Electronically Signed

(1)

F 000 INITIAL COMMENTS F 000

STANDARD SURVEY: 9/17/18 CENSUS: 102

SAMPLE: 24 F 658

SS=D

Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

§483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-

(i) Meet professional standards of quality.

This REQUIREMENT is not met as evidenced by:

F 658 11/1/18

Based on observation, interview, and record review it was determined that the facility failed to communicate with therapy post status (s/p) (after) a resident's fall in a timely manner according to the professional standards of nursing

practice.This deficient practice was identified for 1 of 2 residents reviewed (Resident #92).

The deficient practice was evidenced by the following:

Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states:

"The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care

supportive to or restorative of life and well-being, and executing medical regimens as prescribed by

I. Immediate Correction:

Resident #92 was assessed by an RN and re-evaluated by rehabilitation staff to ensure there were no negative outcomes.

The resident was no longer receiving skilled services related to a return to prior level of functioning. A significant change was completed.

II. Identification of Other Areas:

All residents with incidence of falls will be audited by the DON or designee to ensure the Nursing Communication to Therapy Policy and Procedures were followed. The facility established a fall committee team that meets at least weekly to review and ensure intervention for Physical and Occupational Therapy screens are completed timely. The IDCPT will update and revise any changes in current goals, interventions, treatments in residents person centered care plans accordingly.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE ^{(X6) DATE}

10/08/2018 Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

(2)

F 658 Continued From page 1 F 658 a licensed or otherwise legally authorized

physician or dentist."

Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states:

"The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health

counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist."

On 9/11/18 at 9:31 a.m., the surveyor observed Resident #92 laying on the bed. The resident was alert and oriented and informed the surveyor that he/she had a fall incident a "few months ago" and broke their back.

A review of the resident's Face Sheet (an admission summary), revealed the resident was admitted to the facility on 6/24/11 with diagnoses which included Parkinson's