone, and CNA #1 owed him/her around $330 that was never paid back. The resident stated the facility's Director of Quality Experience (DQE) and current Licensed Nursing Home Administrator (LNHA) spoke to the resident and took pictures of the transactions on the money app, but the DQE and LNHA never did anything further. The resident stated that CNA #1 no longer worked at the facility. The surveyor reviewed the medical record for Resident #47. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/20/24, reflected the resident had a brief interview for mental status score of a 15 out of 15; which indicated a fully intact cognition. On 2/29/24 at 10:00 AM, a request was made to the LNHA to provide all investigations and grievances for Resident #47. On 3/4/24 at 9:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated allegations of abuse were immediately investigated and reported to the Department of Health (DOH) within two hours. On 3/4/24 at 12:16 PM, the LNHA confirmed the surveyor had all the investigations for the resident. A review of the investigations did not include the abuse allegation made by the resident. On 3/5/24 at 11:50 AM, the surveyor interviewed the Director of Nursing (DON) and asked if the resident ever informed the facility he/she was missing anything. The DON stated there was a time there was missing money or a cell phone that she could not speak to that involved CNA #1 who no longer worked at the facility. On 3/5/24 at 12:27 PM, the surveyor interviewed the LNHA who stated there was money exchanged with a former employee (CNA #1), and CNA #1 had not paid back Resident #47 per the resident. The LNHA stated the facility only completed a grievance form since the resident was alert and oriented. The surveyor requested the grievance form. A review of the Grievance Summaries dated reported 10/13/23 and resolved 10/17/23, included the following: Grievance details: resident stated [he/she] had been exchanging money via a [money] app for personal items with [CNA #1]; resident states that [he/she] has not seen the CNA, she was not responding to calls or messages and the CNA owes [him/her] money. Summary of investigation: resident reported that [he/she] had been exchanging money with an employee for them to purchase [him/her] personal items and that the employee was not responding to [his/her] calls or texts. Summary findings: resident was alert and oriented and has been sending money to now a former employee to buy [him/her] things. According to the resident, the individual owes [him/her] money and was no longer responding to [his/her] calls or texts. Summary of actions taken: Administration reached out to the former employee via phone who stated she did not owe the resident any money or items and confirmed [Resident #47] had been sending her money. She also stated when she was not able to get [him/her] the item, she would give the money back to the resident. Resident was made aware of the conversation with the employee and resident stated [he/she] made their attorney aware. The grievance did not include any witness statements from the resident, employee, other staff members, and residents; as well as no facility completed Resident Abuse Form per facility policy. On 3/6/24 at 8:51 AM, re-interviewed Resident #47 who stated he/she loaned CNA #1 money for the aide's personal use; that CNA #1 had never nor was ever asked to purchase the resident personal items. The resident continued that CNA #1 told the resident the facility did not have direct deposit for their paychecks so when she needed money and did not have her paycheck yet, she would borrow money from the resident. The resident stated CNA #1 was paying them back, but then stopped. The resident stated he/she asked CNA #1 for the money owed, and CNA #1 kept telling the resident Tomorrow. The resident stated CNA #1 used to take good care of me doing personal grooming that other aides would not, and the resident felt that he/she did not give CNA #1 the money, they would no longer go above and beyond with care. On 3/6/24 at 10:46 AM, the surveyor asked the LNHA what the types of abuse were, and the LNHA responded physical, verbal, mental, financial, emotional. The surveyor asked the LNHA who was susceptible to abuse in the facility and the LNHA stated all residents were at risk for abuse in the facility. At this time, the surveyor reviewed the facility's abuse policy with the LNHA which indicated the facility had one business day to notify the DOH of abuse, and the LNHA confirmed the facility had one day to notify. On 3/6/24 at 2:29 PM, the surveyor re-interviewed the LNHA who stated since Resident #47 was alert and oriented and gave CNA #1 the money, the facility did not investigate it as abuse since we did not feel it was misappropriation of funds. The LNHA confirmed it was not facility policy for staff to accept money from residents; it would be inappropriate. The LNHA stated CNA #1 was terminated from the facility not for accepting the resident's money, but for refusing to come into the facility to provide a statement. The LNHA confirmed the facility did not report the incident to the DOH. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer, and survey team confirmed the incident was never investigated or reported to the DOH or any other authority. The LNHA also stated that the activities staff and social worker were the staff who purchased residents' personal needs if their families could not. 2. On 2/28/24 at 12:14 PM, the surveyor observed Resident #47 in bed, the resident was alert and oriented and able to be interviewed. The surveyor reviewed the medical record for Resident #47. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included multiple sclerosis, major depressive disorder, insomnia, and anxiety. A review of the most recent comprehensive MDS dated [DATE], reflected the resident had a brief interview for mental status score of a 15 out of 15; which indicated a fully intact cognition. On 2/29/24 at 10:00 AM, a request was made to the LNHA to provide all investigations and grievances for Resident #47. A review of the Grievance Summaries dated 10/13/23 and resolved 10/13/23, included the following: Grievance details: resident states 11:00 PM to 7:00 AM (11- 7) shift [CNA #2] yelled at [him/her] saying you ring your call bell like we are your slaves and that's why everyone talks about you. Resident states that [he/she] asked for ice water and [CNA #2] said there is no ice you have to wait. Resident states that [he/she] told the [CNA #2] that [his/her] boots on [his/her] feet are hurting [him/her] and the CNA stated you slept all night with them on and now all the sudden they hurt you then took the straps off the boots to loosen them. Resident states that CNA left [his/her] light on, curtain open and door open and [he/she] had to ring [his/her] bell again for someone to close the door and turn the lights off. Summary of investigation: resident reported the aide on the 11-7 was disrespectful to [him/her] and yelled at [him/her]. Summary of findings: resident was upset by the interaction [he/she] had with the staff member. [He/she] did not know the employee's name but was able to describe her. Resident was not able to give any information on who answered [his/her] call light to turn the light off or close the door. Summary of actions taken: employee was removed from schedule and was educated. On 3/4/24 at 9:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated allegations of abuse were immediately investigated and reported to the Department of Health (DOH) within two hours. On 3/6/24 at 1:21 PM, the surveyor asked Resident #47 if he/she ever had any issues with a CNA, and the resident stated that CNA #2 who no longer worked at the facility. Resident #47 stated that he/she rang their call bell during the 11-7 shift because they wanted the air conditioner temperature changed, ice, and their catheter bag emptied. CNA #2 stated there was no ice; changed the catheter bag; and went into the hallway and said to someone [he/she] runs us like slaves. When CNA #2 returned to the room, the resident reported asking the aide why she would say that, and CNA #2 stated because you run us like slaves and everyone talks about you. The resident stated it was the night shift and he/she was usually asleep and not ringing the call bell. The resident stated CNA #2 was always nasty. On 3/6/24 at 2:29 PM, interviewed the LNHA regarding the grievance and the LNHA stated it was not investigated or reported to the DOH since CNA #2 speaks very loud, and the resident did not feel like CNA #2 was yelling at him/her. The LNHA stated initially it was looked at as abuse, but abuse was ruled out. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer and survey team confirmed this incident was not reported to the DOH. A review of the facility's undated Abuse Policy & Procedure included the administrator or designee will notify the Office of the ombudsman and the State Department of Health and Senior Services when abuse is suspected. Notification shall be documented within one business day and followed within 72 hours with written confirmation NJAC 8:39-4.1(a)5

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate a.) an allegation of exploitation and misappropriation of resident property and b.) an allegation of verbal abuse. This deficient practice was identified for 2 of 4 incidents of abuse reviewed (Resident #47), and was evidenced by the following: 1. On 2/28/24 at 12:14 PM, the surveyor interviewed Resident #47 who stated he/she had an issue with a Certified Nursing Aide (CNA #1) who no longer worked at the facility. The resident stated he/she developed a bond with CNA #1, and the aide asked the resident to borrow money which he/she provided. The resident continued CNA #1 always paid them back the borrowed money, and there were multiple financial transactions, but CNA #1 stopped paying the resident back the money she borrowed. The resident stated he/she transferred the money using money applications (app) on their phone, and CNA #1 owed him/her around $330 that was never paid back. The resident stated the facility's Director of Quality Experience (DQE) and current Licensed Nursing Home Administrator (LNHA) spoke to the resident and took pictures of the transactions on the money app, but the DQE and LNHA never did anything further. The resident stated that CNA #1 no longer worked at the facility. On 2/29/24 at 10:00 AM, a request was made to the LNHA to provide all investigations and grievances for Resident #47. On 3/4/24 at 9:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated allegations of abuse were immediately investigated. On 3/4/24 at 12:16 PM, the LNHA confirmed the surveyor had all the investigations for the resident. A review of the investigations did not include the abuse allegation made by the resident. On 3/5/24 at 11:50 AM, the surveyor interviewed the Director of Nursing (DON) and asked if the resident ever informed the facility he/she was missing anything. The DON stated there was a time there was missing money or a cell phone that she could not speak to that involved CNA #1 who no longer worked at the facility. On 3/5/24 at 12:27 PM, the surveyor interviewed the LNHA who stated there was money exchanged with a former employee (CNA #1), and CNA #1 had not paid back Resident #47 per the resident. The LNHA stated the facility only completed a grievance form since the resident was alert and oriented. The surveyor requested the grievance form. A review of the facility's undated Abuse Policy & Procedure included when an incident or suspected incident of resident abuse, neglect, misappropriation of resident property, or injury of unknown source is reported, the Administrator/Director of Nursing will immediately be notified. They will appoint a staff member to investigate the incident .The investigation shall consist of: a review of the complete Resident Abuse form for facility and F.R.I.D.A.Y. and Reportable Event Record Report for Department of Health [DOH]; interviews with the person(s) reporting the incident; interviews with any witnesses to the incident; an interview with the resident; an interview with staff members (on all shifts) having contact with the resident during the period of alleged incident; interviews with resident's roommate, family members, and visitors if applicable; interviews with other residents to which the accused employee provided care or services (if applicable); a review of circumstances surrounding the incident; review of pertinent emails. Witness statements shall be in writing. Witness will be required to sign and date such statements. A review of the Grievance Summaries dated reported 10/13/23 and resolved 10/17/23, included the following: Grievance details: resident stated [he/she] had been exchanging money via a [money] app for personal items with [CNA #1]; resident states that [he/she] has not seen the CNA, she was not responding to calls or messages and the CNA owes [him/her] money. Summary of investigation: resident reported that [he/she] had been exchanging money with an employee for them to purchase [him/her] personal items and that the employee was not responding to [his/her] calls or texts. Summary findings: resident was alert and oriented and has been sending money to now a former employee to buy [him/her] things. According to the resident, the individual owes [him/her] money and was no longer responding to [his/her] calls or texts. Summary of actions taken: Administration reached out to the former employee via phone who stated she did not owe the resident any money or items and confirmed [Resident #47] had been sending her money. She also stated when she was not able to get [him/her] the item, she would give the money back to the resident. Resident was made aware of the conversation with the employee and resident stated [he/she] made their attorney aware. The grievance did not include any witness statements from the resident, employee, other staff members, and residents; as well as no facility completed Resident Abuse Form per facility policy. On 3/6/24 at 8:51 AM, re-interviewed Resident #47 who stated he/she loaned CNA #1 money for the aide's personal use; that CNA #1 had never nor was ever asked to purchase the resident personal items. The resident continued that CNA #1 told the resident the facility did not have direct deposit for their paychecks so when she needed money and did not have her paycheck yet, she borrowed money from the resident. The resident stated CNA #1 was paying back the money loaned, but then stopped. The resident stated he/she asked CNA #1 for the money owed, and CNA #1 kept telling the resident Tomorrow. The resident stated CNA #1 used to take good care of me doing personal grooming that other aides would not, and the resident felt that he/she did not give CNA #1 the money, they would no longer go above and beyond with care. On 3/6/24 at 10:46 AM, the surveyor asked the LNHA what the types of abuse were, and the LNHA responded physical, verbal, mental, financial, emotional. The surveyor asked the LNHA who was susceptible to abuse in the facility and the LNHA stated all residents were at risk for abuse in the facility. The LNHA stated at first Resident #47's complaint was CNA #1 would not return his/her phone calls, and then the facility was informed CNA #1 owed the resident money. The LNHA sated CNA #1 refused to come in for a statement, so she was terminated, and the grievance was the resident's statement. On 3/6/24 at 2:29 PM, the surveyor re-interviewed the LNHA who stated since Resident #47 was alert and oriented and gave CNA #1 the money, the facility did not investigate it as abuse since we did not feel it was misappropriation of funds. The LNHA confirmed it was not facility policy for staff to accept money from residents; it would be inappropriate. The LNHA stated CNA #1 was terminated from the facility not for accepting the resident's money, but for refusing to come into the facility to provide a statement. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer, and survey team confirmed the incident was never investigated. The LNHA also stated that the activities staff and social worker were the staff who purchased residents' personal needs if their families could not. 2. On 2/28/24 at 12:14 PM, the surveyor observed Resident #47 in bed, the resident was alert and oriented and able to be interviewed. The surveyor reviewed the medical record for Resident #47. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included multiple sclerosis, major depressive disorder, insomnia, and anxiety. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/20/24, reflected the resident had a brief interview for mental status score of a 15 out of 15; which indicated a fully intact cognition. On 2/29/24 at 10:00 AM, a request was made to the LNHA to provide all investigations and grievances for Resident #47. A review of the Grievance Summaries dated 10/13/23 and resolved 10/13/23, included the following: Grievance details: resident states 11:00 PM to 7:00 AM (11- 7) shift [CNA #2] yelled at [him/her] saying you ring your call bell like we are your slaves and that's why everyone talks about you. Resident states that [he/she] asked for ice water and [CNA #2] said there is no ice you have to wait. Resident states that [he/she] told the [CNA #2] that [his/her] boots on [his/her] feet are hurting [him/her] and the CNA stated you slept all night with them on and now all the sudden they hurt you then took the straps off the boots to loosen them. Resident states that CNA left [his/her] light on, curtain open and door open and [he/she] had to ring [his/her] bell again for someone to close the door and turn the lights off. Summary of investigation: resident reported the aide on the 11-7 was disrespectful to [him/her] and yelled at [him/her]. Summary of findings: resident was upset by the interaction [he/she] had with the staff member. [He/she] did not know the employee's name but was able to describe her. Resident was not able to give any information on who answered [his/her] call light to turn the light off or close the door. Summary of actions taken: employee was removed from schedule and was educated. On 3/4/24 at 9:08 AM, the surveyor interviewed the Director of Nursing (DON) who stated allegations of abuse were immediately investigated and reported to the Department of Health (DOH) within two hours. On 3/6/24 at 1:21 PM, the surveyor asked Resident #47 if he/she ever had any issues with a CNA, and the resident stated that CNA #2 who no longer worked at the facility. Resident #47 stated that he/she rang their call bell during the 11-7 shift because they wanted the air conditioner temperature changed, ice, and their catheter bag emptied. CNA #2 stated there was no ice; changed the catheter bag; and went into the hallway and said to someone [he/she] runs us like slaves. When CNA #2 returned to the room, the resident reported asking the aide why she would say that, and CNA #2 stated because you run us like slaves and everyone talks about you. The resident stated it was the night shift and he/she was usually asleep and not ringing the call bell. The resident stated CNA #2 was always nasty. On 3/6/24 at 2:29 PM, interviewed the LNHA regarding the grievance and the LNHA stated it was not investigated or reported to the DOH since CNA #2 speaks very loud, and the resident did not feel like CNA #2 was yelling at him/her. The LNHA stated initially it was looked at as abuse, but abuse was ruled out. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer and survey team confirmed this incident was not reported to the DOH. A review of the facility's undated Abuse Investigations policy included all reports of resident abuse, neglect, misappropriation of resident property, and injuries of unknown source shall be promptly and thoroughly investigated . NJAC 8:39-4.1(a)5

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 2/28/24 at 10:18 AM, the surveyor observed Resident #45 sleeping in bed on his/her right side. The resident did not wake upon entrance of room and when the surveyor called his/her name. The surveyor reviewed the medical record for Resident #45. A review of the admission Record face sheet reflected the resident was admitted to the facility with diagnoses including but not limited to osteomyelitis (infection of the bone) of left femur, pressure ulcer (stage 4) left hip, and heart failure. A review of the admission Minimum Data Set (MDS), an assessment tool, reflected that the resident was not able to complete the brief interview for mental status (BIMS). A further review in Section H completed for incontinence, identified the resident of being incontinent of bowel and bladder A review of the Order Summary Report identified the following active physician's order (PO) dated 1/24/24, monitor resident for urine output every shift; notify physician if no urine output for eight hours for urinary retention. Document in progress notes how many wet briefs resident had per shift. A review of the corresponding February 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) the PO was reflected with a check mark and initials. A review of the Progress Notes from 1/24/24 to current, included the following entries: 1/24/24 at 2:41 PM, reported that resident's certified nursing assistant (CNA) that resident did not urinate entire shift . 1/24/24 at 3:14 PM, brief was removed it was completely saturated with urine . 1/24/24 at 10:40 PM, resident urinated in [his/her] diaper at the end of the shift at 11:00 PM. 1/25/24 at 11:41 PM, resident did urinate during this shift . No additional entries were identified from 1/25/24 to 3/1/24. On 2/28/24 at 12:47 PM, the surveyor interviewed Certified Nursing Assistant (CNA #1) who stated that residents were to be checked every two hours for incontinence rounds. On 2/29/24 at 12:57 PM, the surveyor interviewed Licensed Practical Nurse (LPN #2) who advised that the CNA completed incontinence rounds every two hours, and anyone who remained dry during the shift, the nurse should be notified. LPN #2 also confirmed that a resident care plan would identify any wounds, its staging, and their interventions. On 3/5/24 at 10:40 AM, the surveyor interviewed CNA #2 who confirmed that urinary retention (inability to voluntarily empty the bladder) was not normal and was something that should be reported to the nurse. CNA #2 further stated that they were responsible for documenting baseline resident functions and anything abnormal which included, not urinating for eight hours, should be reported to the nurse and documented by the nurse. On 3/5/24 at 12:58 PM, the surveyor interviewed LPN #3 regarding their documentation policy. LPN #3 advised that the expectations for physician's order was that they were to be completed in its entirety. LPN #3 stated that if the order required a nursing entry it would be located in the Progress Notes. When asked what kind of additional information would be identified in the Progress Notes, LPN #3 responded, anything out of the resident's baseline. LPN #3 further indicated that any resident with a history of urinary retention would be monitored for urinary output. When asked regarding Resident #45 PO, LPN #3 indicated that the staff were aware of the order, and had been documenting accordingly. Upon reviewing the Progress Notes, LPN #3 confirmed that there was no documentation from the end of January to current. On 3/6/24 at 1:37 PM, the surveyor spoke with the UM/LPN who confirmed that there were no entries in the Progress Notes documenting the amount of wet briefs and physician contact. The UN/LPN acknowledged that it was the facility's expectation that physicians orders be completed in full and any additional documentation requested by the physician would also be completed. On 3/7/24 at 11:32 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), in the presence of Regional Director of Nursing (RDON) and Chief Clinical Officer, who acknowledged that the order was not completed to the fullest since the supplementary documentation of the wet diapers was missing. A review of the facility provided undated Bowel and Bladder Elimination policy included .CNA's must report any concerns, changes, or irregularities in resident's elimination pattern and stool to the nurse or charge nurse immediately. A review of the facility's undated Charting and Documentation policy included .all observations, medications administered, services performed, etc., must be documented in the resident's clinical record . A review of the facility provided undated LPN Nurse Job Position document, included .review the resident's chart for specific treatments, medication order, diets, etc, as necessary .implement and maintain established nursing objectives and standards .ensure that your nurses' notes reflect that the care plan is being followed when administering care or treatment. A review of the facility provided undated Unit Manager Nurse Job Position document, included .responsible for the proper transcription and executing of physician's orders, accurate documentation, maintenance of the clinical record completeness .directly supervises staff nurses to ensure their completion of duties as well as the direct supervision of CNAs. NJAC 8:39-27.1(a) Complaint NJ #162587; 163869 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to a.) administer medications within scheduled parameters on various shifts for two residents (Resident #38 & Resident #42); b.) complete the dialysis communication book for a resident on dialysis (Resident #37); and c.) follow a for physician's order to monitor a resident for urinary retention in accordance with professional standards of practice. This deficient practice was identified for 4 of 27 residents reviewed for professional standards of practice (Resident #37, #38, #42, & #45). 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 evidence was as follows: 1. On 2/29/24 at 11:01 AM, the surveyor observed the Resident #38 in bed watching television. The resident stated in the past, their medications were administered not on time, but lately only during the weekend shifts were their medications administered late. On 3/5/24 at 11:44 AM, the surveyor interviewed the Director of Nursing (DON) who stated that medication ordered for 9:00 AM with no parameters was administered at the time ordered or an hour before or after the scheduled time in accordance with professional standards of practice. If the medications were going to be administered late for the day, the physician would have needed to be contacted. The surveyor reviewed the medical record for Resident #38. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included morbid obesity, generalized anxiety disorder, and major depressive disorder. A review of the April 2023 Medication Administration Record (MAR) revealed the resident had the following physician's orders (PO) to be administered: At 8:00 AM (8 AM), a PO dated 6/17/22, levothyroxine sodium tablet 25 microgram (mcg); give one tablet by mouth one time a day for hypothyroidism and a PO dated 6/21/22, metformin hcl tablet 500 milligram (mg); give one tablet by mouth two times a day for diabetes mellitus (DM). At 9:00 AM (9 AM): PO dated 5/19/22, colchicine tablet 0.6 mg; give one tablet by mouth one time a day for gout. PO dated 6/16/22, Mobic tablet 15 mg (meloxicam); give one tablet by mouth one time a day related to idiopathic gout. PO dated 5/21/22, multivital-M (multiple vitamins-minerals); give one tablet by mouth one time a day for supplement. PO dated 5/19/22, potassium chloride Crys extended release tablet extended release 20 milliequivalent (MEq); give two tablets by mouth one time a day for supplement. PO dated 5/19/22, prednisone tablet 5 mg; give three tablets by mouth one time a day for inflammation. PO dated 5/19/22, Zyloprim tablet 100 mg (allopurinol); give three tablets by mouth one time a day for gout. PO dated 5/24/22, Colace capsule 100 mg (docusate sodium); give one capsule by mouth two times a day for constipation. PO dated 5/20/22, cranberry-vitamin C capsule 450-125 mg; give one capsule by mouth two times a day for supplement. PO dated 5/24/22, metoprolol tartrate tablet 25 mg; give one tablet by mouth two times a day for hypertension (HTN). PO dated 5/23/22, Baleen tablet 10 mg; give one tablet by mouth three times a day for muscles. PO dated 5/23/22, hydrolyzing hcl tablet 25 mg; give one tablet by mouth three times a day for itching. At 1:00 PM (1 PM), a PO dated 5/23/22, Baleen tablet 10 mg; give one tablet by mouth three times a day for muscles and a PO dated 5/23/22, hydrolyzing hcl tablet 25 mg; give one tablet by mouth three times a day for itching. At 5:00 PM (5 PM): PO dated 5/20/22, cranberry-vitamin C capsule 450-125 mg; give one capsule by mouth two times a day for supplement. PO dated 6/21/22, metformin hcl tablet 500 milligram (mg); give one tablet by mouth two times a day for DM. PO dated 5/24/22, meteorology triturate tablet 25 mg; give one tablet by mouth two times a day foot HTN. PO dated 5/23/22, Baclofen tablet 10 mg; give one tablet by mouth three times a day for musculoskeletal. PO dated 5/23/22, hydroxyzine hcl tablet 25 mg; give one tablet by mouth three times a day for itching. At 6:00 PM (6 PM), a PO dated 5/24/22, Colace capsule 100 mg (Docusate Sodium); give one capsule by mouth two times a day for constipation. A review of the corresponding April 2023 Medication Admin Audit Report reflected the following: On 4/1/23, 9 AM and 1 PM doses were administered at 2:21 PM; the 5 PM and 6 PM doses were administered at 7:39 PM. On 4/2/23, the 8 AM doses were administered at 9:32 AM; the 5 PM and 6 PM doses were administered at 7:57 PM. On 4/4/23, the 8 AM doses were administered at 9:18 AM. On 4/6/23, the 5 PM doses were administered at 7:05 PM. On 4/7/23, the 5 PM doses were administered at 6:53 PM. On 4/8/23, the 8 AM and 9 AM doses were administered between 12:06 PM and 12:13 PM; the 1 PM doses were administered at 3:41 PM. On 4/9/23, the 8 AM and 9 AM doses were administered at 1:25 PM. On 4/10/23, the 5 PM doses were administered at 6:37 PM On 4/12/23, the 5 PM and 6 PM doses were administered at 8:58 PM. On 4/14/23, the 5 PM and 6 PM doses were administered at 7:33 PM. On 4/15/23, the 8 AM and 9 AM doses were administered at 12:56 PM; the 1 PM doses were administered at 4:39 PM, the 5 PM doses were administered at 6:23 PM. On 4/16/23, the 8 AM doses were administered at 9:45 AM; the 9 AM doses were administered at 10:11 AM. On 4/17/23, the 5 PM doses were administered at 8:21 PM. On 4/18/23, the 5 PM doses were administered at 6:47 PM. On 4/19/23, the 5 PM doses were administered at 6:42 PM. On 4/20/23, the 5 PM doses were administered at 6:14 PM. On 4/21/23, the 5 PM doses were administered at 7:09 PM. On 4/22/23, the 5 PM and 6 PM doses were administered at 11:30 PM. On 4/23/23, the 8 AM doses were administered at 9:27 AM. On 4/24/23, the 5 PM doses were administered at 6:35 PM. On 4/28/23, the 5 PM doses were administered at 6:30 PM. On 4/29/23, the 8 AM and 9 AM doses were administered at 11:45 AM; the 1 PM doses were administered at 2:45 PM; the 5 PM and 6 PM doses were administered at 11:42 PM, 11:45 PM. On 4/30/23, the 8 AM and 9 AM doses were administered at 11:08 AM; the 1 PM doses were administered at 2:21 PM the 5 PM and 6 PM doses were administered at 7:31 PM. On 3/6/24 at 11:38 AM, the surveyor reviewed with the Chief Clinical Officer (CCO) the resident's April 2023 Medication Admin Audit Report. The CCO acknowledge there were multiple dates and times medications had been administered past the time of scheduled administration. 2. On 2/29/24 at 10:30 AM, the surveyor observed Resident #42 sitting in their wheelchair in the entranceway to their room. The resident in a non-English language stated the words blood and medicine while pointing to their right forearm. The surveyor was unable to interview the resident at the time for further information. At this time, the surveyor observed Licensed Practical Nurse (LPN #1) at their medication cart in the hallway at a resident's room near Resident #42's room. The surveyor asked LPN #1 if she was still administering 9:00 AM medications, and the LPN replied she was administering 10:00 AM medications. The surveyor asked if Resident #42 received any insulin (blood sugar medication) or medication for blood, and the LPN stated the resident was not on any insulin but received a blood pressure medication; that she was unsure of the name. The surveyor asked if the resident had received their medications that morning, and LPN #1 stated that Resident #42 was to receive their medications next. The surveyor reviewed the medical record for Resident #42. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included Parkinson's Disease, depression, and gastro-intestinal reflux disease. A review of the February 2024 Order Summary Report revealed the resident had the following physician's orders (PO) to be administered at 9:00 AM: PO dated 1/8/24, for artificial tear solution 1.4%; instill one drop in both eyes one time a day for corneal scarring in both eyes. PO dated 1/10/24, for aspirin oral tablet chewable 81 milligram (mg); give one tablet by mouth in the morning for coronary artery disease. PO dated 1/9/24, for bisacodyl rectal suppository 10 mg; insert 10 mg rectally one time a day for laxative. PO dated 1/9/24, for bumetanide oral tablet 1 mg; give one tablet by mouth one time a day for high blood pressure. PO dated 1/8/24, for Icy Hot external patch 5%; apply to right shoulder topically one time a day for pain. PO dated 1/9/24, polyethylene glycol 3350 oral powder 17 grams per scoop; give 17 grams by mouth one time per day for laxatives. PO dated 1/9/24, vitamin D3 tablet 1000 unit; give one tablet by mouth one time a day for vitamin supplement. PO dated 1/9/24, for gabapentin oral capsule 300 mg; give one capsule by mouth three times a day for neurological pain. PO dated 1/9/24, for carbidopa-levodopa extended release oral tablet 25-100 mg; give one tablet by mouth four times a day for Parkinson. A review of the February 2024 Medication Admin Audit Report reflected that all nine of the above medications ordered for 9:00 AM administration were signed administered on 2/29/24 at 10:31 AM by LPN #1. The resident had no medications that were ordered to be administered at 10:00 AM as informed by LPN #1 that she was administering 10:00 AM medications. On 2/29/24 at 1:11 PM, the surveyor interviewed LPN #1 who stated she started administering morning medications around 8:00 AM after checking residents' vital signs and blood sugars. LPN #1 stated she had one hour before the medication was ordered and one hour after the medication was ordered to administer that medication. LPN #1 confirmed for a medication that was ordered to be administered at 9:00 AM, should be administered between 8:00 AM and 10:00 AM. LPN #1 acknowledged Resident #42's 9:00 AM medications were administered late that morning because she was observing a wound care treatment with the wound nurse. LPN #1 stated that she typically administered resident treatments at the same time she administered their medications if the treatment was only a topical treatment or bandage and not a lengthy procedure. LPN #1 stated she started the wound observation around 10:00 AM that morning, and then continued to administer 9:00 AM medications afterwards. On 3/4/24 at 11:27 AM, the surveyor interviewed the Unit Manger/LPN (UM/LPN) who stated medications were to be administered at the time ordered, or one hour before or one hour after the ordered time. The UM/LPN confirmed 9:00 AM medication administration should be completed by 10:00 AM. The UM/LPN stated LPN #1 should not have administered treatments and medications at the same time, since medications were ordered for a specific time and treatments were ordered for the shift; medications would not be administered on time if you administered together. The UM/LPN acknowledged LPN #1 administered medications late on 2/29/24 for Resident #42, and there were no adverse outcomes. On 3/5/24 at 11:44 AM, the surveyor interviewed the Director of Nursing (DON) who stated that medication ordered for 9:00 AM with no parameters were administered at the time ordered or an hour before or after the scheduled time in accordance with professional standards of practice. If the medications were going to be administered late for the day, the physician would have needed to be contacted. The DON stated medications and treatments should not be administered at the same time because it would put the nurse behind on medication administration; that all medications should be administered to the residents prior to treatments. On 3/7/24 at 11:52 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Regional DON, Chief Clinical Officer, and survey team acknowledged that medications should be administered at the time ordered, and that treatments should not be administered during morning medication pass. A review of the facility's undated Administering Medications policy included medications must be administered in accordance with the orders, including the required timeframes . 3. On 2/28/24 at 9:21 AM, the surveyor observed Resident #37 in their room. The resident was with the Nurse Practitioner (NP) and was unable to be interviewed. On 2/28/24 at 12:05 PM, the surveyor observed the resident in their room meditating, and they were unable to be interviewed at the time. The surveyor reviewed the medical record for Resident #37. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included end stage renal disease; dependence on renal dialysis; and type II diabetes mellitus. A review of the Medication Review Report included a physician's order (PO) dated 11/13/21, for hemodialysis every Tuesday, Thursday, and Saturday; pick-up at 9:30 AM with a chair time of 10:30 AM to 2:00 PM for end stage renal disease. An additional PO dated 9/13/23, to please ensure dialysis communication book/binder is filled out and accompany resident to dialysis; if resident is non-compliant with having book/binder filled out, please document refusal. A review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], reflected the resident had a brief interview for mental status score of 15 out of 15; which indicated a fully intact cognition. A further review of the MDS indicated the resident had end stage renal disease and received dialysis treatments while in the facility. On 3/4/24 at 11:27 AM, the surveyor interviewed the UM/LPN who stated the dialysis communication books were stored at the nurse's station, and filled out by the nurse prior to the resident leaving for the dialysis center. The UM/LPN stated that the dialysis center completed the communication log while the resident was at treatment, and then the cart nurse reviewed the communication book upon the resident's return to note any changes. The surveyor reviewed Resident #37's dialysis communication book and observed the following blanks in documentation: There was no signature of staff reviewing the sheet upon return on: 1/23/24; 2/3/24; 2/8/24; 2/10/24; 2/22/24; 2/29/24; and 3/5/24. There were no vital signs from the facility on: 2/1/24; 2/8/24; 2/15/24; 2/17/24; 2/27/24; and 3/5/24. There were no vital signs post dialysis on 2/27/24 and 2/29/24. During a follow-up interview with the surveyor on 3/5/24 at 2:05 PM, the UM/LPN acknowledged the missing signatures and vital signs from the resident's dialysis binder. The UM/LPN stated it was the dialysis center's staff who completed the post dialysis vital signs portion. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer, and survey team acknowledged the missing documentation in the resident's dialysis communication book. A review of the facility's undated Hemodialysis Communication policy included nurses to ensure upon return to the facility that the resident has their communication binder with them and filled out completely to include pre and post dialysis weights, vitals, and any medications provided during treatments .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview, review of Nurse Staffing Report sheets, and other pertinent facility documents, it was determined that the facility failed to ensure a Registered Nurse worked seven days a week for at least eight consecutive hours a day for 5 of 16 weekends reviewed. This deficient practice was evidenced by the following: During entrance conference on 2/27/24 at 10:13 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's staff was, and the LNHA stated that staffing was good; that the facility primarily utilized agency staff for certified nursing aides (CNA); the facility did have callouts. At this time, the surveyor requested the Nurse Staffing Report to be completed for the following weeks: 1/1/23 through 1/7/23; 2/12/23 through 2/18/23; 2/19/23 through 2/25/23; 3/12/23 through 3/18/23; 5/21/23 through 5/27/23; 5/28/23 through 6/3/23. The surveyor reviewed the Nurse Staffing Reports which revealed there was no Registered Nurse (RN) to work eight consecutive hours on the following dates: 1. No RN on 1/7/23; the last RN was scheduled on the 3:00 PM to 11:00 PM (3-11) shift on 1/6/23. 2. No RN on 2/18/23; the last RN was scheduled on the 3-11 shift on 2/17/23. 3. No RN on 2/25/23; the last RN was scheduled on the 11:00 PM to 7:00 AM (11-7) shift on 11/24/23. 4. No RN on 3/18/23; the last RN was scheduled on the 7:00 AM to 3:00 PM (7-3) shift on 3/17/23. 5. No RN on 5/27/23 and 5/28/23; the last RN was scheduled on the 3-11 shift on 5/26/23. A review of the corresponding nursing staffing sheets verified the following: During the 3-11 shift on 1/6/23, there was a RN scheduled, and the next RN scheduled to work on 1/7/23. During the 3-11 shift on 2/17/23, there was a RN scheduled, and the next RN scheduled to work was on the 3-11 shift on 3/19/23. During the 11-7 shift on 2/24/23, there was a RN scheduled, and the next RN scheduled to work was on the 11-7 shift on 2/26/23. During the 7-3 shift on 3/17/23, there was a RN scheduled, and the next RN scheduled to work was on the 3-11 shift on 3/19/23. During the 7-3 shift on 5/26/23, there was a RN scheduled, and the next RN scheduled to work was on the 3-11 shift on 5/29/23. On 3/6/24 at 12:23 PM, the surveyor interviewed the Staffing Coordinator who stated she scheduled staff according to state and federal regulations; that there should be a RN scheduled daily. The Staffing Coordinator stated it did not matter which shift the RN was scheduled for; as long as there was a RN scheduled for one shift a day. The Staffing Coordinator stated the facility had difficulty scheduling a RN from the beginning of the year in 2023 until approximately May of 2023, when the facility had permanent RN scheduled for the weekend shifts. The facility did their best to reach out to agency staff for RN coverage, but they had not always been able to obtain. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer, and survey team acknowledged the facility had days where there were no RNs scheduled for eight consecutive hours. A review of the facility's undated Staffing policy included this facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services . NJAC 8:39-25.2(h)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly label and date medication in accordance with manufacturer recommendations and b.) maintain a medication refrigerator temperature log to ensure safe medication storage. This deficient practice was observed in 1 of 2 medication storage rooms (Second-Floor) and 1 of 3 medication carts (low cart- Second-Floor) inspected, and was evidenced by the following: 1. On 3/4/24 at 10:47 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the Second-Floor nursing unit's low cart and observed the following multi-dose medications had been opened and undated: Incruse Ellipta 62.5 microgram (mcg) inhaler (medication used for symptoms of chronic obstructive pulmonary disease, COPD) dated opened 1/14. Instructions on the package were discard the inhaler six weeks after opening the moisture-protective foil tray . Advair HFA 230 mcg/21 mcg inhaler (medication used for asthma or COPD, opened and undated. Instructions on the package were discard 30 days after foil pouch opened. Spiriva Respimat 2.5 mcg/actuation inhaler (medication used for COPD) two inhalers opened and undated. Instructions on the package were discard three months after insertion of the cartridge into inhaler. Both inhalers had the cartridges inserted. Fluticasone propionate and salmeterol inhaler 113 mcg/21 mcg inhaler (medication used for asthma and COPD) opened and undated. Instructions on the package were discard inhaler . 30 days after removal from the foil pouch . Latanoprost 0.005% opthalmic solution (medication used for glaucoma) opened and undated. Instructions on label were discard after six weeks Insulin glargine vial 100 units/milliliter (medication used for diabetes) opened, and bag dated 2/1/24, vial was undated. Instruction on packaging were discard after 28 days. Insulin glargine vials 100 units/milliliter- 2 vials opened, and bag was dated, but the vial was not dated. Instructions on packaging were discard after 28 days. On 3/4/24 at 11:33 AM, the LPN stated the vials, eye drops and inhalers should have all been dated when they were opened. 2. On 3/4/24 at 11:57 AM, the surveyor in the presence of the Second-Floor nursing unit's Unit Manager/LPN (UM/LPN) inspected the Second-Floor medication room. In the medication refrigerator, the surveyor observed an opened and undated bottle of lorazepam 2 milligrams per 1 milliliter (mg/ml) concentrated oral solution in active inventory. The product label instructed Discard opened bottle after 90 days. The LPN acknowledged that neither the medication bottle nor the medication box had been dated when opened or when to be discarded. The surveyor also noted the refrigerator temperature log had not been completed for 3/2/24. The UM/LPN stated there should be no blanks in the log; that the evening nurses should be checking the temperature of the refrigerators and recording them in the log. On 3/4/24 at 11:43 AM, the UM/LPN stated to the surveyor medications such as eye drops, and inhalers should be dated when opened. Insulin vials however, it was enough to date the bag, the vials did not have to also be dated. On 3/6/24 at 10:50 AM, the surveyor interviewed the Regional Director of Nursing (RDON) in the absence of the facility Director of Nursing (DON) who stated all medications should be dated when opened and discarded per manufacturer's instructions and that nurses should be monitoring the refrigerator temperatures to make sure temperatures are within safe range for medication storage. A review of the facility's undated Storage of Medications policy indicated AristaCare at Cherry Hill shall store all drugs and biologicals in a safe, secure, and orderly manner .nursing staff shall be responsible for maintaining medication storage. A review of the facility's undated Refrigerators and Freezers policy did not include medication refrigerators, but did include AristaCare at Cherry Hill will ensure safe refrigeration and freezer maintenance, temperatures and sanitation . monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures . A review of the undated facility Controlled Substance policy revealed AristaCare at Cherry Hill shall comply with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled medications . NJAC 8:39-29.4(h), 29.7(c)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

2. On 2/27/24 at 1:17 PM, the surveyor observed Resident #21 in bed with their food tray on their bedside table. Resident #21 stated that they do not receive their coffee; that staff will sometimes get them their requested coffee when asked. The surveyor reviewed Resident #21's dietary slip that included coffee eight ounces (8 oz). On 2/29/24 at 9:32 AM, the surveyor observed Resident #21 in bed with food tray in front of them without coffee. The surveyor reviewed the medical record for Resident #21. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses including but not limited to acute pancreatic, hip infection, and muscle weakness. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. On 3/5/24 at 10:40 AM, the surveyor interviewed Certified Nursing Aide (CNA #1) who stated that nursing was responsible for checking the trays to make sure that everything on the dietary slip was delivered to the residents. When asked if there was an issue with the resident's coffee, CNA #1 responded yes, it happens all the time. On 3/5/24 at 12:58 PM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who stated that tray accuracy was teamwork, and everyone should ensure that the dietary slip matched what was on the tray. When asked if there has been an issue with residents and their coffee, LPN #1 confirmed that the nursing staff often obtained it for the residents since it was not on their meal tray. On 3/5/24 at 1:28 PM, the surveyor interviewed the RD who stated that a resident's meal ticket should identify everything that they want, and confirmed that what was on the ticket should be on the tray. When asked who was responsible for ensuring that coffee was on resident's tray, the RD stated that the kitchen had a person at the end of the tray line that would ensure tray accuracy. On 3/6/24 at 12:39 PM, the surveyor interviewed the DD who stated that there was not enough coffee cups for the facility. The kitchen had a list of names who would like coffee and, as cups become available throughout the service, they would be washed, filled, and brought out to the residents. On 3/7/24 at 11:23 AM, the surveyor met with the LNHA in the presence of the RDON, Chief Clinical Officer and survey team, and the LNHA confirmed that residents should be receiving their meals based on their preferences. The LNHA also stated she was unaware the kitchen did not have enough coffee cups. 3. On 2/27/24 at 1:17 PM, the surveyor observed Resident #6 seated in wheelchair with lunch tray in front of them. The resident stated that they requested coffee with their lunch, but did not receive it. When asked if this happened often, Resident #6 agreed. The surveyor reviewed Resident #6's dietary slip that included coffee 8 oz. On 2/29/24 at 9:33 AM, Resident #6 informed the surveyor they just woke for the morning. The resident's breakfast tray was observed on the bedside table without coffee. Resident #6 stated that coffee was something that they enjoyed every morning, and it made them upset that they cannot have it. The surveyor reviewed the medical record for Resident #6. A review of the admission Record face sheet reflected the resident was admitted to the facility with diagnoses including but not limited to handsomely (breakdown of skeletal muscle) and acute respiratory failure. A review of the most recent quarterly MDS reflected that the resident had a BIMS score of 15 out of 15, which indicated a fully intact cognition. On 3/5/24 at 10:40 AM, the surveyor interviewed CNA #1 who stated that nursing was responsible for checking the trays to ensure that everything on the dietary slip was delivered to the residents. When asked if there was an issue with the resident's coffee CNA #1 responded yes, it happens all the time. On 3/5/24 at 12:58 PM, the surveyor interviewed LPN #1 who stated that tray accuracy was teamwork, and everyone should ensure that the dietary slip matched what was on the tray. When asked if there has been an issue with residents and their coffee, LPN #1 confirmed that the nursing staff often obtained it for the residents since it was not on their meal tray. On 3/5/24 at 1:28 PM, the surveyor interviewed the RD who stated that a resident's meal ticket should identify everything that they want, and confirmed that what was on the ticket should be on the tray. When asked who was responsible for ensuring that coffee was on resident's tray, the RD stated that the kitchen had a person at the end of the tray line that would ensure tray accuracy. On 3/6/24 at 12:39 PM, the surveyor interviewed the DD who stated that there was not enough coffee cups for the facility. The kitchen had a list of names who would like coffee and, as cups become available throughout the service, they would be washed, filled, and brought out to the residents. On 3/7/24 at 11:23 AM, the surveyor met with the LNHA in the presence of the RDON, Chief Clinical Officer and survey team, and the LNHA confirmed that residents should be receiving their meals based on their preferences. The LNHA also stated she was unaware the kitchen did not have enough coffee cups. 4. On 2/28/24 at 12:18 PM, the surveyor observed Resident #99 seated in reclining chair in the dining room. The surveyor inquired about their meal, and the resident stated that they told the facility that they do not eat pork, but still continued to be served pork products. The surveyor reviewed Resident #99's dietary slip which included ham steak with pineapple glaze. Resident #99 stated that they asked the nursing staff for sandwiches. At 12:26 PM, the surveyor observed Resident #99 was removed from the dining area and returned to their room where medications were administered; their lunch tray remained in the dining room. At 12:31 PM, the surveyor observed Resident #99 in their room, without their tray, while the resident's roommate ate their lunch. At 12:33 PM, the surveyor observed CNA #2 enter the room with Resident #99's tray from the dining room. As CNA #2 cut Resident #99's ham, the resident informed them that they do not eat pork. CNA #2 responded, it's not pork. The resident stopped the CNA and stated, Yes, it is; it's ham. Resident #99 stated that they requested sandwiches. On 2/28/24 at 12:39 PM, the surveyor interviewed with the Unit Manager/Licensed Practical Nurse (UM/LPN) who confirmed that Resident #99's preference for a non-pork lunch should have been honored and taken off their tray. The surveyor reviewed the medical record for Resident #99. A review of the admission Record face sheet reflected the resident was admitted to the facility with diagnoses including but not limited to cerebral infarction (stroke), chenille (paralysis) and empress (weakness). A review of the most recent quarterly MDS reflected that the resident had a BIMS score of 14 of 15, which indicated a fully intact cognition. On 3/5/24 at 1:28 PM, the surveyor interviewed the RD regarding food preferences for Resident #99 who stated that they updated the resident's food preferences on 2/16/24. The RD continued that the resident used to be a vegetarian, but consumed some meat. The RD thought the resident did not prefer ham. When provided with a picture of Resident #99's dietary slip, the RD confirmed that ham was identified. After the RD reviewed the online system, it was confirmed preferences were updated upon surveyor inquiry. On 3/7/24 at 11:23 AM, the surveyor met with the LNHA in the presence of the RDON, Chief Clinical Officer, and survey team, and the LNHA confirmed that residents should be receiving their meals based on their preferences. A review of the facility provided undated Tray Identification document included .1. To assist in setting up and serving the correct food trays/diets to residents, the Food Services Department will use appropriate identification (computer generated diet cards) to identify the various diets. 3. Nursing staff shall check each food tray for the correct diet before serving the residents. NJAC 17.2(b); 17.4(a)3;(e) Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure residents who received the standard serving of the main entree for a regular texture lunch meal was adequate in protein based on the nutritional needs of the residents; b.) ensure the menu was followed; c.) ensure the facility's Registered Dietitian reviewed the menus for nutritional adequacy; and d.) ensure that residents received food and beverage in accordance with their preferences (Resident #6, #21, and #99) This deficient practice was identified for 1 of 2 regular texture meals observed and 3 of 6 residents reviewed for food (Resident #6, #21, & #99), and was evidenced by the following: 1. During entrance conference on 2/27/24 at 10:13 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the facility's menus for the survey period which included that week and the following week. A review of the menu provided titled S/S Week 3 which was identified by the LNHA for the week of 2/25/24 through 3/2/24, revealed the following for the regular texture meal for Friday 3/1/24: Herb baked fish serving size two ounces (2 oz) Summer vegetable medley serving size 1/2 cup Baked sweet potato serving size 1 individual On 3/1/24 between 11:45 AM and 12:48 PM, the surveyor observed the dietary staff serve the above lunch meal, and made the following observations: The surveyor observed the [NAME] plate the first lunch entree where he placed one fish cake (not herb baked fish) on a plate, proceeded to take a knife to the sweet potato and the Director of Dietary (DD) asked what he was doing, the potato was already cut. The surveyor observed slits on the top of the sweet potatoes on the steam table. The DD then demonstrated how the lunch plate should be plated which included one fish cake, one whole sweet potato, a 1/2 cup scoop of summer vegetable medley (green and yellow squash), and an individual portion cup of cinnamon and sugar that was placed next to the sweet potato. The surveyor observed the [NAME] plate the serving for the regular entree meal for the first dining cart. The surveyor observed during the plating of the second dining cart, the [NAME] began to cut the sweet potato in half and proceeded to serve half a sweet potato as a serving. At this time, the surveyor asked the DD what the serving size was for the meal, and the DD explained for the regular meal, it was one fish cake, a half sweet potato, and 1/2 cup scoop of vegetables. The DD continued if the resident requested double or large portions, the resident received two fish cakes and a whole sweet potato. On 3/4/24 at 10:52 AM, the surveyor interviewed the Registered Dietitian (RD) who stated she was a fulltime employee who started working at the facility last June. The RD stated she was a contracted employee and the nutrition vendor [name redacted] who employed her was creating new menus for the facility. The RD stated the menus that the facility was currently using was an older menu that she did not sign off on, but has looked at the menus. The surveyor asked what were the components each meal should have, and the RD stated generally quarter of the plate protein, half the plate fruits and vegetables, and a quarter of the plate starch. The RD continued that some resident's had a preference of larger portions, which would be double the entree portion, and some residents may also request double portions of the sides which would be communicated to the kitchen. The surveyor asked what the serving size for the meal was, and the RD stated the kitchen would have that on the menu, and she would get back to the surveyor. On 3/4/24 at 12:27 PM, the RD in the presence of the Regional RD informed the surveyor that the facility was utilizing an old menu that was signed off by the previous dietitian. The RD stated the typical portion size was 3 oz meat which would yield 24 grams of protein; 4 oz vegetable; and 4 oz of starch. At this time, the surveyor reviewed the menu from Friday with the RD and Regional RD who both stated there should be 3 oz of fish served and not 2 oz, and they both thought the sweet potato would be a whole sweet potato unless it was large in size. The RD and Regional RD stated they would have to ask the DD the size of the sweet potato. The surveyor also requested the product specifications of the fish cake. On 3/4/24 at 1:01 PM, the RD and the Regional RD provided the surveyor with the recipe for fish cakes which indicated portion size two cakes which yielded 34 grams of protein. The surveyor asked both dietitians if the kitchen made the fish cakes and if, so why were they only providing one cake if the portion size was two cakes? The Regional RD stated that some fish cakes were smaller so they served two fish cakes. The surveyor informed the dietitians they observed only residents who received larger or double portions received two fish cakes, and asked if the recipe indicated portion size of two fish cakes, why was the kitchen not following the recipe? The RD and Regional RD could not speak to this and stated they needed to speak to the DD. On 3/4/24 at 1:30 PM, the surveyor interviewed the LNHA who stated it was the RD's responsibility to look at the menus, and the previous dietitian signed off on the current menu. The LNHA continued the portion size was in the facility's electronic meal system which was approved by the previous dietitian, and the kitchen served that portion. At this time, the LNHA provided the surveyor with [name redacted] 2 oz fish cakes ten-pound case, which the LNHA confirmed was served to the residents for Friday's lunch. The surveyor requested the product specifications which included serving size and nutrition information. On 3/4/24 at 1:39 PM, the surveyor interviewed the DD in the presence of the RD and Regional RD who confirmed the fish cakes served for Friday's lunch were the 2 oz commercially bought fish cakes. The DD also stated all the potatoes were 8 oz whole, so the kitchen cut in half to serve 4 oz portions. The surveyor asked if the menu for Friday was herb baked fish, why the kitchen served fish cakes, and the DD stated that the vendor could not provide the herb baked fish, so she substituted with the fish cake. The surveyor asked the RD if the 2 oz fish cake was adequate protein served and the RD confirmed no. The surveyor requested the delivery invoice or product specifications for the sweet potatoes. On 3/5/24 at 10:08 AM, the surveyor interviewed the RD in the presence of the DD who stated she was unaware of the fish cake substitution for Friday's meal and confirmed a 2 oz cake was an inadequate amount for protein. The RD also confirmed she did not review last week's menu that indicated the serving size for the herb baked fish was 2 oz. The DD stated the only information she was able to obtain for the sweet potatoes was she received one forty-pound case, and it did not specify each sweet potato was 8 oz. The surveyor asked the RD and DD if everyone on the sub-acute unit who received the first dining cart with whole sweet potatoes was on larger or double portions, and the RD confirmed no. The RD acknowledged if the sweet potatoes were 8 oz whole and 4 oz cut in half, then some residents received double portions of starch instead of a single portion. The RD acknowledged that the kitchen should be serving the portions indicated on the menu to ensure nutrition adequacy. On 3/5/24 at 10:34 AM, the surveyor reviewed the facility's dietary manual in the presence of the LNHA, RD, and DD. The surveyor asked the RD to review the dietary manual and asked if there were any concerns with the manual. The RD stated the manual was not current since it was based on the 2000 Nutrition Guidelines and followed the Food Pyramid and not My Plate. The RD stated she would follow-up on with what the current nutrition guideline dates were. On 3/5/24 at 10:41 AM, the surveyor re-interviewed the LNHA who stated the menus were reviewed by the previous dietitian, and the expectation was for the kitchen to follow the menu and portion size since a dietitian approved it. The LNHA stated any changes to the menu, the RD typically made the substitution, and the residents were made aware. The LNHA stated the nurses made the residents as well as the Resident Council President aware of any menu changes. On 3/5/24 at 11:35 AM, the surveyor interviewed Resident #18 who stated he/she was not informed of the menu change last Friday from herb baked fish to fish cakes. Resident #18 further stated that no one ever informed him/her there would be a menu change that he/she usually was not served what they ordered. On 3/5/24 at 11:40 AM, the surveyor interviewed Resident #65 who stated no one informed them of the menu change from last Friday, nor do they inform him/her when they change the menu. The resident continued that he/she no longer completed their menu request, since he/she never receive what they ordered. On 3/6/24 at 10:41 AM, the RD informed the surveyor that the current nutrition guidelines were the 2020-2025 recommendations. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional Director of Nursing (RDON), Chief Clinical Officer, and survey team acknowledged these concerns. During a post survey review on 3/13/24 at 4:04 PM, the LNHA provided the surveyor via email with the product specifications for the fish cakes. According to the manufacturer's Nutrition Facts, a serving size was two 2 oz fish cakes which yield 4 oz and six grams (6 gm) of protein per serving. The RD during survey stated the protein source should yield 24 grams of protein, so this was 18 grams less protein than what was recommended. A review of the undated facility's Menu Substitutions policy included food substitutions will be made as appropriate or necessary; the Food Services Manager, in conjunction with the Clinical Dietitian, may make food substitutions as appropriate or necessary .the Food Service Manager will maintain an exchange list. When in doubt about an appropriate substitution, the Food Services Manager will consult the Dietitian prior to making the substitution .all substitutions are noted on the menu and filed in accordance with established dietary policies. Notations of substitutions must include the reason for the substitution .the Food Services Manager or designee will ensure the residents' are made aware of changes.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to serve residents a nourishing snack when there was more than a fourteen-hour span of time between the dinner and breakfast mealtimes. This deficient practice was identified for five of five residents sampled for bedtime snacks (Resident #18, #19, #51, #65, and #73), and was evidenced by the following: On 2/29/23 at 10:33 AM, the surveyor conducted a Resident Council meeting which included five residents (Resident #18, #19, #51, #65, and #73). All five residents informed the surveyor during the meeting that bedtime (HS) snacks were not offered every night. They further stated that they had to ask for a snack and if there were any snacks left in the bins kept under the nurses station, they were given chips, pretzels, or cookies. All residents stated it would be nice if the facility automatically provided each resident with an HS snack. The residents confirmed dinner was served between 4:30-5:00 PM on the First-Floor nursing unit and breakfast between 8:00-8:45 AM. The surveyor reviewed the Mealtimes provided by the facility upon entrance conference, which indicated the first dinner cart was served to the Chapel nursing unit first floor at 4:15 PM, and the first breakfast cart was served to the Chapel nursing unit at 7:40 AM. This was a fifteen-hour and twenty-five-minute period between dinner and breakfast. On 3/4/24 at 11:20 AM, the surveyor interviewed the Registered Dietitian (RD) who stated she did not oversee the snacks that the residents received. The RD stated that the Director of Dietary (DD) ordered them and delivered the snacks to the units. The surveyor asked the RD how often the snacks were delivered, and the RD replied that she was not sure. The RD stated that breakfast was delivered between 8:30-9:00 AM, lunch was delivered between 12:00-1:00 PM, but she was not sure what time dinner was delivered. When asked what a nourishing snack was, the RD responded snacks could not be anything perishable since they were kept in the bins at the nurse's station. The RD stated that nutritious snacks could be pretzels or peanut butter crackers, there was no definition of a nourishing snack or what would be considered a sufficient snack at night. The RD stated that she was not aware of what snacks the diabetic residents received at night, but that they would probably be carbohydrate controlled and that the DD took care of that. On 3/4/24 at 12:15 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LP) who stated there were no snacks since the kitchen did not send them up. The UM/LP further stated that snacks were only provided to the residents upon request. On 3/4/24 at 1:01 PM, the surveyor interviewed the DD who acknowledged that the time frame from when a resident was provided dinner and breakfast should be no longer than fourteen hours and acknowledged that the residents in the facility were between 15-16 hours. The DD further acknowledged that each resident should be provided a nutritious snack at HS because of the extended length of time between dinner and breakfast. The DD confirmed that snacks were available upon request only, residents were not automatically served a snack and the first dinner cart was served at 4:15 PM, and the first breakfast cart was served at 7:40 AM. On 3/7/24 at 11:02 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Regional Director of Nursing, Chief Clinical Officer, and survey team confirmed that all residents should have been provided nutritious snacks because of the extended time between dinner and breakfast. The LNHA acknowledged that a nourishing snack was considered a food that contained protein such as a sandwich, yogurt, fruit, nuts, and not just a cookie or a bag of chips. A review of the facility's undated Serving of Food policy did not include their procedure for providing nourishing HS snacks to all residents if the period between the dinner and breakfast meal was greater than fourteen hours. NJAC 8:39-17.2 (f)(1)(i-ii)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store, label, and date potentially hazardous foods to prevent food-borne illness; b.) discard potentially hazardous foods past their date of expiration; and c.) maintain storage areas in a sanitary manner. This deficient practice was evidenced by the following: On 2.27/24 at 10:42 AM, the surveyor toured the kitchen with the Director of Dietary (DD) and observed the following: 1. In the walk-in refrigerator, one five-pound container of sour cream dated opened 2/1/24. The container had a manufacturer printed expiration date of 5/24/24, but the DD was unsure how many days the sour cream could be used for once opened. 2. In the walk-in refrigerator, one five-pound container of cottage cheese dated opened 2/13/24, with an expiration date of 2/24/24. 3. In the walk-in refrigerator, one gallon of mayonnaise opened. The container had no opened date or when to use by; the DD stated mayonnaise was good for one month after opened. 4. In the walk-in freezer, the vinyl strip curtains located in the entrance to the freezer were missing three strip curtains on the outer sides of the doorway. These curtains protect the inside of the freezer from outside dust particles as well as keep the cold air from escaping the freezer when the door was opened. 5. In dry storage, seven 108-ounce (oz) cans of rice pudding; five 105-oz cans of whole peeled tomatoes; eight six-pound cans of sliced apples all with visible white particles, debris, and dust on the can lids. The DD stated staff do not dust the cans in dry storage; that she would add to the cleaning list. 6. In dry storage, one forty-pound bucket of chicken flavored base. The lid of the bucket was heavily soiled. 7. In reach-in milk box #2 which contained juice, the right latch did not close which kept the side ajar. 8. In the ice cream freezer, built up accumulation of ice. On 3/7/24 at 11:52 AM, the Licensed Nursing Home Administrator in the presence of the Regional Director of Nursing, Chief Clinical Officer, and the survey team acknowledged these concerns. A review of the undated facility provided Labeling and Dating System Protocol policy included follow manufacturer's expiration date on all un-opened product. If there is no printed manufacturer's date on product following below dating protocol . refrigerated items opened [mayonnaise], garlic, dressing, salsa thirty days .cottage cheese, ricotta, cream cheese one week from opened date . A review of the undated facility's Food Storage policy included food storage areas shall be maintained in a clean, safe, and sanitary manner; Food Services, or other designated staff, will maintain clean food storage areas at all times .all packaged food, canned foods, or food items will be kept clean and dry at all times . NJAC 8:39-17.2(g)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0836 (Tag F0836)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Complaint NJ# 162587 Based on interview and review of pertinent facility documents, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 75 out of 105 day shifts reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. During entrance conference on 2/27/24 at 10:13 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's staff was, and the LNHA stated that staffing was good; that the facility primarily utilized agency staff for certified nursing aides (CNA); the facility had callouts. At this time, the surveyor requested the Nurse Staffing Report to be completed for the following weeks: 11/20/22 to 11/26/22; 11/27/22 to 12/3/22; 1/1/23 to 1/7/23; 1/14/23 to 1/20/23; 1/21/23 to 1/27/23; 2/12/23 to 2/18/23; 2/19/23 to 2/25/23; 3/12/23 to 3/18/23; 3/19/23 to 3/25/23; 4/2/23 to 4/8/23; 4/9/23 to 4/15/23; 5/21/23 to 5/22/23; 5/28/23 to 6/3/23; 2/11/24 to 2/17/24; and 2/18/24 to 2/24/24. The surveyor reviewed the facility completed Nurse Staffing Reports which revealed the following: 1. For the two weeks of staffing from 11/20/22 to 12/03/2022, the facility was deficient in CNA staffing for residents on 10 of 14 day shifts as follows: 11/20/22 had 8 CNAs for 121 residents on the day shift, required at least 15 CNAs. 11/21/22 had 14 CNAs for 121 residents on the day shift, required at least 15 CNAs. 11/22/22 had 10 CNAs for 121 residents on the day shift, required at least 15 CNAs. 11/25/22 had 10 CNAs for 121 residents on the day shift, required at least 15 CNAs. 11/26/22 had 12 CNAs for 121 residents on the day shift, required at least 15 CNAs. 11/27/22 had 12 CNAs for 121 residents on the day shift, required at least 15 CNAs. 11/28/22 had 9 CNAs for 121 residents on the day shift, required at least 15 CNAs. 11/29/22 had 13 CNAs for 120 residents on the day shift, required at least 15 CNAs. 12/3/22 had 13 CNAs for 114 residents on the day shift, required at least 14 CNAs. 2. For the week of staffing from 1/1/2023 to 1/7/2023, the facility was deficient in CNA staffing for residents on 5 of 7 day shifts as follows: 1/1/23 had 8 CNAs for 118 residents on the day shift, required at least 15 CNAs. 1/2/23 had 10 CNAs for 117 residents on the day shift, required at least 15 CNAs. 1/3/23 had 12 CNAs for 117 residents on the day shift, required at least 15 CNAs. 1/6/23 had 14 CNAs for 117 residents on the day shift, required at least 15 CNAs. 1/7/23 had 10 CNAs for 117 residents on the day shift, required at least 15 CNAs. 3. For the two weeks of staffing from 1/14/23 to 1/27/23, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts as follows: 1/14/23 had 14 CNAs for 125 residents on the day shift, required at least 16 CNAs. 1/15/23 had 11 CNAs for 125 residents on the day shift, required at least 16 CNAs. 1/16/23 had 11 CNAs for 125 residents on the day shift, required at least 16 CNAs. 1/17/23 had 11 CNAs for 125 residents on the day shift, required at least 16 CNAs. 1/18/23 had 11 CNAs for 125 residents on the day shift, required at least 16 CNAs. 1/19/23 had 11 CNAs for 125 residents on the day shift, required at least 16 CNAs. 1/20/23 had 12 CNAs for 125 residents on the day shift, required at least 16 CNAs. 1/21/23 had 11 CNAs for 131 residents on the day shift, required at least 16 CNAs. 1/22/23 had 9 CNAs for 129 residents on the day shift, required at least 16 CNAs. 1/23/23 had 11 CNAs for 127 residents on the day shift, required at least 16 CNAs. 1/24/23 had 11 CNAs for 127 residents on the day shift, required at least 16 CNAs. 1/25/23 had 12 CNAs for 127 residents on the day shift, required at least 16 CNAs. 1/26/23 had 9 CNAs for 125 residents on the day shift, required at least 16 CNAs. 1/27/23 had 14 CNAs for 122 residents on the day shift, required at least 16 CNAs. 4. For the two weeks of staffing from 1/12/23 to 2/25/23, the facility was deficient in CNA staffing for residents on 13 of 14 day shifts as follows: 2/12/23 had 8 CNAs for 122 residents on the day shift, required at least 15 CNAs. 2/13/23 had 11 CNAs for 119 residents on the day shift, required at least 15 CNAs. 2/14/23 had 10 CNAs for 118 residents on the day shift, required at least 15 CNAs. 2/15/23 had 13 CNAs for 118 residents on the day shift, required at least 15 CNAs. 2/16/23 had 14 CNAs for 118 residents on the day shift, required at least 15 CNAs. 2/17/23 had 9 CNAs for 118 residents on the day shift, required at least 18 CNAs. 2/18/23 had 10 CNAs for 118 residents on the day shift, required at least 15 CNAs. 2/19/23 had 9 CNAs for 117 residents on the day shift, required at least 15 CNAs. 2/20/23 had 9 CNAs for 117 residents on the day shift, required at least 15 CNAs. 2/21/23 had 10 CNAs for 117 residents on the day shift, required at least 15 CNAs. 2/22/23 had 14 CNAs for 117 residents on the day shift, required at least 15 CNAs. 2/23/23 had 11 CNAs for 117 residents on the day shift, required at least 15 CNAs. 2/25/23 had 12 CNAs for 120 residents on the day shift, required at least 15 CNAs. 5. For the two weeks of staffing from 3/12/23 to 3/25/23, the facility was deficient in CNA staffing for residents on 13 of 14 day shifts as follows: 3/12/23 had 9 CNAs for 124 residents on the day shift, required at least 15 CNAs. 3/13/23 had 10 CNAs for 122 residents on the day shift, required at least 15 CNAs. 3/14/23 had 12 CNAs for 122 residents on the day shift, required at least 15 CNAs. 3/15/23 had 12 CNAs for 122 residents on the day shift, required at least 15 CNAs. 3/16/23 had 12 CNAs for 122 residents on the day shift, required at least 15 CNAs. 3/17/23 had 10 CNAs for 122 residents on the day shift, required at least 15 CNAs. 3/18/23 had 11 CNAs for 123 residents on the day shift, required at least 15 CNAs. 3/19/23 had 10 CNAs for 123 residents on the day shift, required at least 15 CNAs. 3/20/23 had 10 CNAs for 121 residents on the day shift, required at least 15 CNAs. 3/21/23 had 11 CNAs for 120 residents on the day shift, required at least 15 CNAs. 3/22/23 had 14 CNAs for 118 residents on the day shift, required at least 15 CNAs. 3/23/23 had 13 CNAs for 118 residents on the day shift, required at least 15 CNAs. 3/25/23 had 14 CNAs for 117 residents on the day shift, required at least 15 CNAs. 6. For the two weeks of staffing from 4/2/23 to 4/15/23, the facility was deficient in CNA staffing for residents on 10 of 14 day shifts as follows: 4/2/23 had 11 CNAs for 115 residents on the day shift, required at least 14 CNAs. 4/3/23 had 11 CNAs for 115 residents on the day shift, required at least 14 CNAs. 4/4/23 had 13 CNAs for 114 residents on the day shift, required at least 14 CNAs. 4/8/23 had 14 CNAs for 119 residents on the day shift, required at least 15 CNAs. 4/9/23 had 7 CNAs for 116 residents on the day shift, required at least 14 CNAs. 4/10/23 had 12 CNAs for 116 residents on the day shift, required at least 14 CNAs. 4/11/23 had 11 CNAs for 113 residents on the day shift, required at least 14 CNAs. 4/13/23 had 13 CNAs for 111 residents on the day shift, required at least 14 CNAs. 4/14/23 had 8 CNAs for 111 residents on the day shift, required at least 14 CNAs. 4/15/23 had 11 CNAs for 110 residents on the day shift, required at least 14 CNAs. 7. For the two weeks of staffing from 5/21/23 to 6/3/23, the facility was deficient in CNA staffing for residents on 6 of 7 day shifts as follows: 5/21/23 had 10 CNAs for 108 residents on the day shift, required at least 13 CNAs. 5/22/23 had 10 CNAs for 108 residents on the day shift, required at least 13 CNAs. 5/23/23 had 10 CNAs for 108 residents on the day shift, required at least 13 CNAs. 5/24/23 had 12 CNAs for 108 residents on the day shift, required at least 13 CNAs. 5/25/23 had 12 CNAs for 112 residents on the day shift, required at least 14 CNAs. 5/27/23 had 11 CNAs for 112 residents on the day shift, required at least 14 CNAs. 5/28/23 had 11 CNAs for 110 residents on the day shift, required at least 14 CNAs. 6/1/23 had 11 CNAs for 106 residents on the day shift, required at least 13 CNAs. 6/2/23 had 10 CNAs for 111 residents on the day shift, required at least 14 CNAs. 8. For the two weeks of staffing prior to survey from 2/11/24 to 2/24/24, the facility was deficient in CNA staffing for residents on 4 of 14 day shifts as follows: 2/11/24 had 12 CNAs for 116 residents on the day shift, required at least 14 CNAs. 2/15/24 had 14 CNAs for 119 residents on the day shift, required at least 15 CNAs. 2/18/24 had 14 CNAs for 119 residents on the day shift, required at least 15 CNAs. 2/19/24 had 14 CNAs for 121 residents on the day shift, required at least 15 CNAs. On 3/6/24 at 12:23 PM, the surveyor interviewed the Staffing Coordinator who stated she scheduled staff according to state and federal regulations; 1 to 8 CNAs to residents for the 7:00 AM to 3:00 PM shift (day shift); 1 to 10 CNAs for the 3:00 PM to 11:00 PM shift (evening shift); and 1 to 15 CNAs to residents for the 11:00 PM to 7:00 AM shift (night shift). The Staffing Coordinator stated she tried her best to schedule per the required ratio, but the facility did fall short at times. The facility used two agency staff companies for callouts or lack of facility staff. The Staffing Coordinator stated she was a CNA and had to at times work on the floor when the facility was short staffed. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional DON, Chief Clinical Officer, and survey team acknowledged the facility had days where the staffing requirements did not meet state ratios. A review of the facility's undated Staffing policy included this facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the deliver of resident care services; certified nursing assistants are available each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan .this facility continues to strive to meet the guidance from the DOH . NJAC 8:39-5.1(a)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

7. On 3/1/24 from 7:57 AM through approximately 8:10 AM, the surveyor during Medication Pass observation with LPN #3 made the following observations: LP #3 stated she needed to take Resident #52's blood pressure (BP) before she could administer his/her medication. LPN #3 brought the BP machine into the resident's room, proceeded to take the resident's BP. When LP #3 was finished, she used ABHR on her hands and proceeded to remove the BP machine from the resident's room, and placed it back into the hallway. LPN #3 then returned to the medication cart, prepared the resident's medications; administered the medications; and signed for the administration in the resident's electronic medical record (eMR). The surveyor then asked LPN #3 if she had she completed the medication pass for Resident #52, and the nurse responded yes. The surveyor did not observe LPN #3 sanitize the BP machine after use on Resident #52. On 3/1/24 at 11:18 AM, the surveyor interviewed LPN #3 who confirmed when she was finished with using the BP machine, it should have been cleaned prior to moving on to the next resident. On 3/1/24 from 8:16 AM through approximately 8:45 AM, the surveyor during Medication Pass observation of LPN #3 made the following observations: As the surveyor approached LPN #4 at her medication cart, she removed a wipe from a container of germicidal wipes and proceeded to wipe the BP cuff on the portable BP cart. The nurse then immediately entered Resident #74's room to take their blood pressure without allowing the disinfectant to dwell. After taking the BP, the nurse again wiped the BP cuff with the germicidal wipe, and used ABHR on her hands. LPN #4 then proceeded to the medication cart to prepare the medications for Resident #74, and placed the prepared medication cup on the back of a clipboard that she utilized as a tray without sanitizing the clipboard. LPN #4 then proceeded into the resident's room and placed the clipboard directly on the resident's overbed table, administered the medications, then took the clipboard and placed it on her medication cart. The surveyor did not observe LPN #4 sanitize the clipboard or resident's overbed table. On 3/1/24 at 11:22 AM, the surveyor interviewed LPN #4 who acknowledged she should have waited for the BP cuff to dry and allowed for the dwell time to complete before using the cuff. LPN #4 further stated she should not have brought the clipboard into the room without sanitizing it and should not have placed it on the resident's overbed table, that once she was finished administering the medications, she should have gone back to the resident's room and sanitized the overbed table. On 3/1/24 at 11:30 AM, the surveyor interviewed the IP/RN who stated LPN #3 should disinfected the BP cuff and any tubing or equipment that could have touched the resident to avoid cross contamination. The IP/RN further stated LPN #4 should have waited for the dwell time to complete before using the cuff and she should have wiped down all the equipment before and after using each item, including the clipboard, the overbed table and the top of the medication cart to prevent cross contamination. On 3/6/24 at 10:50 AM, the surveyor interviewed the RDON who stated after each use of equipment such as BP cuff the nurse should be cleaning with a bleach wipe or acceptable alternative such as a germicidal wipe cloth to clean the cuff. The RDON further stated the nurse should not have used her clipboard as a tray to bring medications into a resident's room and should not have placed it on the overbed table; that would be an infection control issue. NJAC 8:39-19.4 (a-c)(k)(n); 27.1 (a) 6. On 2/28/24 at 1:21 PM, the surveyor observed Resident #83 with a family member at the bedside. The resident was in bed with the head of the bed elevated with a feeding pump was on a pole by the him/her. The surveyor reviewed the medical record for Resident #83. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses that included seizures (sudden burst of electrical activity in the brain), cerebral infarction (a process that results in disrupted blood flow to the brain) and atrial fibrillation (abnormal heart rhythm). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/3/23, reflected the resident had a brief interview for mental status (BIMS) score of 1 out of 15, which indicated a severe cognitive impairment. A review of Section K Swallowing/Nutrition Status included the resident had a feeding tubing to provide nutrition. On 2/29/24 at 10:17 AM, the surveyor observed Resident #83 in bed with the head of the bed elevated. The surveyor observed the feeding pump and pole were soiled with a dried beige/brown substance on the front of the feeding pump, at the base of the pole, and on the floor around the base of the pole. On 2/29/24 at 12:06 PM, the surveyor showed LPN #2 the feeding pump, pole, and floor, who stated that it was the CNAs and the housekeepers responsibility to maintain cleanliness of the room. On 2/29/24 at 12:11 PM, the surveyor interviewed UM/LPN #1, who stated that anyone can keep the feeding pole and the feeding pump clean. UM/LPN #1 further stated the area should have been clean. On 3/5/24 at 1:28 PM, the surveyor interviewed the Director of Housekeeping (DH) who stated that when medical equipment like a tube feeding pump and pole were soiled, the nurses requested another pole, and the pole would be switched out so the housekeepers could clean the dirty pole. The DH stated that she was made aware that the pole and feeding pump were soiled, and she did not know why the nurses did not switch the pole out. On 3/6/24 at 4:00 PM, the LNHA was informed of the surveyor's findings. A review of the undated Cleaning and Disinfection of Resident-Care Items and Equipment policy included resident-care equipment, including reusable items and durable medical equipment, which will be cleaned and disinfected according to current CDC recommendations. Complaint # NJ161584 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by a.) ensuring appropriate personal protective equipment was worn for residents on enhanced barrier precautions; b.) maintaining and storing medical supplies and tubing in a sanitary manner to prevent infection; c.) ensure medical equipment and privacy curtains were maintained in a sanitary manner to prevent infection; d.) ensure proper and hygiene was performed prior to dining; and e.) infection control practices were followed during medication observation. This deficient practice was identified on 2 of 3 nursing units (First and Second-Floor) and was evidenced by the following: 1. On 2/27/24 at 10:55 AM, the surveyor observed outside Resident #58's room, a sign that indicated the resident was on Enhanced Barrier Precautions which instructed before entering and exiting the room, you must perform hand hygiene; wear (don) a gown for high contact resident care activities which included .dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tube, tracheostomy; wound care including any skin opening requiring a dressing. The surveyor did not observe any readily available personal protective equipment (PPE) which included but not limited to isolation gowns or disposable gloves. On 2/28/24 at 11:28 AM, the surveyor observed Licensed Practical Nurse (LPN #1) without an isolation gown, reposition Resident #58 and readjusted their corrugated oxygen tubing. On 3/5/24 at 9:45 AM, the surveyor observed LPN #1 without an isolation gown, administer Resident #58's nutrition formula via their gastrostomy tube (a surgical opening into the stomach). On 3/5/24 at 9:47 AM, the surveyor observed Unit Manager/LPN (UM/LPN #1) enter Resident #58's room without performing hand hygiene using an alcohol-based hand rub (ABHR). At that this time, the surveyor interviewed LPN #1 who acknowledged that she should have put on an isolation gown prior to administering Resident #58's nutrition formula via the gastrostomy tube. The surveyor also interviewed UM/LPN #1 who acknowledged that she should have performed hand hygiene utilizing an ABHR prior to entering Resident #58's room. UM/LP #1 stated that she was not aware that staff should be wearing isolation gowns for high-contact resident care. On 3/5/24 at 10:05 AM, the surveyor observed the Infection Preventionist/Registered Nurse (IP/RN) provide readily accessible PPE supplies outside of Resident #58's room. At this time, the surveyor interviewed the IP/RN who acknowledged that the PPE was not readily accessible to staff, but should have been since Resident #58 was on enhanced barrier precautions. On 3/5/24 at 2:16 PM, the surveyor interviewed the IP/RN who confirmed that Resident #58 was on enhanced barrier precautions, and staff were expected to perform hand hygiene using ABHR prior to entering and exiting the room. The IP/RN also confirmed that staff should have been wearing isolation gowns and gloves as instructed by the sign on the door when touching the resident and their environment. On 3/7/24 at 11:52 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Regional Director of Nursing (RDON), Chief Clinical Officer, and survey team confirmed that the staff should be wearing PPE as instructed by the signage on the door. 2. On 2/27/24 at 10:55 AM, the surveyor observed outside Resident #58's room, a sign that indicated the resident was on Enhanced Barrier Precautions which instructed before entering and exiting the room, you must perform hand hygiene; wear (don) a gown for high contact resident care activities which included .dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tube, tracheostomy; wound care including any skin opening requiring a dressing. At this time, the surveyor observed Resident #58 in bed with their eyes closed. The surveyor observed that Resident #58 had a tracheostomy (a surgical opening through the neck into the windpipe to allow air to fill the lungs), and was receiving oxygen via a concentrator. The surveyor observed that the corrugated tubing that was attached to the oxygen concentrator and tracheostomy was on the floor between the bed frame and the floor mat. On 2/28/24 at 9:40 AM, the surveyor observed Resident #58 in bed with the corrugated oxygen collar detached from their tracheostomy and on the floor. On 2/28/24 at 9:44 AM, the surveyor accompanied by UM/LPN #1 entered Resident #58's room, and they observed the resident's corrugated tubing on the floor. The surveyor asked UM/LP #1 if the corrugated tubing should be on the floor, and the UM/LPN acknowledged the tubing should not for infection control reasons. At this time, UM/LPN #1 asked the Cardiac Wound Nurse (CWN) to assist her with Resident #58's care and positioning. The CWN picked the corrugated oxygen collar off the floor and connected it the resident's tracheostomy collar, then UM/LPN #1 and the CWN repositioned Resident #58. The surveyor observed that both UM/LPN #1 and the CWN did not don isolation gowns prior to providing Resident #58's care. On 3/5/24 at 2:16 PM, the surveyor interviewed the IP/RN who confirmed that if Resident #58's corrugated tubing was on the floor, it should have been discarded and new tubing obtained to prevent infection. The IP/RN confirmed that Resident #58 was on enhanced barrier precautions, and that staff should have worn isolation gowns when touching the resident's medical equipment and performing care such as turning and repositioning the resident. On 3/7/24 at 11:52 AM, the LNHA in the presence of the RDON, Chief Clinical Officer, and survey team acknowledged that staff needed to be re-educated on appropriate infection control practices. 3. On 2/27/24 at 10:55 AM, the surveyor entered Resident #58's room and observed a soiled suction machine (a medical device used to suction oral secretions) on the resident's bedside table, a soiled privacy curtain, and a box of tracheostomy supplies stored on the floor. On 2/28/24 at 9:40 AM, the surveyor entered Resident #58's room and observed a soiled suction machine on the resident's bedside table, a soiled privacy curtain, and a box of tracheostomy supplies stored on the floor. On 2/29/24 at 1:12 PM, the surveyor accompanied by the IP/RN entered Resident #58's room, and they observed the resident's tracheostomy supplies on the floor; the suction machine heavily soiled with debris and dust; and the privacy curtain soiled with several brown stains. The IP/RN confirmed that the tracheostomy supplies should have been stored off the floor for infection prevention; the suction machine needed to be changed out for a new clean one; and the privacy curtain should be taken down and replaced with a new clean curtain. On 3/7/24 at 11:52 AM, the LNHA in the presence of the RDON, Chief Clinical Officer, and survey team stated that staff needed to re-educated on appropriate infection control practices. 4. On 2/29/24 at 12:00 PM, the surveyor observed outside Resident #102's room, a sign that indicated the resident was on Enhanced Barrier Precautions which instructed prior to entering and exiting the room, you must perform hand hygiene; wear a gown for high contact resident care activities which included .dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tube, tracheostomy; wound care including any skin opening requiring a dressing. The surveyor did not observe any readily available PPE which included but not limited to isolation gowns or disposable gloves. At that time, the surveyor observed Resident #102's urinary drainage bag and catheter tubing directly on the floor. On 3/1/24 at 12:45 PM, the surveyor observed Resident #102's urinary catheter drainage bag and catheter tubing directly on the floor. On 3/1/24 at 12:48 PM, the surveyor accompanied by the IP/RN entered Resident #102's room, and they observed the resident's urinary catheter drainage bag and tubing on the floor. The IP/RN stated the drainage bag and tubing should not be on the floor, and proceeded to pick up the tubing without donning an isolation gown as instructed by the sign on the door. On 3/5/24 at 2:16 PM, the surveyor asked the IP/RN if they needed to wear a gown to touch the resident's urinary catheter tubing, and the IP/RN acknowledged that she should have put on a gown before touching the tubing. The IP/RN further acknowledged that the PPE should have been readily accessible, but had not been until surveyor inquiry. On 3/7/24 at 11:52 AM, the LNHA in the presence of the RDON, Chief Clinical Officer, and survey team stated that staff needed to re-educated on appropriate infection control practices. A review of the facility's Isolation Steps-Categories of Transmission Based Precautions policy and procedure updated 5/19/20, included .Enhanced Barrier Precautions (EBP) are an infection control prevention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. A review of the facility's undated Infection Prevention and Control Program policy included .The infection prevention and control program is coordinated and overseen by an infection prevention specialist. Important facets of infection prevention include: educating staff and ensuring that they adhere to proper techniques and procedures; implementing appropriate isolation precautions when necessary; following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC); those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment; the facility provides personal protective equipment . checks for its proper use. A review of the facility's undated Cleaning and Disinfection of Resident-Care Items and Equipment policy included .Resident care equipment .including durable medical equipment will be cleaned and disinfected according to CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The Infection Preventionist will be included on the decision making of the products used and purchased . A review of the facility's undated Catheter Care, Urinary policy included the purpose of this procedure is to prevent infection of the resident's urinary tract .be sure the catheter tubing and drainage bag are kept off the floor . 5. On 3/1/24 at 11:53 AM, the surveyor observed ten residents seated in the Second-Floor dining room preparing for their lunch meal. On 3/1/24 at 12:15 PM, the surveyor observed Certified Nursing Aide (CNA #1) assisted the residents with their hand hygiene. The surveyor observed CNA #4 cleaned a resident's hands with hand wipes and without performing hand hygiene, CNA #1 handed hand wipes to three other residents. On 3/1/124 at 12:21 PM, the surveyor interviewed CNA #1 who acknowledged that she should have performed hand hygiene after she wiped the resident's hands with the hand wipe and before handing wipes to other residents. On 3/7/24 at 11:52 AM, the LNHA in the presence of the RDON, Chief Clinical Officer, and survey team stated that staff needed to re-educated on appropriate infection control practices.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and review of pertinent documents, it was determined that the facility failed to implement an adequate antibiotic stewardship program. This deficient practice was identified during a review of the last three months of antibiotic use and conducted surveillance from November 2023 through February 2024, and was evidenced by the following: This deficient practice was evidenced by the following: On 3/5/24 at 8:54 AM, the surveyor requested the facility's surveillance for the facility's Antibiotic Stewardship Program. At that time, the Infection Preventionist (IP) met with the surveyor, but the IP could not provide surveillance documentation for antibiotics used. The IP stated that the nurses filled out blue forms on the units for antibiotic use, and she reviewed them during the morning meeting. She stated that she had a spreadsheet that she documented and prepared a monthly report for the Director of Nursing (DON). At that time, the surveyor requested the forms and the spreadsheet from the IP, but the IP could not provide the forms. On 3/6/24 at 1:06 PM, the Chief Clinical Officer Licensed Nursing Home Administrator (CCO/LNHA) provided April 2023 through October 2023 Antibiotic tracking sheets that were found. She stated that no further tracking sheets after October 2023 were to be provided. On 3/7/24 at 11:16 AM, the LNHA acknowledged that the facility had no further documentation for antibiotic tracking. A review of the facility's undated Infection Control Program Overview dated 8/1/19, included surveillance of infections, ongoing monitoring of infections among residents and personnel, and subsequent documentation of infections .the IP monitors the residents' infection cases, and they complete the line listing of infections and the monthly reports . NJAC 8:39-19.4 (d)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain a resident bathroom sink (Resident room [ROOM NUMBER]) in a sanitary working condition and b.) maintain resident rooms and common area in a safe, sanitary, and comfortable environment for 1 of 3 nursing units (Second-Floor). The evidence was as follows: 1. During a water temperature tour on 2/29/24 at 10:50 AM, the surveyor observed in the presence of the Maintenance Director (MD) in Resident room [ROOM NUMBER]'s bathroom, the sink did not operate properly, that the water dripped out. The MD stated at the time of the observation, that he was unaware that Resident room [ROOM NUMBER]'s bathroom sink was not working. The MD stated all maintenance work that needed to be done was entered into the electronic work order system [name redacted]. At this time the surveyor requested the electronic work order system [name redacted] report for the year. On 2/29/24 at 12:09 PM, the surveyor interviewed Certified Nursing Aide (CNA #1) who was assigned to Resident room [ROOM NUMBER] for the day, who stated she had not used the resident's bathroom today for care, but stated she was aware that the water pressure in the bathroom sink was off; meaning only a thin amount of water came out of the waterspout. CNA #1 stated she told the MD at the time, and she thought she entered it into the electronic work order system [name redacted]. On 2/29/24 at 12:14 PM, the surveyor interviewed CNA #2 who stated she routinely cared for the residents in Resident room [ROOM NUMBER], and she did not provide care for the residents in their bathroom because the water in the sink did not work. CNA #2 thought the water in the sink did not work for maybe one month. CNA #2 thought she informed the nurse the water did not work; that the nurse entered maintenance requests in the electronic work order system [name redacted]. On 2/29/24 at 12:32 PM, the surveyor reviewed the electronic work order system [name redacted] report for the year, and Resident room [ROOM NUMBER]'s bathroom sink was not on the report. On 3/1/24 at 1:22 PM, the surveyor interviewed the MD who stated he fixed the faucet in Resident room [ROOM NUMBER]; that faucet completely did not work, and he had to replace it. The MD confirmed no work order was ever entered into the system. On 3/7/24 at 11:52 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Regional Director of Nursing, Chief Clinical Officer, and survey team acknowledged that the sink in Resident room [ROOM NUMBER] should have been reported by staff so it could be repaired and maintained in working condition. 2. On 2/28/24 at 12:30 PM, the surveyor conducted a tour of the Second-Floor nursing unit and observed the following: 1. Resident room [ROOM NUMBER], a hole in the wall behind door handle. 2. Resident room [ROOM NUMBER] wallpaper along the bottom left wall in room's entrance way peeling off. 3. Resident room [ROOM NUMBER] panel of wallpaper missing from the right entranceway wall. 4. Resident room [ROOM NUMBER] wallpaper was missing right entranceway. 5. In the Second-Floor day room there was paint peeling from the walls, holes in the walls of the bottom left side walls; a section of floorboard missing under a resident table that measured approximately four feet long by one foot wide. On 2/29/24 at 10:53 AM, the surveyor and the MD conducted water temperature observations on the Second-Floor. The MD acknowledged the missing wallpaper in Resident room [ROOM NUMBER], and stated that there was wallpaper missing throughout the floor as well as the Second-Floor day room needed the walls repaired and new flooring. On 3/7/24 at 11:52 AM, the LNHA in the presence of the Regional Director of Nursing, Chief Clinical Officer, and survey team acknowledged that there should not be holes in the walls or missing wallpaper in residents rooms as well as the day room. A review of the facility's undated Homelike Environment policy included residents are provided with a safe, clean, comfortable and homelike environment .the facility and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment . NJAC 8:39-31.4(a)

MINOR (B)

Minor Issue - procedural, no safety impact

MDS Data Transmission (Tag F0640)

Minor procedural issue · This affected multiple residents

Read full inspector narrative →

Based on interview and review of pertinent facility documents, it was determined that the facility failed to complete discharge Minimum Data Set (MDS) assessments, an assessment tool, as required for 2 of 2 system selected for residents with a MDS record over 120 days reviewed (Resident #13 and Resident #111), and was evidenced by the following: On 3/6/24 at 11:00 AM, the surveyor reviewed the system selected MDS record over 120 days which revealed Resident #13 and Resident #111 were overdue for a MDS assessment. On 3/6/24 at 11:45 AM, the surveyor interviewed the MDS/Registered Nurse (RN) who stated MDS assessments were completed upon admission, quarterly, annually, any significant changes in status, or at discharge. The MDS/RN continued that the assessments were completed within ninety-four days of the previous quarterly assessment or within fourteen days of discharge. At this time, the surveyor asked the MDS/RN when the last completed MDS assessments were for Resident #13 and Resident #111, and the MDS/RN revealed the following: Resident #13 was discharged from the facility on 11/4/23, and no discharge MDS assessment was completed. The discharge MDS should have been completed by 11/18/23. Resident #111 was discharged from the facility on 10/30/23, and no discharge assessment was completed. The discharge MDS should have been completed by 11/14/23. The MDS/RN stated she began working at the facility in January, so she could not speak to why the assessments were not completed. On 3/7/24 at 9:08 AM, the surveyor interviewed the MDS Coordinator who confirmed the two MDS discharge assessments were not completed. The MDS Coordinator stated at the time, there was someone assisting with quarterly assessments, but she should have completed both of the MDS discharge assessments for the two residents. The MDS Coordinator stated she had fourteen days from discharge to complete the assessment and an additional fourteen days to submit the assessment. On 3/7/24 at 11:52 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Regional Director of Nursing, Chief Clinical Officer, and survey team confirmed the MDS assessments should have been completed for both residents' discharges. A review of the Centers for Medicare & Medicaid Services' (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated October 2019, provided by the MDS Coordinator, included 09. Discharge Assessment-Return Not Anticipated must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days; must be completed within 14 days after the discharge date ; must be submitted within 14 days after the MDS completion date . A review of the facility's undated MDS Submission Timeframes policy, included the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . NJAC 8:39- 11.1

Nov 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #:NJ00164488 Based on observation, interview, record review, and review of other facility documentation on 11/28/23 and 11/30/23, it was determined that the facility failed to provide care for a resident with a suprapubic catheter (a tube used to drain urine from the bladder through a cut in the abdomen) in accordance with physician's orders. The deficient practice was identified for Resident #1, 1 of 3 residents reviewed for bladder and bowel care and was evidenced by the following: On 11/28/23 at 10:32 AM the surveyor observed Resident #1 lying in bed with a drainage bag hanging off their bed with a small amount of yellow liquid inside the bag. When interviewed, Resident #1 stated that it depended on which staff members were working if their drainage bag was emptied or their suprapubic catheter was flushed. According to the admission Record, Resident #1 was admitted on [DATE], with medical diagnoses that included but were not limited to multiple sclerosis (a potentially disabling disease of the brain and spinal cord), obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract), and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord, or nerve problems). The quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/17/23, revealed the resident had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The MDS also indicated that Resident #1 had an indwelling urinary catheter. Review of Resident #1's care plan revealed a Focus, that the resident had a suprapubic catheter for neurogenic bladder (lack of bladder control due to brain, spinal cord, or nerve problems). Review of Resident #1's Order Summary Report (OSR), revealed a physician's order (PO) dated 07/01/22 to, Change catheter drainage bag weekly on Fridays to prevent infections every night shift every Fri [Friday]. Review of Resident #1's May 2023 Treatment Administration Record (TAR) revealed the aforementioned 07/01/22 order, with the administration time of night shift. The TAR reflected no documentation that the catheter drainage bag was changed on the following dates: Night shift: 05/05/23, 05/12/23, and 05/19/23. Further review of Resident #1's OSR, revealed a PO, dated 05/01/23 to, Empty foley bag every 4 hours. Review of Resident #1's May, October, and November 2023 TARs revealed the aforementioned 05/01/23 order, with the administration times of 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. The TARs reflected no documentation that the foley bag was emptied on the following dates and times: 12:00 AM: 05/13/23. 4:00 AM: 05/02/23, 05/06/23, 05/08/23, 05/13/23, 10/01/23, 10/13/23, 10/23/23, 10/27/23, 10/28/23, and 11/03/23. 8:00 AM: 10/12/23, 10/14/23, 10/15/23, 10/20/23, 10/22/23, 10/26/23, 11/04/23, and 11/26/23. 12:00 PM: 05/01/23, 10/12/23, 10/14/23, 10/15/23, 10/20/23, 10/22/23, 10/26/23, 11/04/23, and 11/26/23. 8:00 PM: 10/07/23. Further review of Resident #1's OSR, revealed a PO dated 06/28/23 to, Flush suprapubic catheter with 60 ml of NSS [normal saline solution] every 8 hours. Review of Resident #1's October, and November 2023 TARs revealed the aforementioned 06/28/23 order, with the administration times of 12:00 AM, 8:00 AM, and 4:00 PM. The TARs reflected no documentation that the suprapubic catheter was flushed on the following dates and times: 8:00 AM: 10/12/23, 10/14/23, 10/15/23, 10/20/23, 10/22/23, 10/26/23, 11/04/23, and 11/26/23. Review of Resident #1's Progress Notes failed to reveal any documentation that the foley bag was emptied or that the suprapubic catheter was flushed on the aforementioned dates. During an interview with the surveyor on 11/28/23 at 12:18 PM, Certified Nursing Assistant (CNA) #1 stated she was expected to empty Resident #1's drainage bag and tell the nurse the amount of output recorded. During an interview with the surveyor on 11/28/23 at 1:21 PM, Licensed Practical Nurse (LPN) #1 stated that she provided care for Resident #1's suprapubic catheter and that it included cleansing, flushing, and monitoring it for any abnormal signs. LPN #1 continued that she flushed Resident #1's catheter once a shift. LPN #1 stated that once you signed that the flushes were completed that it would be reflected on the TAR. LPN #1 added that it was important to sign off that the care tasks for the suprapubic catheter were completed because it verified that the tasks were done. During an interview with the surveyor on 11/28/23 at 2:58 PM, the Director of Nursing (DON) stated she expected residents with suprapubic catheters to have their catheters flushed and emptied. The DON continued that nursing staff should monitor residents with suprapubic catheters for sediment, odors, and the color of the urine in the tube. The DON continued that these POs were put into place to prevent the tube from becoming clogged and to prevent infection. The DON added that all the interventions should be documented in the TAR as frequently as they were ordered. Review of the undated facility policy, Catheter Care, Urinary did not address the care which was supposed to be provided for residents with suprapubic catheters. NJAC 8:39-27.1(a); 19.4(a)(5).

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00163880, NJ00164147 Based on observation, interview, record review, and review of other facility documentation on 11/28/23 and 11/30/23, it was determined that the facility failed to follow up with a medical provider when a routinely scheduled medication was unavailable. The deficient practice was identified for Resident #2, 1 of 3 residents reviewed for medication administration, and was evidenced by the following: On 11/28/23 at 11:02 AM, the surveyor observed Resident #2 in their bed. The resident did not respond to the surveyor's questions. According to the admission Record, Resident #2 was admitted on [DATE], with medical diagnoses that included but were not limited to seizures, cerebral infarction (disrupted blood flow to the brain), and traumatic subdural hemorrhage (bleeding in the area between the brain and the skull) with loss of consciousness. The annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/02/23, revealed that the resident had short-term and long-term memory problems. The MDS also indicated that Resident #2 had a feeding tube as a resident. Review of Resident #2's care plan revealed a Focus, that the resident had a seizure disorder. The care plan included an intervention to, Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. Review of Resident #2's Order Recap Report for the dates of 04/01/23-04/30/23 revealed a 12/09/22 active Physician's Order (PO) for Lacosamide Tablet (a medication used to treat seizures) 200 milligrams (MG). The PO specified to give 1 tablet every 12 hours for seizure. Review of Resident #2's April 2023 Medication Administration Record (MAR) revealed the aforementioned 12/09/22 order, with the administration times of 9:00 AM and 9:00 PM. The MAR reflected the following documentation: 04/09/23 09:00 AM: blank. 04/10/23 09:00 AM: Other/See Progress Notes 04/10/23 09:00 PM: Other/See Progress Notes Review of the 04/09/23 Progress Notes (PN) did not reveal any documentation that the Lacosamide was administered. Review of the PN revealed an, Order Note, dated 04/10/23 and timed 11:30 AM, that the nurse called the pharmacy to check on the reorder status of the Lacosamide 200 MG. The PN continued that the nurse was told by the pharmacy that the resident's Lacosamide was on order and that it would be delivered later that day. Review of the PN revealed an Orders- Administration Note, dated 04/10/23 and timed 11:40 AM, that the Lacosamide Tablet 200 MG was on order. Review of the PN revealed an Orders-Administration Note, dated 04/10/23 and timed 10:01 PM, that Lacosamide Tablet 200 MG was, awaiting delivery. Review of the PN revealed a Health Status Note, dated 04/10/23 and timed 11:48 PM, that the resident missed his/her 9 PM seizure medication Lacosamide. The PN continued that the nurse called the pharmacy around 10 PM to find out when the medication would be delivered and was told around 12 AM. The Resident had two seizures, one from 10:10 PM- 10:16 PM and the second from 11:11 PM-11:17 PM. The PN continued that the Nurse Practitioner was notified and said that the resident should be sent to the hospital. At 11:20 PM, 9-1-1 was called and the resident was transferred to the hospital. Further review of the PN did not reveal any documentation that the resident's physician was made aware that Resident #2 did not receive Lacosamide on 04/09/23 at 9:00 AM, 04/10/23 at 9 AM, and 04/10/23 at 9:00 PM. Review of the LTC Reportable Event Survey regarding the 04/09/23 medication error revealed under the Summary and Investigation (Summary) section that a dose of Lacosamide was missed on Sunday 04/09/23 and that according to the nurse the Lacosamide was not available. However, the nurse failed to call the physician to make them aware. The Summary further revealed that the medication was not delivered by the pharmacy which led to Resident #2 missing two more doses of Lacosamide on Monday 04/10/23. Resident #2 had two witnessed seizures on 04/10/23 at 10 PM and 11 PM and was sent to the hospital. During an interview with the surveyor on 11/28/23 at 1:21 PM, Licensed Practical Nurse (LPN) #1 stated medication should be administered between an hour before and an hour after the time for which they were ordered. LPN #1 continued that nurses were responsible to reorder medications from the pharmacy. LPN #1 added that she reordered medication when there were between 8 and 10 doses of medication left. LPN #1 stated if there were no doses of a medication left that she would call the physician or health care provider. During an interview with the surveyor on 11/30/23 at 12:02 PM, LPN #2 stated that he worked as Resident #2's nurse on 04/09/23 on the 3PM-11PM shift. LPN #2 stated that he administered Resident #2's last dose of Lacosamide on 04/09/23. LPN #2 continued the medication was already ordered and was to be delivered on Monday 04/10/23, but it was not delivered. During an interview with the surveyor on 11/30/23 at 12:18 PM, LPN #3 stated that on 04/10/23 at 9:00 AM Resident #2's Lacosamide was not available. LPN #3 stated that she called the pharmacy to see an estimated time of arrival when it would be delivered to the facility. LPN #3 continued that she was not aware that she was supposed to call the physician when a medication was not available and stated that she received education, after the incident where Resident #3 had a seizure and was sent to the hospital. During an interview with the surveyor on 11/30/23 at 1:47 PM, the Medical Doctor (MD) stated the nurse should first call the pharmacy if a medication was not available. The MD continued that if the pharmacy could not give the medication, the nurse would contact the resident's physician to discuss other options. The MD continued that Lacosamide was an, important medication to help control Resident #2's seizures. During an interview with the surveyor on 11/30/23 at 1:59 PM, and in the presence of the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA) stated that Resident #2 missed a dose of Lacosamide on Sunday 04/09/23 and two doses on Monday 04/10/23. The LNHA continued that LPN #4 did not sign the MAR on 04/09/23 at 09:00 AM and that a dose was not recorded in the medical record. The DON stated she expected for medications to be administered between an hour before and an hour after the designated administration time. The DON continued that when a dose of medication is missed, she expected to see a progress note explaining why the medication was not given. The DON continued that she expected the nurses to called the pharmacy regarding the missing medication and then call the physician. The DON further stated the importance of administering Lacosamide was to prevent seizures. During an interview with the surveyor on 11/30/23 at 2:40 PM, the LPN #4 stated she did not administer Resident #2's Lacosamide on 04/09/23 at 09:00 AM because at first, she could not find it. LPN #4 stated that she did not reach out to the health care provider about the missed dose of medication because she was, adamant about finding the medication. LPN #4 continued that she located the medication at change of shift with the oncoming nurse, LPN #2, and that he administered the medication to Resident #2 after she left. LPN #4 stated that if she could not locate a medication that she would call the pharmacy and call the doctor. Review of the facilty's undated Administering Medications policy, revealed under the Policy Interpretation and Implementation section that, Medications must be administered in accordance with the orders, including any required time frame. The facility policy also indicated, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall click N on the EMAR [electronic medication administration record] and then document as prompted by [electronic medical record]. NJAC 8:39-29.2(d),(e)(5).

MINOR (B) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00164488 Based on observation, interviews, medical record review, and review of other pertinent facility documents on 11/28/23 and 11/30/23, it was determined that the facility staff failed to consistently document on the Documentation Survey Report the Activities of Daily Living (ADL) status and care provided to the resident. The deficient practice was identified for Resident #1, 1 of 3 residents reviewed for documentation and was evidenced by the following: On 11/28/23 at 10:32 AM, the surveyor observed Resident #1 lying in bed and interviewed him/her at this time. Resident #1 stated it depended which staff member was assigned as their CNA if they received timely ADL care. According to the admission Record, Resident #1 was admitted on [DATE], with medical diagnoses that included but were not limited to multiple sclerosis (a potentially disabling disease of the brain and spinal cord), muscle weakness, neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord, or nerve problems), and difficulty in walking. The quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/17/23, revealed the resident had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The MDS also indicated that Resident #1 had an indwelling urinary catheter and that they required between substantial/maximal assistance and total dependence with ADL care. Review of Resident #1's care plan revealed a Focus, that the resident had a decline in self-care. Review of Resident #1's Documentation Survey Report v2 form (DSR) (a form that documents the ADL care provided by the Certified Nursing Assistants (CNAs)) for May 2023 revealed blank spaces indicating the tasks were not completed as follows: Bed Mobility, Locomotion off Unit, Locomotion on Unit, Personal Hygiene, Toilet Use, Transferring, Walk in Corridor, Bladder Elimination, Bowel Elimination, Monitor Behavior Symptoms, and Skin Observation on 05/01/23-05/09/23, 05/12/23-05/16/23, and 05/18/23-05/31/23 on the day shift, 05/01/23-05/04/23, 05/07/23-05/13/23, 05/20/23-05/24/23, and 05/26/23-05/28/23 on the evening shift, 05/02/23, 05/03/23, 05/05/23-05/09/23, 05/13/23-05/16/23, 05/19/23, 05/21/23, 05/24/23, 05/28/23, and 05/29/23 on the night shift. Dressing, Walk in in Room, and Change in Patient Status on 05/01/23-05/09/23, 05/12/23-05/16/23, and 05/18/23-05/31/23 on the day shift, 05/01/23-05/04/23, 05/07/23-05/13/23, 05/20/23-05/24/23, and 05/26/23-05/28/23 on the evening shift. Snacks on 05/01/23-05/04/23, 05/07/23-05/13/23, 05/20/23-05/24/23, and 05/26/23-05/28/23 on the evening shift. Eating on 05/01/23-05/10/23, and 05/12/23-05/31/23 for the 8:00 AM meal, 05/01/23-05/10/23, and 05/12/23-05/31/23 for the 12 PM meal, 05/01/23, 05/02/23, 05/04/23, 05/07-23-05/13/23, 05/20/23-05/24/23, and 05/26/23-05/28/23 for the 5 PM meal. Amount Eaten on 05/01/23-05/10/23, and 05/12/23-05/31/23 for the 8:00 AM meal, 05/01/23-05/10/23, and 05/12/23-05/31/23 for the 12 PM meal, 05/01/23- 05/04/23, 05/07-23-05/13/23, 05/20/23-05/24/23, and 05/26/23-05/28/23 for the 5 PM meal. Review of Resident #1's DSR for November 2023 revealed blank spaces indicating the tasks were not completed as follows: Dressing, Change in Patient Status, Lower Body Dressing, Oral Hygiene, Putting On/ Taking off Footwear, Upper Body Dressing, Walk 10 Feet, Walk 150 Feet, Walk 50 Feet with Two Turns, Wheel 150 Feet, Wheel 50 Feet with Two Turns, and Wheelchair/Scooter Use on 11/06/23, 11/09/23-11/11/23, 11/13/23, 11/14/23, 11/16/23, 11/20/23-11/25/23, and 11/27/23-11/30/23 on the day shift, 11/10/23, and 11/28/23-11/30/23 on the evening shift. Toilet Use, Transferring, Bladder Elimination, Bowel Elimination, 1 Step, 12 Steps, 4 Steps, Chair/ Bed-to-Chair Transfer, Lying to Sitting on Side of Bed, Personal Hygiene, Picking up Object, Roll Left and Right, Shower/ Bathe Self, Sit to Lying, Sit to Stand, Toilet Transfer, Toilet Hygiene, Tub/ Shower Transfer, Monitor Behavior Symptoms, and Skin Observation on 11/06/23, 11/09/23-11/11/23, 11/13/23, 11/14/23, 11/16/23, 11/20/23-11/25/23, and 11/27/23-11/30/23 on the day shift, 11/10/23, and 11/28/23-11/30/23 on the evening shift, 11/04/23, 11/29/23, and 11/30/23 on the night shift. Snacks on 11/10/23, and 11/28/23-11/30/23 on the evening shift. Amount Eaten on 11/06/23, 11/09/23-11/14/23, 11/16/23, 11/20/2311/22/23, 11/24/23, 11/25/23, and 11/28/233-11/30/23 for the 8:00 AM meal, 11/06/23, 11/09/23-11/14/23, 11/16/23, 11/20/2311/22/23, 11/24/23, 11/25/23, and 11/28/233-11/30/23 for the 12 PM meal, 11/10/23, and 11/28/23-11/30/23 for the 5 PM meal. During an interview with the surveyor on 11/28/23 at 12:18 PM, CNA #1 stated she took care of Resident #1. CNA #1 stated that she provided high quality ADL care to the residents assigned to her including checking them for incontinence every 2 hours and whenever they rang the call bell. CNA #1 added that ADL care should be documented on the DSR for every resident every shift. During an interview with the surveyor on 11/28/23 at 1:21 PM, Licensed Practical Nurse (LPN) #1 stated that staff were able to provide high quality ADL care for all the residents including checking residents for incontinence every 2 hours. LPN #1 stated that CNAs were expected to document the ADL care they provided to residents every shift in order to verify that the task was completed. During an interview with the surveyor on 11/30/23 at 02:58 PM, the Director of Nursing (DON) stated ADL care should be documented in the DSR. The DON continued that the nurses, unit managers, and nursing administration were responsible to make sure that there was 100% completion of the ADL sheets. The DON added the purpose of the ADL documentation was to verify that the care was provided. NJAC 8:39-35.2 (d)(6).

Nov 2021 8 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain the call bell within reach for 1 of 4 residents (Resident #52) reviewed for accidents. This deficient practice was evidenced by the following: On 11/16/2021 at 9:40 AM, the surveyor observed Resident #52 lying in bed asleep and the call bell was on the floor, to the left side of the resident's bed. On 11/17/2021 at 1:04 PM, the surveyor observed Resident #52 lying in bed awake and the call bell was on the floor, at the foot of the bed. The resident stated he/she uses the call bell to call for help, but that the call bell is usually on the floor. On 11/18/2021 at 10:43 AM, the surveyor observed Resident #52 lying in bed awake and the call bell was on the floor, at the foot of the bed. The resident stated that he/she yells out for help when the call bell is not within reach or relies on his/her roommate to get assistance. According to the admission Record, Resident #52 was admitted with diagnoses that included, but were not limited to, cerebral infarction (stroke) and hemiplegia (partial paralysis) and hemiparesis (partial weakness) affecting the left non-dominant side. Review of the resident's Quarterly Minimum Data Set (MDS), dated [DATE], an assessment tool used to facilitate the management of care, revealed the resident had a Brief Interview for Mental Status of 14, which indicated that the resident's cognition was intact. Further review of the MDS revealed that the resident required extensive assistance with activities of daily living, had impairment in range of motion on one side of the upper and lower extremities, and had one fall with injury since the last assessment. Review of the resident's Care Plan (CP) included a focus for high risk for falls related to left sided weakness, revised 12/17/2020, with an intervention to maintain call bell within reach. Further review of the resident's CP included a focus for an actual fall on 08/02/2021 and 08/23/2021. Review of the resident's Progress Note (PN), dated 08/02/2021, revealed the resident fell out of bed reaching to pick up a remote off the floor. Review of the resident's PN, dated 08/24/2021, revealed the resident was found on the floor next to the bed. During an interview with the surveyor on 11/18/2021 at 10:55 AM, the Certified Nursing Assistant (CNA) stated Resident #52 was paralyzed on one side of the body, but could use his/her good arm to use the call bell. At that time, the surveyor accompanied the CNA to the resident's room and the CNA acknowledged that the call bell was on the floor. The CNA then gave the resident the call bell and stated that the call bell should be within reach of the resident. During an interview with the surveyor on 11/18/2021 at 11:00 AM, the Registered Nurse (RN) stated that Resident #52 had a history of stroke affecting his/her left side and had multiple falls within the last few months. The RN further stated that the resident will either yell out for help or use the call bell. The RN also stated that the resident's call bell should be attached to the resident's bed sheet, near the resident's right hand. During an interview with the surveyor on 11/18/2021 at 11:11 AM, the Unit Manager (UM) stated that Resident #52 can use the call bell with his/her good hand. The UM further stated that the call bell should be attached to the bed within reach of the resident. During an interview with the surveyor on 11/18/2021 at 11:14 AM, the Director of Nursing (DON) stated that Resident #52 had a history of falls and that the call bell should be placed within the resident's reach. Review of the facility's Call Bells policy, dated 08/01/2019, revealed, all residents are to have access to call bells at all times, even if it is generally believed that the resident is unable to use it and Staff is expected to be as vigilant as possible in keeping the call bell within reach of the resident. Further review of the policy included, Be sure the call light is plugged in and within reach at all times, and Ensure call bell is within the resident's reach before leaving resident room. NJAC 8:39-31.8 (c) (9)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview, record review, and review of other facility documentation, it was determined that facility staff failed to complete neurological assessments after a resident fall, in accordance with professional standards. This deficient practice was identified for 1 of 4 residents (Resident #95) reviewed for accidents and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The surveyor obtained and reviewed a copy of the resident's admission Record, which revealed diagnoses that included, but were not limited to, lack of coordination. The surveyor requested, obtained, and reviewed a copy of an incident report, a checklist related to falls, and a Neurological Assessment Form related to a fall that occurred on 10/07/21, for Resident #95. According to the incident report on the referenced date, the fall was not witnessed. The fall checklist indicated that neurological assessments are initiated for all unwitnessed falls or head injury. The Neurological Assessment Form indicated that any resident who may have struck his/her head, using a fall as an example, will have a neurological assessment done every 15 minutes x1 hour, every 30 minutes x4 hours, every hour x4 hours, every 4 hours x24 hours, and every 8 hours for 40 hours. A review of the Neurological Assessment Form revealed that neurological checks were implemented after the fall on 10/07/21 at 8 PM. There was a period on 10/07/21 at 11:15 PM through 10/08/21 at 2:45 AM, during which the resident was noted to be sleeping and omitted the resident's vital signs, assessments, and nurse's initials. Neurological assessments were noted to be resumed on 10/08/21 at 3:45 AM. During an interview with the surveyor on 11/22/21 at 9:45 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM), described the process for conducting neurological assessments on a resident who experiences a fall. If the fall is witnessed and there is no head injury, then neurological assessments are not necessary. If a fall is not witnessed or there is a known head injury, the neurological assessments are initiated as per the Neurological Assessment Form and should continue for 3 days. According to the LPN/UM, an exception to conducting neurological assessments was possible if a resident was admitted to the hospital. The LPN/UM further stated that in this case, it looked like the resident was found on the floor, neurological assessments were determined to be necessary and were initiated, but not completed. The LPN/UM confirmed that Resident #95 did not go to the hospital until 10/11/21, so neurological assessments should have been completed in their entirety, since the resident remained in the facility for the 3 days following the fall on 10/07/21. During an interview with the surveyor on 11/22/21 at 12:25 PM, the Director of Nursing (DON) stated that the fall involving Resident #95 on 10/07/21 was not witnessed. The DON further stated that neurological assessments were initiated and should have occurred consistently as per protocol over the 3 days that followed the fall. The DON confirmed that the neurological assessments were not completed, during the referenced times, on the Neurological Assessment Form and acknowledged that they should have been completed without interruption for the 3 days following the fall on 10/07/21. During a follow-up interview with the surveyor on 11/23/21 at 9:45 AM, the Director of Nursing (DON) acknowledged an interruption in the neurological assessments for Resident #95. The DON stated that if neurological checks were not going to be completed, the physician should have been notified to act accordingly. The surveyor obtained and reviewed two policies from the facility. An undated policy titled, Falls - Clinical Protocol revealed the need for nursing staff to assess and document neurological status, related to a fall. A policy titled, Neurological Assessment that was revised as of September 2021, indicated that unless otherwise indicated, neurological assessment is to be conducted at the following time intervals: every 15 minutes x1 hour, every 30 minutes x4 hours, every hour x4 hours, every 4 hours x24 hours, and every 8 hours x40 hours. NJAC 8:39-29.2(d)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a floor mat was in place for 1 of 3 residents (Resident #52) reviewed for falls. This deficient practice was evidenced by: On 11/17/2021 at 1:04 PM, the surveyor observed Resident #52 lying in bed. The resident's left side of the bed was against the wall and a floor mat was folded next to the resident's right side of the bed, exposing the bottom right half of the bed to the floor. On 11/18/2021 at 10:43 AM, the surveyor observed Resident #52 lying in bed. The resident's left side of the bed was against the wall and a floor mat was folded at the foot of the resident's bed, exposing the entire right side of the bed to the floor. According to the admission Record, Resident #52 was admitted with diagnoses that included, but were not limited to, cerebral infarction (stroke) and hemiplegia (partial paralysis) and hemiparesis (partial weakness) affecting the left non-dominant side. Review of the resident's Quarterly Minimum Data Set (MDS), dated [DATE], an assessment tool used to facilitate the management of care, revealed the resident had a Brief Interview for Mental Status of 14, which indicated that the resident's cognition was intact. Further review of the MDS revealed that the resident required extensive assistance with activities of daily living, had impairment in range of motion on one side of the upper and lower extremities, and had one fall with injury since the last assessment. Review of the resident's Care Plan (CP) included a focus, revised 08/24/2021, for an actual fall on 08/02/2021 and 08/23/2021 with an intervention for floor mats while in bed, initiated on 09/01/2021. Review of the resident's Progress Note (PN), dated 08/02/2021, revealed the resident fell out of bed and hit his/her right side of the head on the floor. Review of the resident's PN, dated 08/24/2021, revealed the resident was found on the floor next to the right side of the bed. During an interview with the surveyor on 11/18/2021 at 10:55 AM, the Certified Nursing Assistant (CNA) stated Resident #52 was paralyzed on one side of the body and that he/she has a floor mat that is put in place when the resident is left alone. At that time, the surveyor accompanied the CNA to the resident's room and the CNA acknowledged that the floor mat was folded at the foot of the bed. The CNA then placed the floor mat down, unfolded, on the resident's right side of the bed and stated the floor mat should have been in place. During an interview with the surveyor on 11/18/2021 at 11:00 AM, the Registered Nurse (RN) stated that Resident #52 had a history of stroke affecting his/her left side and had multiple falls within the last few months. The RN further stated that the resident's bed is placed against the wall and that he/she has a floor mat to the right side of the bed at all times. The RN also stated that when the floor mat is not in place, the resident is supervised. During an interview with the surveyor on 11/18/2021 at 11:11 AM, the Unit Manager (UM) stated that Resident #52 had a history of falls and that he/she has a floor mat in place when the resident is in bed. During an interview with the surveyor on 11/18/2021 at 11:14 AM, the Director of Nursing (DON) stated that Resident #52 had a history of falls and that the floor mat should be in place if the resident is in bed. The surveyor notified the DON of the above observations and the DON stated that the floor mat should have been unfolded and in place. Review of the facility's Falls - Clinical Protocol policy, undated, revealed, The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. NJAC 8:39-27.1 (a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and review of other facility documents, it was determined that the facility failed to provide a sanitary environment for residents, staff and the public by failing to keep the garbage container area free of garbage and debris, and failed to have a cover over the openings of 1 of 2 garbage containers/dumpsters. This deficient practice was evidenced by the following: On 11/16/21 at 10:51 AM, the surveyor toured the kitchen with the Food Service Director (FSD), and requested to see the outside garbage receptacle area. The surveyor observed a garbage container (GC) that was uncovered and exposed to the elements. The GC had a closed lid on the left-side, but the right-side lid was open exposing multiple trash bags inside. The surveyor further observed that both the left-side and right-side doors of the GC was also open exposing multiple trash bags inside. The surveyor observed that the outside garbage receptacle area was littered with debris, used gloves, clear bags, and juice cartons. When interviewed at that time, the FSD stated that everyone was responsible for cleaning the garbage receptacle area, and the lids and doors of the GC should be closed when not in use. A reviewed the facility's 9/1/2018 Sanitation: Waste Disposal policy indicated to keep dumpsters site areas clean and free of debris. NJAC 8:39-19.7

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to administer medication in accordance with the physician's orders. This deficient practice was identified in 1 of 5 residents reviewed for unnecessary medications (Resident #95) and was evidenced by the following: According to the resident's admission Record, Resident #95 had a diagnosis including, but not limited to, essential (primary) hypertension (high blood pressure in which additional and underlying causes contributing to the high blood pressure are not present). According to the Physician's Orders, Resident #95 had an order for Hydralazine tablet 50 milligrams (mg) - give 50 mg by mouth three times a day for hypertension - hold if SBP is less than 130 mm HG, where SBP (systolic blood pressure) is the first (top) number and is a measure of the exertion of blood against the artery walls, when the heart beats. Further review of the orders revealed that the referenced medication order and hold parameter began on 08/12/21 and remained current into November of 2021. A review of the MAR from August 2021 through November of 2021 revealed that the referenced medication was administered by nursing staff when the resident's SBP was below 130 mm HG during multiple occasions, as follows: On 08/14/21 at 0900 (9:00 AM) and 1400 (2:00 PM), 08/16/21 at 2100 (9:00 PM), 08/17/21 at 0900, 1400, and 2100, 08/21/21 at 2100, 08/22/21 at 1400 and 2100, 08/24/21 at 0900 and 1400, 08/25/21 at 0900 and 1400, and 08/30/21 at 2100. On 09/04/21 at 2100, 09/05/21 at 2100, 09/14/21 at 0900 and 1400, 09/18/21 at 2100, 09/19/21 at 2100, 09/20/21 at 0900 and 1400, 09/23/21 at 1400, 09/24/21 at 2100, and 09/27/21 at 2100. On 10/02/21 at 2100, 10/03/21 at 1400 and 2100, 10/04/21 at 0900 and 1400, 10/17/21 at 2100, 10/25/21 at 2100, 10/28/21 at 1400, and 10/30/21 at 2100. On 11/10/21 at 1400. During an interview with the surveyor on 11/22/21 at 9:45 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) confirmed that the presence of a checkmark and initials on the MAR indicated that medication was administered by the nurse and the initials corresponded to the nurse who administered the medication. The LPN/UM confirmed that there were multiple instances from August 2021 through November 2021 in which nursing staff members administered Hydralazine 50 mg to Resident #95, outside of the parameters ordered by the physician. The LPN/UM elaborated that the referenced medication should not have been given if the resident's SBP was less than 130 mm Hg and it was given to the resident, despite and SBP reading under the defined parameter. During an interview with the surveyor on 11/23/21 at 9:45 AM, the Director of Nursing (DON) acknowledged and confirmed that nursing staff were not being attentive to the physician's parameters, but rather just clicking buttons within the computer system. There were multiple instances in which Hydralazine 50 mg was documented as administered to Resident #95 and should not have been given to the resident, from August 2021 through November 2021. The DON further stated it would be an expectation of nursing staff to administer medication in accordance with a physician's orders and if there were any question, problem, or concern, the physician should have been contacted. Finally, the DON stated that such a nursing practice is unacceptable, with no excuse for it. The surveyor obtained an undated facility policy, Administering Medications for review. According to the policy, medications must be administered in accordance with orders and vital signs must be checked, if necessary. NJAC 8:39-29.2(d)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

On 11/16/2021 at 10:16 AM, during the initial tour of the second-floor unit, Resident #8 stated that the food at the facility tastes awful. Resident #8 also added that, Everyone hates the food around here. During an interview with surveyor #3 on 11/16/2021 at 10:17 AM, Resident #71 stated that he/she thinks there is a new cook at the facility because the food is different and I don't always get what I order. During lunch service on 11/16/2021 at 1:33 PM, Surveyor #3 observed Resident #8's lunch meal ticket which indicated navy bean soup and the soup was not on the tray. On 11/16/2021 at 1:39 PM, Surveyor #3 observed Resident #71 sitting on his/her bed. Resident #71 stated that he/she was waiting for his/her lunch tray and that they are always dead last to be served, and by the time they receive their trays, everything is cold. Resident #71 further stated the coffee's cold and yogurt is warm. During an interview with Surveyor #1 on 11/16/21 at 12:06 PM, the Food Service Director (FSD) stated the breakfast meal consisted of one hard-boiled egg, an English muffin, oatmeal, milk, orange juice, and coffee. The FSD further stated the breakfast meal had been substituted and that the breakfast ham was not provided because she did not have a cook that morning to prepare it. When asked why she did not prepare the breakfast ham, the FSD replied the breakfast meal trays were already late and that she wanted to get the breakfast trays out to the residents as quick as possible. On 11/19/21 at 12:52 PM, food service staff sent a test tray from the kitchen along with other resident trays on a food cart to the second-floor unit. Trays arrived on the unit at 12:55 PM. At 1:00 PM, the last tray was served to a resident. At 1:01 PM, in the presence of Surveyor #1, the FSD used a calibrated thermometer to check temperatures on the test tray. The following unacceptable temperatures were observed on the tray with regular textured food: Mac-n-cheese: 119 degrees Fahrenheit (F) Juice: 45 F Milk: 44 F A review of the facility's undated Food Storage policy indicated that cold foods would be maintained at temperatures of 40 F or below and hot foods would leave kitchen at 140 F or above. NJAC 8:39 - 17.4(c) On 11/16/21 at 9:58 AM, Surveyor #2 observed Resident #297 eating breakfast in his/her room. Resident #297 stated he/she did not receive what was on the menu for breakfast. The menu ticket indicated egg and cheese, breakfast ham, English muffin, juice and coffee but he/she only received one hardboiled egg, an English muffin and juice. The surveyor observed the breakfast tray consisted of only one hard boiled egg, an English muffin and juice. During an interview with Surveyor #2 on 11/16/21 at 12:11 PM, Resident #26 stated that for breakfast that morning, he/she only received one hard boiled egg and an untoasted English muffin, when the menu indicated egg and cheese and breakfast ham. Resident #26 further stated that he/she did not eat the breakfast and only drank the juice and coffee. During an interview with Surveyor #2 on 11/16/21 at 1:27 PM, Resident #298 described his/her lunch as cold chicken finger and cold fries. He/she further stated that for breakfast that morning he/she received only one hardboiled egg, an English muffin and coffee, when the menu indicated egg and cheese and breakfast ham. Resident #298 then stated that he/she did not eat the breakfast and was not made aware of substitutions for breakfast items prior to the meal service. On 11/16/21 at 1:40 PM, Surveyor #2 observed that Resident #297 received rice pudding instead of the fresh fruit, which was listed on the lunch menu ticket. On 11/18/21 at 10:30 AM, Surveyor #2 conducted a meeting with five residents in attendance. During the meeting, all five residents stated that their food was usually cold when served to them, they did not receive everything on their tray that was on the menu ticket and they were not made aware of any substitutions to the menu prior to the meal service. Based on observation and interview, it was determined that the facility failed to a.) provide residents' meals with food items as requested, b.) speak to the residents about alternate food items when the items first requested were not available and c.) provide food at a preferable and appetizing temperature. This deficient practice was identified for Residents #8, #21, #26, #37, #71, #247, #297, and #298 observed by the surveyors during a breakfast and lunch meal on 2 of 2 nursing units (1st Floor and 2nd Floor Units), and 5 of 5 residents who attended the Resident Council and was evidenced by the following: On 11/16/21 at 9:33 AM, during the initial tour of the 1st Floor Unit, Surveyor #1 observed Resident #247 sitting at beside with a disposable breakfast tray on the overbed table. When interviewed, the resident stated the breakfast meal consisted of a boiled egg, muffin, oatmeal, and that it was not hot. Surveyor #1 reviewed Resident #247's breakfast meal ticket which indicated the following under Hot items: oatmeal, egg and cheese, breakfast ham, and an English muffin. Resident #247 further stated he/she was not informed of the menu change, disliked the food and was not going to finish the meal. During an interview with Surveyor #1 on 11/16/21 at 9:40 AM, Resident #37 stated the food at the facility was horrible and regularly served cold. The resident further stated he/she was not informed of any menu changes for the 11/16/21 breakfast meal and that a lot of times, the meal tray did not match the meal ticket. During an interview with Surveyor #1 on 11/16/21 at 10:26 AM, Resident #21 stated the food at the facility was horrible. The resident further stated that he/she often did not eat facility meals and would instead order takeout.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 11/19/21 at 10:29 AM, the surveyor, in the presence of the Food Service Director (FSD), observed the following during the kitchen tour: 1. A stack of five aluminum pans was stored on a multi-tiered cart. The surveyor observed the five aluminum pans were wetnesting and noted a slimy unknown substance on the edge of the bottom aluminum pan. The surveyor wiped the edge of the bottom aluminum with a napkin and noted debris and a slimy unknown substance on the napkin. 2. A soiled dishware was stored on the top shelf of a multi-tiered cart alongside clean and sanitized dishware. 3. A stack of seven one-third pans was stored on a multi-tiered cart. The seven one-third pans were wetnesting. 4. In the juice box area, a juice nozzle was not attached to a juice box and touched the floor. When interviewed, the FSD stated they were not currently using that specific juice nozzle and that it should not be touching the floor. The FSD then picked up the nozzle and wrapped it around the other tubing. 5. A scooper and its holder were attached to the side of the ice machine. The surveyor observed that the bottom of the ice scooper holder had build-up and debris at the bottom. When interviewed, the FSD confirmed the surveyor's findings and stated the ice scooper holder was cleaned whenever the ice machine was cleaned. 6. The can opener was soiled with debris and a red unknown substance stuck to the blade. When interviewed, the FSD stated the blade was washed daily. 7. In the reach-in freezer, a package of pasta shells was stored in a box. The package of pasta shells was opened, undated, and exposed the contents inside. When interviewed, the FSD stated the package of pasta shells should be closed and labeled with an open date. 8. In the reach-in freezer, a package of breast steaks was stored in a box. The package of breast steaks were opened, undated, and exposed the contents inside. When interviewed, the FSD stated the package of breast steaks should be closed and labeled with an open date. 9. In the walk-in refrigerator, two stacks of sliced white cheese wrapped in clear plastic was stored on a multi-tiered cart. The two stacks of sliced white cheese were opened and undated. 10. In the walk-in refrigerator, one block of white cheese wrapped in clear plastic was stored on a multi-tiered cart. The block of white cheese was opened and undated. When interviewed, the FSD stated the two stack of sliced white cheese and the block of white cheese should be labeled with an open date. 11. In the walk-in refrigerator, a bag of carrots, wrapped in clear plastic, was stored on a multi-tiered shelf. The bag of carrots was opened and undated. When interviewed, the FSD stated the bag of carrots should labeled with an open date. 12. A box of plastic spoons was stored on a multi-tiered cart. The box and plastic packaging were opened and exposed the contents inside. When interviewed, the FSD stated the plastic packaging should have been closed. 13. A box of plastic forks was stored on a multi-tiered cart. The box and plastic packaging were opened and exposed the contents inside. When interviewed, the FSD stated the plastic packaging should have been closed. 14. In the dry storage room, a stack of coffee filters was stored directly on a multi-tiered cart. When interviewed, the FSD stated the stack of coffee filters were supposed to be stored in its plastic packaging and not directly on the multi-tiered cart. On 11/22/21 at 10:45 AM, the surveyor, in the presence of FSD, observed the following during the follow-up kitchen tour: 15. The surveyor observed a Food Service Worker (FSW) prepping fruit in the prep area. The FSW had a black cap on with hair exposed below the cap on the back of his head. The FSW did not have his hair contained in a hairnet. 16. The inside of the right stove was noted with brown and black build-up. The surveyor observed that the right side of the stove was warm to touch. When interviewed, the FSD stated they placed oven cleaner inside the right side of the stove and that it would be cleaned by end of day. 17. In the dry storage room, a dented six-pound eight-ounce can of sliced beets was stored on a multi-tiered shelf alongside undented cans. When interviewed, the FSD stated the dented can was not supposed to be on the multi-tiered rack and should have been placed in dented can area. A review of the facility's undated Food Storage policy indicated that prepared foods should be dated and tightly sealed in plastic wrap, foil, or a lid. The policy also revealed that dented cans should be placed in the designated dented can area. A review of the facility's undated Refrigerators and Freezers policy indicated that all foods should be appropriately dated to ensure proper rotation. The policy further revealed opened food items should be labeled with an open date. A review of the facility's undated Disposable Dishes and Utensils policy indicated single-service articles would be stored in the original protective package or in a manner that provides protection from contamination until used. A review of the facility's Uniform Policy, revised on 5/27/20, indicated that hairnets are to be worn and should cover hair from front to back. NJAC 8:39-17.2(g)

MINOR (B)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected multiple residents

Read full inspector narrative →

Based on observation, interview, and review of facility documents, it was determined that the facility failed to ensure that the posted 24-hour staffing report was completed in its entirety. This deficient practice was evidenced by the following: On 11/19/2021 at 8:00 AM, the surveyor observed the facility's Nursing Home Resident Care Staffing Report, dated 11/19/21 Day Shift, posted at the visitor entrance, which omitted information in the # of Staff, Total Hours Worked, and Staff to Resident Ratio columns. During an interview with the surveyor on 11/19/2021 at 10:05 AM, the Receptionist stated the Staffing Coordinator posts the Staffing Report daily and provided a copy of all the Staffing Reports posted at the visitor entrance. Review of the following facility's New Jersey Department of Health Nursing Home Resident Care Staffing Report revealed: On 11/16/21 Day Shift, the Staffing Report omitted the number of Total Hours Worked and the Staff to Resident Ratios for each staff category. On 11/16/21 Evening Shift, the Staffing Report omitted the number of Total Hours Worked and the Staff to Resident Ratios for each staff category. On 11/16/21 Night Shift, the Staffing Report omitted the number of Registered Nurses (RNs), the number of Total Hours Worked, and the Staff to Resident Ratios for each staff category. On 11/17/21 Day Shift, the Staffing Report omitted the number of Total Hours Worked and the Staff to Resident Ratios for each staff category. On 11/17/21 Evening Shift, the Staffing Report omitted the number of Total Hours Worked and the Staff to Resident Ratios for each staff category. On 11/17/21 Night Shift, the Staffing Report omitted the number of Registered Nurses (RNs), the number of Total Hours Worked, and the Staff to Resident Ratios for each staff category. On 11/18/21 Day Shift, the Staffing Report omitted the number of Total Hours Worked and the Staff to Resident Ratios for each staff category. On 11/18/21 Evening Shift, the Staffing Report omitted the Current Resident Census number, the number of Total Hours Worked, and the Staff to Resident Ratios for each staff category. On 11/18/21 Night Shift, the Staffing Report omitted the Current Resident Census number, the number of Registered Nurses (RNs), the number of Total Hours Worked, and the Staff to Resident Ratios for each staff category. On 11/19/21 Day Shift, the Staffing Report omitted the number of Registered Nurses (RNs), the number of Total Hours Worked, and the Staff to Resident Ratios for each staff category. During an interview with the surveyor on 11/19/2021 at 10:11 AM, the Staffing Coordinator (SC) stated she is responsible for completing the Staffing Reports. She further stated that for day and evening shift, she verifies the staff working prior to posting the day and evening shift Staffing Reports, but that she completes the night shift Staffing Report the following day since she is not in the building on that shift. The SC also stated she is responsible for completing the # of Staff column, but that the Assistant Administrator completes the Total Hours Worked, and Staff to Resident Ratio columns. During an interview with the surveyor on 11/19/2021 at 10:15 AM, the Assistant Administrator stated that the SC was responsible for completing the Staffing Reports and that she should complete the form for day and evening shift, but provided the form for the night shift supervisor to complete for the night shift. The Assistant Administrator reviewed the copies of the Staffing Reports and stated, it looks like we have not been filling that out, and, it was the Staffing Coordinator's responsibility to fill out. Review of the facility's Posting Direct Care Daily Staffing Numbers policy, undated, revealed, The information recorded on the form shall include: . f. Type and category of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift. NJAC 8:39-41.2 (a)

Jan 2020 5 deficiencies 2 IJ (1 affecting multiple)

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Quality of Care (Tag F0684)

Someone could have died · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to provide immediate emergency treatment to a resident that choked on food during the breakfast meal in the dining room. After the resident became unresponsive and cyanotic, the resident was removed from the dining room by the Certified Nurse Aide (CNA) and taken back to the resident's room, where the Heimlich maneuver (Heimlich) was performed and the food expelled. This deficient practice was identified for Resident #58, 1 of 1 resident who choked on 01/26/20, and a delay in emergency response placed the resident at a significant risk of death. The facility failed to ensure that emergency treatment was provided at the time and place of the resident's choking episode. On 01/26/20, at 9:32 AM, under the direction of a Licensed Practical Nurse (LPN #1), the resident was removed from the dining area by a CNA and transported down the hallway to the resident's room where LPN #1 performed the Heimlich. This failure constituted immediate jeopardy (IJ) to the resident's health and safety, with the potential to affect all residents who resided in the facility. The Administrator was made aware of the IJ on 01/29/20 at 4:35 PM, and a removal plan was accepted on 01/30/20 at 11:22 AM. The implementation of the removal plan was not verified upon completion of the survey. This deficient practice was evidenced by the following: On 01/26/20 at 9:30 AM, the surveyor began a tour of the second floor unit and introduced self to LPN #1. LPN #1 stated he was not the charge nurse and that there was not a specific charge nurse for the second floor on that day. While the surveyor was interviewing a resident in their room on 01/26/19 at 9:32 AM, the surveyor overheard the shout of code. The surveyor proceeded to the doorway of the resident's room and observed CNA #4 transporting Resident #58 in a high-back wheelchair (wheelchair). In a clear unobstructed view, the surveyor observed that Resident #58 was sitting motionless and upright. His/her face was blue in color. The surveyor observed that Resident #58 was transported to his/her room. The surveyor proceeded to Resident #58's room and observed the door to the room was not fully closed. The surveyor overheard voices coming from the inside of Resident #58's room stating that the resident was sleepy, it is a code, they were feeding [him/her], and [he/she] wasn't eating, and [he/she] was sleepy, and [he/she] choked. (Cross refer F808). On 01/26/20 at 9:41 AM, the surveyor observed LPN #1 at the second floor nursing station. LPN #1 stated he was preparing the emergency transfer form for Resident #58. LPN #1 stated at 9:43 AM, that he performed the Heimlich and got out little particles of food. At that time, LPN #1 did not indicate where he performed the Heimlich. On 01/26/20 at 9:55 AM, the surveyor observed Resident #58 on a stretcher and was being transported out of the facility by emergency medical service (EMS). On 01/26/20 at 10:26 AM, the surveyor, in the presence of two surveyors, interviewed CNA #4 who stated the resident was drowsy and that she had to wake the resident up to start feeding the resident. She stated the resident wasn't breathing right so she left the resident to go get LPN #1. CNA #4 stated that she was instructed by LPN #1 to take the resident to his/her room. She stated when the resident was taken to the his/her room, the resident was blue. She stated there were two other CNAs with her in the resident's room and she was not sure who they were. She stated the CNAs transferred the resident to the resident's bed and LPN #1 tried to do CPR. She stated LPN #1 then stood the resident up and did the Heimlich and a piece of pancake flew out of the resident's mouth. On 01/28/20 at 12:14 PM, the surveyor interviewed LPN #1 regarding the incident that occurred on 01/26/20 with Resident #58 in the dining room. LPN #1 stated he observed CNA #4 exit the dining room as he was headed toward the unit pantry, which was across from the nurses' station. He stated CNA #4 asked him to come and see Resident #58 because the resident had shortness of breath, or something like that. He stated at that time, he went into the dining room and noticed that Resident #58 had fixed eyes and was blue. He stated at that time he decided to remove the resident from the public and take him/her to the resident's room. He further stated the normal procedure was to start emergency care in the dining room and then take the resident to the room. The surveyor inquired if LPN #1 wrote a statement of the events and he stated that he still needed to write one. Immediately upon statement inquiry, LPN #1 changed his prior statement. LPN #1 now stated that as soon as CNA #4 showed him Resident #58, he could tell that the resident was choking. He stated that he performed the Heimlich and removed food from the resident's mouth in the dining room before the resident was taken to the room, where he performed the Heimlich again in the resident's room. At 01/28/20 at 1:38 PM, in the presence of two surveyors, LPN #1 requested to speak with the surveyor. LPN #1 stated that he wanted to clarify his statement made during the previous interview at 12:14 PM. LPN #1 stated he did not perform the Heimlich in the dining room and that he realized that he did not do the Heimlich on the resident until the resident was brought out of the dining room and taken into the resident's room. The surveyor inquired about the resident's status when he entered the dining room. LPN #1 responded that the resident's color was turning blue and that he didn't notice any breathing issues. The surveyor asked LPN #1 what he should have done. He responded that he was still trying to figure out what to do when he went into the dining room. After he looked at the resident, he stated he left to call the supervisor and 911. On 01/28/20 at 1:56 PM, during an interview with LPN #2, LPN #2 stated she heard a Code Blue and went to Resident #58's room, where LPN #1 was doing the Heimlich with the resident in a standing position. LPN #2 stated she saw a pretty big piece of pancake come out of the resident's mouth about this big and motioned with her hands to show a piece approximately one to two inches in circumference. On 01/28/20 at 2:17 PM, the surveyor interviewed the LPN/Unit Manager (UM #1) who stated that the nursing staff were required to assess a resident at the scene of the event. If the resident was choking, the nurse was to initiate the Heimlich Maneuver and call a Code Blue with an overhead page. She stated the recertification for CPR and Heimlich with the American Heart Association was just done at the facility. She stated they had a large group and when CPR certification was completed, a copy was given to the DON and she thought human resources also received a copy. On 01/27/20 at 11:07 AM and on 01/28/20 at 1:52 PM, in the Administrator's office, two surveyors along with the DON and Administrator, reviewed the facility's video surveillance footage on 01/26/20. The two camera views reviewed were Camera 13 (dining room second floor) and Camera 15 (short hallway second floor). The time stamp on the video footage between the two cameras differed by approximately 16-17 minutes. This was acknowledged by the DON who stated she was informed by the computer department that the time stamps that were on the videos were approximately 15 minutes ahead of the actual time. The DON stated both cameras were timed and each camera had it's own time stamp. She stated the time on the cameras had been a problem lately. The facility provided a copy of the video footage from each camera view to the survey team. The video evidenced the following on 1/26/20: Camera #13 (Dining Room): The video footage started at 09:31:53. At 09:31:54, CNA #4 placed a meal tray on the table where resident #58 was seated in a high back wheelchair (wheelchair). Resident #58 was the only resident seated at the table. From 09:32:46 to 09:40:02, CNA #4 was observed seated in a chair located to the right side of the resident's wheelchair, feeding Resident #58. At 09:40:05, CNA #4 stood up and walked toward the dining room entrance. At 09:40:11, CNA #4 walked out of camera view. Resident #58 remained seated unaccompanied at the table. There was no other staff observed in the camera view at that time. At 09:40:33, CNA #4 appeared in camera view and walked in the direction of the resident. At 09:40:37, LPN #1 entered the camera view and walked in the direction of the resident. At 09:40:38, CNA #4 returned to the resident's side. At 09:40:41, CNA #4 sat down in a chair located on the right side of Resident #58's wheelchair. At 09:40:41, LPN #1 arrived at resident's table. LPN #1 stationed himself to the rear and right side of the resident, in between the resident's wheelchair and where CNA #4 was seated. LPN #1 placed his left hand on the grab bar located on the back of Resident #58's wheelchair and peered around the right side of resident. His right arm was positioned on the armrest of the resident's wheelchair. At 09:40:45, LPN #1 used the grab bar to pull the resident's wheelchair backwards and away from the table. LPN #1 made a hand motion to CNA #4 who then started to stand from the chair. At 09:45:47, LPN #1 let go of the wheelchair and walked towards dining room entrance. At 09:45:48, CNA #4 turned the resident's wheelchair forward facing and pushed the resident towards the dining room entrance. At 09:40:50, LPN #1 walked out of camera view. At 09:40:56, CNA #4 walked out of camera view pushing the resident in the wheelchair. The following was observed on Camera #15 (Hallway): The video footage started at 09:56:31. At 09:56:51-09:56:56, CNA #4 entered camera view in front of the nurses' station. At 09:56:58, LPN #1 walked out of camera view. At 09:57:23, LPN #1 entered camera view in front of nurses' station and then immediately went out of camera view. At 09:57:29, LPN #1 moved into camera view, behind the nurses' station, and then out of camera view at 09:57:34. At 09:57:32, Resident #58, seated upright in a wheelchair, appeared in the camera view with CNA #4 in front of the nurses' station. At 09:57:36, LPN #1 entered camera view, behind resident. LPN #1 motioned with hands towards CNA #4 to follow at 09:57:37. At 09:57:43, CNA #4 transported Resident #58 down the hallway. At 09:57:56, CNA #4 entered the resident's room with the resident, followed by CNA #8. At 09:58:01, LPN #1 stepped a foot into the resident's room, then stepped back out. He motioned with his arms while looking towards the nurses' station. At 09:58:05, LPN #1 entered the resident's room. At 09:58:10, LPN #1 exited the resident's room and ran down the hallway, out of camera view. CNA #5 entered the resident's room. At 09:58:31, LPN #1 entered camera view, carrying a portable oxygen tank. At 09:58:36, LPN #1 returned to the resident's room with the oxygen tank. At 09:58:44, CNA #5 exited the resident's room. At 09:59:03, CNA #8 exited the resident room, walked down the hall, toward the nurses' station, turned around, ran back to the resident's room, and re-entered the resident's room at 09:59:25. At 09:59:32, CNA #1 entered the resident's room. At 09:59:36, LPN #2 entered the resident's room. At 09:59:38, CNA #5 entered the resident's room and exited the room at 09:59:51 and pulled the door ajar. At 10:00:26, LPN #2 exited the resident's room, followed by CNA #1 At 10:01:07, the DON entered the resident's room with a back board and LPN #3 entered the room with a code cart. At 10:04:20, RN/S #1 entered the resident's room. At 10:10:51, emergency responders entered the resident's room. On 01/28/20 at 3:09 PM, the surveyor, in the presence of another surveyor and the Administrator, interviewed the DON during review of the surveillance footage. The DON stated she was called into the facility when she was notified the surveyors were in the building. She stated that she was the one that told LPN #1 to call 911 and that she also wrote a statement about the incident. On 01/28/20 at 3:19 PM, the DON stated that if a nurse walked into a situation and a resident was blue, that meant that the resident's airway was obstructed. The DON said the nurse should automatically call a code. She stated that a nurse can yell out to get assistance and tell a CNA to call a code so the nurse could remain with the resident and start emergency care. The DON stated LPN #1 should have stayed with the resident at all times. On 01/28/20 at 4:50 PM, the surveyor interviewed the DON in the presence of the survey team. The DON stated she was unsure of the exact time that she heard the code called overhead and went to Resident #58's room. She stated she checked the resident's pulse. The surveyor inquired if the DON assessed the resident. The DON stated she documented the resident assessment on the statement she completed for the investigation. A review of the Progress Notes, dated 01/26/20 at 15:16 (3:16 PM), revealed a Health Status Note that was completed by LPN #1. The note revealed that around 9:30 AM, this writer was informed by a CNA that [Resident #58] is having shortness of breath while eating at the 2nd floor dining room. Unfortunately, resident was choking and this nurse immediately did an helmrick manover [sic], sweep out the remaining food in [his/her] mouth and applied re-breathable mask due to low pulse sox (87%) [sic] . The Administrator provided the survey team with a copy the investigation for the choking incident that occurred on 01/26/20. The investigation included an Individual Statement Form (ISF), completed 01/26/20 by the DON, which revealed the DON entered Resident #58's room and the resident was in bed with oxygen on via nasal cannula; the resident had a pulse; was taking shallow breaths; and the DON applied a non-rebreather mask to the resident as the other nurse was checking the resident's blood pressure and oxygen. She instructed LPN #1 to call 911. There was no evidence of a documented assessment completed by a Registered Nurse in Resident #58's medical record. Review of the ISF, dated 01/26/20 and completed by LPN #1, revealed Resident #58 was having shortness of breath while eating in the dining room and unfortunately the resident was choking and the nurse immediately performed the Heimlich Maneuver and swept the remaining food out of the resident's mouth. On 01/29/20 at 9:47 AM, the surveyor, in the presence of the survey team asked the DON and Administrator regarding any policies for oversight of the dining room at meal service and any policies related to emergency procedures for resident care. On 01/29/20 at 10:22 AM, the DON, in the presence of the survey team and Administrator, stated there were no policies regarding oversight of the dining room or related to emergency procedures related to resident care. On 01/29/20 at 10:47 AM, the DON provided the surveyor with a CPR policy and stated that was the only emergency policy and there was nothing specific for the dining room. On 01/29/20 at 1:01 PM, the surveyor, in the presence of the survey team, completed a telephone interview with the Registered Nurse/Supervisor (RN/S) who worked on 01/26/20. She stated she worked double shifts on the weekend and her responsibilities included to conduct rounds of residents and that she was available for emergencies. She stated she did not monitor the dining room. She stated she was available when help was needed and when a code was called. RN/S stated that on 01/26/20 she thought she was on the first floor in a resident's room and did not hear a code being called. She stated she thought that a CNA told her around 9:30 AM and she responded as quickly as she could but the elevator was taking time to arrive. She stated by the time she arrived at Resident #58's room, the DON and a whole bunch of people were in the room. She stated if a resident was unresponsive, the nurse should have directed someone to call her, and that the nurse should have stayed with the resident until the she responded. She stated the nurse should not leave the patient. RN/S further stated that if a person was not breathing and if you knew the person was choking, the nurse should do the Heimlich on the spot. At 01/29/20 at 2:03 PM, the surveyor measured a distance of 94 feet from the dining room table where the resident was seated, to the resident's room. On 01/30/20 at 2:58 PM, the surveyor in the presence of the survey team, interviewed CNA #5. CNA #5 stated she was in the hallway when Resident #58 was brought out of the dining room. She stated CNA #4 and CNA #8 stated to her that Resident #58 was choking, and at that time, LPN #1 came down the hallway and instructed the CNAs to take Resident #58 to the resident's room. She stated when the resident was brought to the resident's room, she did not enter the room, but the door was open and she could see that LPN #1 started to stand the resident up. She stated that at that time, she left the area. She stated she wrote a statement. An ISF, dated 01/28/20 and completed by CNA #5, revealed she observed the CNAs and Resident #58 coming out of the day room and LPN #1 told the CNAs to take the resident to the resident's room. The statement further revealed that CNA #5 went to Resident #58's room and closed the door and remained outside in the hallway. On 01/31/20 at 10:52 AM, in the presence of the survey team, the surveyor interviewed, CNA #8. CNA #8 stated that on 01/26/20, during the breakfast meal, she assisted a resident to the bathroom, which was across from the dining room. She stated she then observed LPN #1 come out of the dining room with Resident #58 and stated the resident was turning blue and to call a code. She stated the nurse pushed the resident in a wheelchair to the resident's room. CNA #8 stated that she, CNA #1 and another CNA followed LPN #1 with Resident #58 to the resident's room and during that time, CNA #1 and the other CNA were telling LPN #1 that Resident #58 was choking. CNA #8 stated at that time the resident's nose was blue and the resident looked like he/she was struggling to get air. She stated LPN #1 instructed her to get oxygen and she left and brought it in the room. She said she told LPN #1 that the resident was choking and that LPN #1 proceeded to leave the room, leaving the three CNAs alone with the resident. At that time, CNA #8 stated the resident was making a gurgling sound, that sounded like choking, and that CNA #4 tried to hit the resident on the back. She further stated LPN #1 returned to the room and picked the resident up from the bed, performed the Heimlich and something came out. On 01/31/20 at 11:37 AM, the surveyor reviewed LPN #1's employee file and the Licensed Practical Nurse (LPN) Job Description, provided by the Human Resources Director (HRD). A Nursing Core Competency Annual Assessments revealed a hire date of 01/23/18 and was signed by LPN #1. The Administrator and Director signature was blank. The HR director stated the DON and Administrator should have signed it and there should be someone's initials next to each competency to indicate that it was done. She further stated that the 2019 competencies were not done, because if they were, they would be in the file. The unsigned job description revealed specific requirements for an LPN which included thorough knowledge of principles, methods and techniques involved in performing general nursing services and adapting or modifying standard nursing practices for care of specific cases. A Cardiopulmonary Resuscitation Initiation competency, dated 11/15/19, for LPN #1 revealed the competencies included critical elements to establish unresponsiveness and attempt to arouse the resident and call for help and stay with the resident. The competencies were checked off as met and there was no evaluators signature on the document. Review of a typed, undated letter, revealed LPN #1 successfully completed his/her CPR training course on 01/23/20 and was awaiting a card. The letter revealed a copy of a Basic Life Support Instructor (BLS #1) Certification card. On 02/11/20 at 4:23 PM, the surveyor interviewed BLS #1 by telephone. BLS #1 stated the typed letter was her certification that she completed a private course with LPN #1 on 01/23/20 and stated that she trained LPN #1 in CPR, the Heimlich Maneuver and use of an AED (automated external defibrillator that immediately diagnoses life threatening heart arrhythmia's). According to the hospital records received at the NJ Department of Health on 02/05/20, Resident #58 arrived at the Emergency Department with EMS for evaluation of choking. EMS reported the patient choked on pancakes that morning at the facility, the Heimlich was performed and the patient coughed up the pancakes. The resident had a CAT (computerized axial tomography, an X-ray test that provided cross section views of anatomy) scan of the chest, dated 01/26/20, that revealed right upper lobe and bilateral lower lobe patchy opacity, in keeping with aspiration pneumonitis (lung inflammation caused by a substance entering the lungs). NJAC 8:39-27.1(a)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0808 (Tag F0808)

Someone could have died · This affected multiple residents

Read full inspector narrative →

**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 provide the correct diet for 2 of 41 residents reviewed for altered consistency diets, Resident #58 and Resident #64. a.) Resident #58, who had a diagnosis of dysphagia (difficulty swallowing), a history of pocketing food (not swallowing food, but holding the food in their mouth) and was lethargic (decreased alertness) at meals, was fed a chopped diet instead of the physician ordered pureed diet. The resident choked on the food, became cyanotic (bluish color to the skin), and required emergency treatment. On 01/26/20 at 3:45 PM, the facility Administrator was notified that an Immediate Jeopardy situation (IJ) had been identified. The survey team accepted the removal plan on 01/27/20 at 1:56 PM. There was a systemic failure when multiple facility staff failed to identify and provide the correct physician ordered modified consistency diets to multiple residents; b.) The facility failed to follow their removal plan, which resulted in a subsequent IJ identified on 01/29/20 at 12:10 PM, for Resident #64, who had a diagnosis of dysphagia and was identified as at risk for silent aspiration, and was served mechanically ground vegetables instead of the physician ordered pureed vegetables; and c.) The facility failed to follow their removal plan for 2 of 2 residents, Resident # 64 and Resident #34, who received their meal tray without the two-person point review system for meal tray accuracy at the point of service, in accordance with the facility's removal plan. During the standard survey of 01/31/20, the facility Administration was notified of the IJ situation on 01/26/20 at 3:49 PM. The facility failed to ensure that the correct physician ordered mechanically altered diet consistency was provided to a resident who had a diagnosis of dysphagia, a history of lethargy at meals, and was at risk for aspiration. Resident #58 had an order for a puree diet and was provided a chopped consistency meal tray. A Certified Nurse Aide (CNA #4) fed the resident the incorrect diet. The resident choked, became unresponsive, and 911 was activated. The facility provided a removal plan on 01/27/20 at 1:56 PM. The IJ was continued at a lower scope and severity when it was identified the removal plan was not fully implemented. On 01/28/20, a CNA #6 distributed a late meal tray to Resident #34 without having the meal checked by two staff in accordance with the facility's removal plan. On 01/29/20, the facility Administration was notified of a subsequent IJ situation at 4:31 PM. The facility failed to ensure the implementation of the removal plan, dated 01/27/20, and ensure that the correct physician ordered mechanically altered diet consistency was provided to Resident #64 who had a diagnosis of dysphagia. The resident had an order for a puree diet. The cook plated the food incorrectly, and the resident was provided a meal tray that contained ground vegetables. CNA #3 fed the resident the incorrect diet. The removal plan was accepted on 01/30/20 at 11:22 AM. The implementation of the removal plan was not verified upon completion of the survey. Part A. Resident #58 This deficient practice was evidenced by the following: While the surveyor was interviewing a resident in their room on 01/26/19 at 9:32 AM, the surveyor overheard the shout of code. The surveyor proceeded to the doorway of the resident's room and observed CNA #4 transporting Resident #58 in a wheelchair. In a clear unobstructed view, the surveyor observed that Resident #58 was sitting motionless and upright. His/her face was blue in color and the resident was motionless. The surveyor observed that Resident #58 was transported to his/her room. The surveyor proceeded to Resident #58's room and observed the door to the room was not fully closed. The surveyor overheard voices coming from the inside of Resident #58's room stating that the resident was sleepy, it is a code, they were feeding [him/her], and [he/she] wasn't eating, and [he/she] was sleepy, and [he/she] choked. The surveyor reviewed Resident #58's medical record and noted the following: An admission Record revealed the resident was admitted to the facility with diagnoses that included Dementia with Behavioral Disturbances and Muscle Weakness. A Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care dated 12/09/19, revealed the resident had a Brief Interview for Mental Status Score of 00' which indicated the resident was severely cognitively impaired. The MDS revealed the resident required extensive assistance of one person to eat meals and was totally dependent on staff for personal hygiene. The MDS indicated the resident had a swallowing disorder, loss of liquids/solids from mouth when eating or drinking, coughing or choking during meals or when swallowing medications, and complaints of difficulty or pain with swallowing, and was on a mechanically altered diet. The Care Plan revealed a Focus, initiated 03/07/19, that indicated the resident was on an altered diet texture due to his/her diagnoses of dysphagia and easier toleration. A goal, initiated 09/14/18, revealed the resident would be free from signs and symptoms of aspiration or dehydration. A Medication Review Report, dated 01/26/20, revealed the resident had a physician order for a NAS (No Added Salt) diet Pureed Texture, dated 01/26/17. A review of the Progress Notes, dated 01/26/20 at 15:16 (3:16 PM), revealed a Health Status Note that was completed by LPN #1. The note revealed that around 9:30 AM, LPN #1 was informed by CNA #4 that Resident #58 was choking in the dining room and LPN #1 immediately did the Heimlich maneuver and swept out the remaining food in the resident's mouth and applied a re-breather mask (oxygen mask). A review of a quarterly Nutrition/Dietary Note, dated 12/06/19 at 10:57 AM and completed by the Dietitian, revealed Resident #58 continued on a NAS, puree diet which was appropriate and tolerated well. Resident was dependent for eating, weight was gradually trending downward due to decreased food intake, and that the resident was sleeping during meals. A review of the Census List (a listing of the resident's diets and used by dietary and nursing), dated 01/26/20, revealed that Resident #58 was on a NAS (no added salt), Pureed Diet (smooth textured diet). On 01/26/20 at 9:37 AM, the surveyor observed a meal tray at an unoccupied table with a meal ticket that reflected Resident #54's name and an order for a chopped diet consistency which also allowed soft sandwiches and soft snacks. The tray contained approximately 16 one-inch pieces of pancake, which appeared dry, and approximately six one-inch pieces of sausage patty with a plastic fork stuck into the pancakes. A four-ounce container of orange juice, an unopened container of pancake syrup, an unopened package of butter, an unopened package of cereal and unopened container of farina was also observed on the tray. The surveyor observed the first name printed on Resident #54's meal ticket was the same first name as Resident #58. During this observation, CNA #4 entered the dining room and approached the surveyor during the surveyor's observation of Resident #54's meal tray. CNA #4 held up the meal ticket that was located on Resident #54's meal tray and stated to the surveyor that she fed Resident #58 that meal tray. She stated she fed Resident #54's meal tray to Resident #58 and stated, I was feeding [Resident #58] and something must have gotten stuck in [his/her] throat. She further examined Resident #54's meal tray ticket and stated that wasn't Resident #58's tray, and that the resident received the wrong tray. She continued to state that she fed Resident #58 pancakes. On 01/26/20 at 9:40 AM, the surveyor continued the interview with CNA #4 in the dining room. CNA #4 stated, I accidentally gave [Resident #58] the wrong tray, I am not sure what [Resident #58] gets. CNA #1 stated that she was employed through an agency and had been at the facility for a while. CNA #1 stated she had taken care of Resident #58 in the past. On 01/26/20 at 9:41 AM, the surveyor observed Licensed Practical Nurse (LPN #1) at the second-floor nursing station. LPN #1 stated he was preparing the emergency transfer form for Resident #58. At that time, CNA #4 approached LPN #1, in the presence of the surveyor, and stated to LPN #1 that she accidentally gave Resident #58, Resident #54's tray. At that time, the surveyor interviewed LPN #1 about Resident #58's diet and LPN #1 stated that Resident #58's diet is a puree, full puree. On 01/26/20 at 9:42 AM, the surveyor brought CNA #1 into the dining room to observe Resident # 54's meal tray and the corresponding meal ticket located on the meal tray. CNA #1 observed the meal tray and meal ticket and stated that this was not Resident #58's name on the meal ticket and the the meal was the wrong diet. She stated, this was the wrong diet, this was not [Resident #58's name] and this was not even [Resident #58's] food at all. CNA #1 stated she was a full-time employee of the facility. On 01/26/20 at 9:43 AM, the surveyor interviewed LPN #1 who stated he performed the Heimlich maneuver on Resident #58 and got out little pieces of food. On 01/26/20 at 9:55 AM, the surveyor observed Resident #58 on a stretcher and was transported out of the facility by Emergency Medical Service (EMS). On 01/26/20 at 10:06 AM, the surveyor interviewed the second-floor unit manager (UM #1) who stated Resident #58 had been on a puree diet for a while and she showed the surveyor a book of recent diet orders. A review of the book revealed that there were no recent diet order changes for Resident #58. At that time, UM #1 provided a copy of Resident #58's CNA [NAME] (resident specific care report used by nurse aides) information. The [NAME] did not include information regarding the type of diet Resident #58 consumed. UM #1 also provided a copy of the 01/26/20 Daily Assignment Sheet, which revealed that CNA #4 was assigned to Resident #58 to provide care. On 01/26/20 at 10:26 AM, the surveyor, in the presence of two surveyors, interviewed CNA #4 who stated that she worked at the facility often and stated that she thought Resident #58 was on a puree diet. She stated she didn't pay attention to the resident's last name on the tray ticket. She stated the resident was drowsy and she woke the resident to feed him/her. She stated that she fed Resident #58 a piece of pancake and then noticed the resident was not breathing right. She stated she left the resident alone in the dining room to get the nurse. CNA #4 stated that she observed that the resident's meal was not puree; however, she thought the tray was correct because it matched the diet printed on the meal ticket. She further stated she did not cut the pancake or sausage any more than the way it was served on the tray. She fed Resident #58 pancake first and then sausage. She stated the diet Resident #58's was prescribed was not listed on her assignment sheet and she would have to ask the nurse if she needed to know. She stated that she would know the resident's diet by reading what was printed on the resident's tray ticket. On 01/26/20 at 10:41 AM, the interview continued, and CNA #4 stated Resident #58 was taken to the resident's room and during that time the resident was blue. She stated there were two other CNAs with her in the resident's room and she was not sure who they were. She stated the CNAs transferred the resident to the resident's bed and the nurse tried to do CPR, and after that the nurse stood the resident up and did the Heimlich maneuver and a piece of pancake flew out of the resident's mouth. On 01/26/20 at 11:07 AM, the surveyor interviewed the Food Service Director (FSD) who stated that a puree consistency diet was the consistency of baby food or applesauce with no lumps. He further stated that regular pancakes and sausage were not provided on a puree diet because a resident could choke. On 01/26/20 at 11:24 AM, the surveyor, in the presence of the survey team, interviewed the Director of Nursing (DON) and facility Administrator. The DON stated the aides know their assignments and which residents need to be fed. The DON stated that the CNAs have access to the information in the kiosk (computer CNA assignment). The DON showed the surveyor the 01/26/20 Daily Assignment Sheet where CNA #4 was assigned to the Dayroom to feed residents. The DON further stated that when the trays arrived on the floor, CNAs were supposed to check the meal ticket and the diet to make sure the tray was accurate. She stated that they should also check the name of the resident and the meal ticket to ensure that the resident received the correct tray. The DON stated the CNAs were trained on the dining process and how to properly feed a resident during orientation and that the training was part of their annual competencies. The DON was interviewed regarding agency staff being included in the facility orientation training or annual competencies. The DON stated that she was not aware of the agency staff being provided with education at the facility. On 01/26/20 at 1:09 PM, the surveyor interviewed LPN #1 who stated that the CNAs should check that the resident's name band matched the meal ticket and that they should check even when they are familiar with the residents. He stated that the CNAs were also supposed to confirm the accuracy of the tray for the correct diet and check for missing items. A review of Resident #58's Speech Therapy Encounter Note, dated 10/24/19 and signed by the speech clinical fellow (SCF), revealed that the SCF examined Resident #58's oral cavity and found right buccal (inside of check) pocketing and removed a bolus (ball like mixture of food). The patient was unsafe to continue feeding by mouth at that time and the nursing and the aides verbalized understanding and agreement. A review of Resident #58's Speech Therapy Encounter Note, dated 10/25/19 and signed by the Speech Clinical Fellow (SCF), revealed that the resident was on a puree consistency diet. On 01/26/20 at 2:57 PM, the surveyor, interviewed the Regional Manager of Speech Therapy (RMSP) who stated she cosigned the SCF notes and stated she had seen Resident #58 a handful of times. She stated the resident was not always arousable and that the resident was known to nursing for pocketing food. She stated any education would have been done with staff at that time and that there wasn't any documentation. She stated the strategies should be on the care plan and stated that she should not have been fed regular sausage and pancakes. On 1/26/20 at 12:30, the DON provided a copy of an undated Serving of Food policy, which revealed food shall be prepared and served in a manner that prevents foodborne illness and meets the individual needs of each resident. The policy further revealed that nursing staff and feeding assistants would serve resident trays and would help residents who require assistance with eating. Residents who could not feed themselves would be fed with attention to safety, comfort and dignity. Part B. Resident #64 There was a systemic failure when multiple facility staff failed to follow the removal plan accepted on 01/27/20 at 1:56 PM, which indicated a two person point of contact for review of meal tray at point of service. The facility served a resident a ground diet instead of a physician ordered puree diet. The facility's failure to ensure the resident, who had difficulty swallowing and was at risk for aspiration, received the appropriate altered diet. Serving the wrong consistency constituted an Immediate Jeopardy (IJ) to the resident's health and safety. This IJ was identified on 01/29/20 at 12:10 PM, in the main dining room, after the surveyor observed CNA #3 feeding Resident #64 a spoonful of ground Italian mixed vegetables. Resident #64 ingested the ground mixed vegetables and swallowed the mixture. The IJ was reported to the Administrator and the Director of Nursing (DON) on 01/29/20 at 4:31 PM and the removal plan was requested. The removal plan was accepted on 01/30/20 at 11:22 AM. This deficient practice was evidenced by the following: The surveyor reviewed Resident #64's medical record and noted the following: The admission Record revealed the resident was admitted to the facility with diagnoses which included: Alzheimer's Disease, Cerebral Infarction (stroke) and Respiratory Disorders. The Quarterly Minimum Data set (MDS), an assessment tool dated 12/23/19, revealed the resident had a Brief Interview for Mental Status (BIMS) of 3, which indicated that the resident's cognition was severely impaired. The MDS also indicated that the resident was on a mechanically altered diet (change in food or liquids texture). The Care Plan for Dysphagia, dated 09/21/18, revealed the resident had a history of Dysphagia. The goal was for the resident to be free from signs and symptoms of aspiration or dehydration. The intervention listed was for staff to serve the resident's diet as ordered. A Physician Order sheet, dated 05/31/17, revealed the resident was prescribed a puree diet with nectar thickened liquids. A review of the Nutrition/Dietary Note, dated 12/26/19 at 02:49, revealed the resident required a puree diet with nectar thick liquids. A Speech Therapy (ST) (SLP Evaluation & Plan of Treatment) report, dated 01/27/20, revealed the resident was referred to ST for an exacerbation of dysphagia. The evaluation was done to assess the least restrictive oral intake and to restore the resident's oral function. The report also revealed the resident had a past medical history of dysphagia. On 01/29/20 at 11:53 AM, the surveyor conducted a dining room observation to ensure the removal plan of 01/27/20 was implemented. At that time, the surveyor observed Resident #64 seated in his/her wheelchair being fed ground Italian mixed vegetables by CNA #3. The surveyor reviewed Resident #64's meal ticket that was lying on the table next to the resident's meal plate. The surveyor compared the resident's meal ticket to the meal the resident was being fed by CNA #3. The meal ticket revealed the resident was to be served puree ham, mashed sweet potatoes and puree Italian mixed vegetables; however, the resident's lunch meal plate contained, pureed ham, mashed sweet potatoes and ground consistency Italian mixed vegetables. CNA #3 immediately stopped feeding the resident and asked the surveyor if Resident #64's meal was incorrect. When interviewed by the surveyor, CNA #3 stated the vegetables were puree consistency. The surveyor requested for a nurse to come to the dining room. CNA #3 stated there was no nurse inside the dining room during meals. The surveyor observed the Nurse Consultant (NC #1) walking down the hallway and requested for her to come inside the dining room. NC #1 reviewed the resident's lunch meal and stated the vegetables looked to be either chopped or ground and were not a puree consistency. When interviewed by the surveyor at that time, NC #1 stated the resident was supposed to have been served a puree diet. NC #1 stated that if the resident was to ingest the ground vegetables, the resident could choke on the food. During an interview on 01/29/20 at 12:11 PM, in the presence of four surveyors, the FSD and Regional Manager, Cook/Supervisor #1, stated that he had worked at the facility as the PM (evening) Cook/Supervisor for 30 days. Cook/Supervisor #1 stated that he had a Safe Serve certification, but his certification had expired. When Cook/Supervisor #1 was asked to describe the difference in the consistency of a pureed meal verses a ground meal, Cook/Supervisor #1 stated a pureed consistency was like baby food and the ground consistency diets had little pieces inside. The surveyor showed Cook/Supervisor #1, Resident #64's lunch meal plate. Cook/Supervisor #1 stated the ham and sweet potatoes were pureed consistency and the Italian vegetables were ground consistency. Cook/Supervisor #1 stated that he was responsible for reviewing the resident's meal ticket prior to plating the resident's food. Cook/Supervisor #1 stated the Food Service Workers (FSWs) provided the second check to ensure residents received the correct diets. Also, the FSWs were responsible for comparing the meal tickets to what was on the plate. Cook/Supervisor #1 reviewed Resident #64's meal ticket in the presence of the surveyor and stated the resident's entire meal should have been a pureed diet and not ground vegetables. Cook/Supervisor #1 stated, it is my mistake and the mix-up occurred because the tray line wasn't set up properly. Cook/Supervisor #1 stated he could not remember which FSW checked Resident #64's plate because the kitchen was very busy. Cook/Supervisor #1 stated the mix-up was all his fault and he had just messed up. During an interview on 01/29/20 at 12:40 PM, in the presence of four surveyors, Activity Aide (AA #1) and CNA #3 stated they were trained by the facility on how to identify altered diets and to serve the residents their meal trays. AA #1 stated she removed Resident #64's meal tray from the cart and compared the meal ticket to what was on the plate. AA #1 stated that she did not see anything wrong with the meal on the plate. CNA #3 stated she also compared the meal ticket to the plated meal and did not find anything wrong with the meal she fed to the resident. CNA #3 stated the facility was giving them more and more responsibility and she was finding it difficult to remember everything she had been taught. A review of a Speech In-Service titled, Diet Textures, dated 01/28/20, revealed the second-floor staff were provide an in-service on all diet consistencies: pureed, ground, chopped, and regular. The in-service also included modified liquid level consistencies: nectar, honey and pudding. According to the attendance register, CNA #3 attended this in-service and another in-service on 01/28/20. A review of the undated Pureed Diet guidelines revealed the facility provided pureed diets meats, and that starches and vegetables were pureed to a smooth consistency without lumps or solid materials. A review of the Tray line Service policy, updated 01/2019, revealed the tray line positions and set up procedure were planned for efficient and orderly delivery. All meals were to be checked by food service personnel for accuracy, and the employee serving the meals prior to serving to the individual. Each meal will be checked for: correct name, room number, diet order, accuracy of the following therapeutic diet extension, and proper portion size. On 01/30/20 at 11:13 AM, the Chief Operating Officer (COO) provided the surveyor with a new tray line policy, dated 01/30/20. The policy implemented a color coded meal ticket to increase awareness for diets that were altered food and liquid consistencies. Part C. Resident #34: The deficiency continued at a level D and was evidenced by the following: The facility staff did not follow the removal plan accepted on 01/27/20 at 1:56 PM which indicated a two person point of contact for review of meal tray at point of service. On 01/28/20 at 9:12 AM, the surveyor was at the second floor nursing station and observed a dietary staff member place a meal tray at the nursing station. The dietary staff stated to CNA #6, who was working at the computer, that the tray was for Resident #34. CNA #6 lifted the lid of the meal tray and looked at the meal. The surveyor followed CNA #6 to Resident #34's room where CNA #6 placed the meal tray in front of the resident on the bedside table which was located next to the resident's bed. At that time, the surveyor interviewed CNA #6, who stated she brought the resident the meal tray and confirmed that the tray was placed in front of Resident #34 without another staff member checking the tray. On 01/28/20 at 9:16 AM, the surveyor interviewed LPN #1 who was observed at the medication cart directly outside of Resident #34's room. The LPN stated that two CNAs were supposed to double check the meal trays with the nurse prior to giving the tray to the resident. He stated that was for any resident and any tray. On 01/28/20 at 9:24 AM, the surveyor interviewed CNA #6 who stated if she removed the tray from the cart, then she would be the one who would check the tray. She stated the tray for Resident #34 was a late tray and that she checked the tray to ensure everything was on it. A review of the Quarterly MDS, dated [DATE], revealed Resident #34 had a BIMS score of 9, which indicated moderate cognitive impairment. The MDS did not indicate that the resident had a swallowing disorder or was on a specialized diet. The Census List, dated 01/26/20, revealed Resident #34 was on a CCD/NCS, NAS diet (low carbohydrate, no concentrated sweets, no added salt). NJAC 8:39-17.4(a) (1-2); 27,1(a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, it was determined that the facility failed to maintain complete and accurate documentation for 1 of 1 resident reviewed for catheter care and medical record completion (Resident #42). This deficient practice was evidenced by the following: On 01/30/2020 at 10:41 AM, the surveyor observed the Licensed Practical Nurse (LPN #2) irrigate Resident #42's indwelling urinary catheter and noted the following: During an observation of Resident #42's cognition prior to the catheter care, the resident demonstrated lack of awareness to the environment and was unable to respond to the surveyor. The surveyor observed 200 milliliters (mL) of dark amber urine in the catheter tubing and drainage bag that was uncovered and secured to the side of the bed. LPN #2 proceeded to perform the indwelling catheter irrigation procedure. Once the catheter was flushed, LPN #2 reconnected the catheter to the drainage tubing and amber colored urine began to drain into the drainage bag that was secured to the bed. The surveyor observed that the resident remained non-verbal and demonstrated a lack of awareness to the environment during the catheter irrigation procedure. The surveyor also observed that the resident exhibited no facial grimacing, elevation in mood or tone of voice, or other behaviors of intolerance. According to the admission Record, the resident was admitted to the facility with diagnoses which included, but were not limited to, urinary tract infection (UTI) (infection in any part of the urinary system), reflex neuropathic bladder (lack of bladder control due to a brain, spinal cord, or nerve condition), and anoxic brain damage (lack of oxygen to the brain). A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/15/2019, revealed that the resident was in a persistent vegetative state with no discernible consciousness. A review of the January 2020 Order Summary Report (OSR) revealed a physician order with a start date of 01/19/2020, to flush [indwelling urinary] catheter with 30 cc of normal saline solution (NSS) every shift for prevention of clogging from sediment, every shift for prevention of clogging. The OSR also showed a physician's order with a start date of 12/07/2019 that revealed [Indwelling Catheter Care] and drain bag, record the amount every shift. A review of the January 2020 Treatment Administration Record (TAR) reflected the above physician orders. A review of the Care Plan, revised on 01/27/2020, indicated that the resident required an indwelling catheter related to Neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem). The interventions included to monitor the indwelling urinary catheter for patency every shift and to monitor, record and report to the physician signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. A review of the Progress Notes on 01/30/2020 at 2:48 PM, revealed there was no documentation by the LPN that reflected Resident #42's response following the catheter irrigation procedure or documentation regarding catheter output, type, color, presence of odor or leakage. On 01/31/2020 at 3:17 AM, the Director of Nursing (DON) provided a copy of the Medication Administration Audit Report and confirmed, in the presence of the surveyor, that LPN #2 had documented on the TAR that the indwelling catheter flush was performed on 01/30/2020 at 11:29 AM. The DON stated that LPN#2 should have documented the urine output, type, color, presence of odor, leakage, and the resident's response to the procedure immediately following the irrigation procedure in the progress notes. The DON confirmed that there was no documentation of this information in the progress notes. During an interview with the surveyor on 01/30/20 at 10:50 AM, LPN #2 stated that the indication for Resident #42 catheter was that he/she was unable to urinate on his/her own. The LPN stated that she observed that Resident #42 was passing urine, had no bleeding, pain, or discomfort. LPN #2 stated that she does not document an assessment in the progress note before and after the procedure and that she only documents on the TAR that the procedure was completed. The facility's undated Intermittent Irrigation of Indwelling Urinary Catheter policy indicated to document in the clinical record the urine characteristics before and after procedure, type and amount of irrigating solution instilled, and the client's tolerance of the procedure. NJAC 8:39-35.2

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate infection control protocols for hand hygiene (hand washing or use of an alcohol-based hand rub) and indwelling catheter care (a tube placed inside the bladder to facilitate the flow of urine). This deficient practice was identified for 1 of 1 nurse observed during catheter care on 1 of 1 resident (Resident #42) reviewed for indwelling urinary catheter and was evidenced by the following: On 01/30/20 at 10:23 AM, the surveyor entered Resident #42's room and observed the resident's bedside table with white debris scattered across the top. There was also two individual packets of ointment, a nail clipper, and a bottle of perineal skin cleanser observed stored on the table. On 01/30/20 at 10:34 AM, the surveyor observed the Licensed Practical Nurse (LPN #2) perform irrigation of Resident #42's indwelling urinary catheter as follows: LPN #2 entered the resident's room carrying catheter care supplies, which included, a 100 milliliter (mL) sterile (free from bacteria) container, 250 mL sterile saline solution (SSS), one black sharpie marker, multiple individual alcohol pads, catheter irrigation kit with piston syringe, 2000 mL urine drainage bag, and one box of medium gloves. LPN #2 placed the catheter care items directly on the resident's uncleaned bedside table, without barrier. LPN #2 also brought in a urethral catheter tray which she placed directly on the bed, at the foot of the bed. She donned gloved (put on), adjusted the resident's tracheostomy collar, and then removed and discarded her gloves. At 10:38 AM, after glove removal, the survey observed LPN #2 perform handwashing as followed: LPN #2 turned on the water, applied soap to dry hands and rubbed hands together with friction for three seconds. She placed both hands under running water to wet hands and washed hands with a lather of soap and water for 20 seconds outside the flow of water. She rinsed her hands and then dried her hands with paper towels that were bunched together. She used those same paper towels to turn off the water. At 10:39 AM, LPN #2 opened the 250 mL container of SSS and the 100 mL sterile container. LPN #2 poured the SSS into the 100 ml sterile container. LPN #2 then performed handwashing as followed: LPN #2 turned on the water, applied soap to dry hands, and rubbed hands together with friction for three seconds. She placed both hands under running water to wet hands and washed hands with a lather of soap and water for 10 seconds outside the flow of water. She rinsed her hands and then dried her hands with paper towels that were bunched together. She used those same paper towels to turn off the water. At 10:41 AM, LPN #2 applied gloves, opened an alcohol pad, placed the pad on top of the alcohol pad wrapper, and then placed the wrapper directly onto the bedside table that was covered with white debris. She used the piston syringe to withdraw 30 cubic centimeter (cc) of SSS. She opened the plastic bag from the catheter irrigation kit and placed it on the bedside table. She placed the container and syringe on top of the plastic bag. Without changing gloves and performing hand hygiene, LPN #2 started the irrigation procedure as followed: LPN #2 removed an unopened alcohol pad from the bedside table, and walked towards the resident. She unfastened the catheter strap (strap worn around the leg to secure the catheter tube in place), opened the alcohol pad and wiped the catheter port that was located on the catheter tubing. She disconnected the catheter from the tubing and flushed the catheter with 30 cc of SSS. Once the catheter was flushed, LPN #2 immediately reconnected the catheter to the drainage tubing and amber colored urine began to drain into the drainage bag that was secured to the bed. She secured the catheter to the leg strap. Following the procedure, LPN #2 removed her gloves, and without performing hand hygiene, she used the black marker that was on the bedside table to date the SSS container. At that time, LPN #2 stated that she needed to return the unused urine drainage bag and urethral catheter tray to the medication room, and return the SSS container to the treatment cart. At 10:47 AM, the surveyor observed LPN #2 exit the resident's room without performing hand hygiene. LPN #2 walked to the treatment cart and placed the SSS container in the drawer. LPN #2 then walked to the medication room where she placed the urine drainage bag and the urethral catheter tray in the cabinets. LPN #2 walked out of the medication room to the nurse's desk and stated that she was finished. LPN #2 did not perform hand hygiene. During an interview with the surveyor on 01/30/20 at 10:50 AM, in Resident #42's room, LPN #2 stated that the outside packaging of the catheter care items were not sterile; however, the inside packaging was sterile. She also stated that the catheter irrigation was a sterile procedure (technique used to maintain environment free from germs where contamination could create problems) because sterile water was used. LPN #2 confirmed that the bedside table was not cleaned and stated she should have cleaned the table before placing the items on the table. LPN #2 stated that a drape (protective covering to prevent contamination) was not available to place on the table as a barrier. LPN #2 also confirmed that she did not clean the bedside table before leaving the resident's room. She stated that she forgot to wash her hands before leaving the resident's room and confirmed that she touched the treatment cart and then went into the medication room to return items. On 01/30/20 at 11:15 AM, after the interview with LPN #2, the surveyor observed LPN #2 perform handwashing in the resident's room as followed: LPN #2 turned on the water, applied soap to dry hands, and rubbed hands together with friction for three seconds. She placed both hands under running water to wet hands and washed hands with a lather of soap and water for 20 seconds outside the flow of water. She rinsed her hands and then dried her hands with paper towels that were bunched together. She used those same paper towels to turn off the water. The surveyor resumed the interview with LPN #2 on 01/30/20 at 11:17 AM. LPN #2 stated that she was last in-serviced on handwashing one week ago and did not recall the educator's name. LPN #2 stated that the facility policy and procedure for handwashing was to turn on the water, put soap on both hands, wet hands, scrub hands with soap and water for 20 seconds between fingers, rinse hands in a downward motion, use paper towels to dry hands, and turn off the water with the paper towel. She stated that soap to scrub time was 20 seconds out of the flow of water. She also stated that she used the same paper towel to dry her hands and turn off the faucet and that it was alright to use the same paper towels to turn off the water. On 01/30/20 at 1:35 PM, the Director of Nursing (DON) provided a copy of the Handwashing in-service, dated 11/27/2019, that confirmed LPN #2 had attended the education training. The DON also provided the surveyor with the facility handwashing policy. The surveyor reviewed the documents and noted that the in-service education differed from the handwashing policy. The in-service education included a diagram titled, How to Handwash? which contained instructions to wash hands outside of the running water. The facility policy titled, Handwashing/Hand Hygiene included instructions to wash hands under a moderate stream of running water. On 01/31/20 at 3:38 PM, in the presence of the survey team, the DON confirmed that the facility's handwashing policy and the in-service diagram on handwashing did not correlate with each other. She also stated that the policy did not match what was taught to the facility staff. The DON stated that staff were educated on the procedure for handwashing in accordance with in-service diagram and not the handwashing policy as followed: wet hands, apply soap to hands, lather hands for 30 seconds all surfaces, rinse hands under running water, use a paper towel to dry hands, use another clean paper towel to turn off the faucet, and then discard the paper towel in the trash receptacle. The DON stated that the facility policy was incorrect. During an interview with the DON on 01/31/20 at 4:14 PM, the DON stated that she oversees the Infection Control education and made sure that it was done monthly. The DON stated that she would provide the Infection Control Policy (ICP) which would include any additional information related to infection control with handwashing and keeping residents equipment clean. She also confirmed that the bedside table was to be cleaned with antiseptic wipes (disinfecting cloths used to prevent the spread of infection) before and after a procedure to prevent the spread of infection. During an interview with the DON and the Regional Director of Operations on 01/31/20 at 4:23 PM, in the presence of the survey team, the DON did not provide the Infection Control Policy. The DON and the Regional Director of Operations had no comment when asked by the surveyor for the ICP Policy. The facility's undated Handwashing/Hand Hygiene policy, indicated that handwashing must be performed before and after direct contact with residents; after contact with blood, body fluids, secretions, mucous membranes, or nonintact skin; and after removing gloves. The procedure for handwashing included, vigorously lather hands with soap and rub them together, creating friction to all surfaces, for 20-30 seconds under a moderate stream of running water, at a comfortable temperature. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. The facility's undated Intermittent Irrigation of Indwelling Urinary Catheter policy indicated to open the sterile irrigation tray and establish sterile field. Place waterproof drape under the catheter. Place sterile basin next to the client's thigh. [NAME] sterile gloves. Cleanse connection site of catheter and drainage bag with antiseptic swab. Disconnect catheter from drainage bag. Keep end of catheter sterile. Cap or position drainage tubing to maintain sterility. Remove the syringe and allow the solution to drain into the basin. Cleanse open end at adapter site with alcohol prep pad and reconnect with end of catheter. NJAC 8:39 19.4 (a)

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation, interview and document review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to ensure items are not beyond safe use by dates, b.) maintain and reheat hot food items in a manner to minimize the potential for food borne illness, c.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was evidenced by the following: On 01/26/20 at 8:24 AM, the surveyor toured the kitchen during the breakfast meal tray line preparation with a cook (Cook #1), who stated they were short a staff person because someone called out. On 01/26/20 at 8:26 AM, [NAME] #1 stopped the tray line, went to the dirty dish area and began cleaning a large blender. [NAME] #1 stated she ran out of the ground food and needed to make more food. At that time, a Speech Therapist (ST #2) entered the kitchen without a head covering and requested a tray from the kitchen staff. The surveyor observed the slicer was observed uncovered and was soiled with food shavings on the base and blade area. [NAME] #1 stated the slicer was not used for the breakfast meal preparation. A Diet Aide (DA #1) stated it was used yesterday and that they did not clean it, but are supposed to. The surveyor observed a large puddle of dirty waster that was adjacent to the tray line. DA #1 stated that a pipe was not properly placed in a drain and it leaked all over the floor. On 01/26/20 at 8:54 AM, the surveyor observed the [NAME] #1 stop the tray line. [NAME] #1 washed hands, put on gloves, removed frozen pancakes from the freezer, and placed them in a pan that was then put into the into the steamer. On 01/26/20 at 8:56 AM, DA #1 left the tray line and went to an uncovered deep pan, located on top of the stove. There was no flame observed. DA #1 proceeded to scoop hot cereal into burgundy bowls and placed a plastic lid on top. He placed the bowls in a pan on the tray line. DA #1 stated he usually put the oatmeal in the steam table to heat it up and that this was okay. During this observation at 8:58 AM, the surveyor interviewed [NAME] #1 regarding the hot cereal that DA #1 scooped into bowls and placed in a pan on the tray line. She stated the cereal was farina (a hot cereal) and the temperature of the farina was checked when it was cooked. Upon surveyor inquiry, [NAME] #1 proceeded to take a thermometer and took the temperature of the farina in the steam table pan locate on top of the stove. The temperature was 98 degrees Fahrenheit (F). She stated the farina should have been 140 degrees (F). She then removed all of the bowls of farina from the tray line and placed them inside of the steamer. she stated since they were uncovered, they needed to be reheated. The cook further stated that it was not okay to reheat foods on the tray line and that was why she put the farina back into the steamer. She further stated the white digital thermometer she used was calibrated and that was the thermometer that she used at 7:30 AM to take the food temperatures. She further stated she did not have a Serve Safe certification (nationally accredited food safety certification); however, our head boss had that and he was called in because of the survey team being in the building. On 01/26/20 at 9:09 AM, the Food Service Director (FSD) entered the kitchen and resumed the tour with the surveyor. The refrigerated walk-in box contained a plastic pan with two packages of wrapped cold cuts, sitting in water. One item was undated and one item had a date of open of 01/14/20 and expiration date of 03/14/20. The FSD stated the item was ham and they were taken out of the freezer and were missing a pull date. He stated he will throw them out right away. The surveyor interviewed the FSD regarding the large puddle on the floor. The FSD stated the floor shouldn't have been left like that. On 01/26/20 at 9:13 AM, a Regional Food Service Director (RFSD #1) joined the tour. A package of shredded cheese was located on a shelf in the walk-in refrigerator and was open to air. The RFSD #1 stated the cheese should be sealed. On 01/31/20 at 9:27 AM, the Chief Operating Officer (COO) stated during interview that the FSD was the only person in the kitchen who was Serve Safe Certified. A review of an undated Labeling and Dating System Protocol revealed that all fresh and frozen foods must be dated with the date it was received into the kitchen, unless it has a purveyor shipping label on it. Opened sliced deli meat has a three day expiration when it is sliced. A review of the Trayline Service Policy, updated January 2019, revealed the food service manager or designee was responsible to assure that all foods needed for meal assembly were present at the appropriate time. All foods would be covered and hot foods would be kept hot (greater than 135 degrees Fahrenheit). A review of an undated Meal Temperature Policy revealed that if hot foods were not greater than or equal to the standards, or cold temperatures were not less than or equal to the standards, respond accordingly. Do not serve food at unacceptable temperatures. Record temperatures for all replacement pans. A review of the Slicer Cleaning Instructions, updated January 2020, revealed the slicer would be cleaned and sanitized after each use. NJAC 8:39 17.2(g)

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• $4,194 in fines. Lower than most New Jersey facilities. Relatively clean record.

Concerns

• Multiple safety concerns identified: 2 life-threatening violation(s). Review inspection reports carefully.
• 45 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• Grade F (9/100). Below average facility with significant concerns.
• 60% turnover. Above average. Higher turnover means staff may not know residents' routines.

Bottom line: Trust Score of 9/100 indicates significant concerns. Thoroughly evaluate alternatives.

Email me this report

About This Facility

What is Aristacare At Cherry Hill's CMS Rating?

CMS assigns ARISTACARE AT CHERRY HILL an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within New Jersey, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Aristacare At Cherry Hill Staffed?

CMS rates ARISTACARE AT CHERRY HILL's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the New Jersey average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Aristacare At Cherry Hill?

State health inspectors documented 45 deficiencies at ARISTACARE AT CHERRY HILL during 2020 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 40 with potential for harm, and 3 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Aristacare At Cherry Hill?

ARISTACARE AT CHERRY HILL is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ARISTACARE, a chain that manages multiple nursing homes. With 140 certified beds and approximately 130 residents (about 93% occupancy), it is a mid-sized facility located in CHERRY HILL, New Jersey.

How Does Aristacare At Cherry Hill Compare to Other New Jersey Nursing Homes?

Compared to the 100 nursing homes in New Jersey, ARISTACARE AT CHERRY HILL's overall rating (1 stars) is below the state average of 3.2, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Aristacare At Cherry Hill?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.

Is Aristacare At Cherry Hill Safe?

Based on CMS inspection data, ARISTACARE AT CHERRY HILL has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in New Jersey. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Aristacare At Cherry Hill Stick Around?

Staff turnover at ARISTACARE AT CHERRY HILL is high. At 60%, the facility is 14 percentage points above the New Jersey average of 46%. Registered Nurse turnover is particularly concerning at 60%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Aristacare At Cherry Hill Ever Fined?

ARISTACARE AT CHERRY HILL has been fined $4,194 across 1 penalty action. This is below the New Jersey average of $33,121. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Aristacare At Cherry Hill on Any Federal Watch List?

ARISTACARE AT CHERRY HILL is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 140
Avg. Residents: 130
Occupancy: 93.3%
Ownership: For profit - Corporation
Chain: ARISTACARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
2 Immediate Jeopardy citations: -24
45 Deficiencies: -10
Fines ($4,194): -2
Final Score: 9/100

Nearby Alternatives

LAUREL MANOR HEALTHCARE AND RE... 5-star UNITED METHODIST COMMUNITIES A... 5-star THE SUBACUTE AT AUTUMN LAKE HE... 5-star

View all in CHERRY HILL →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 315245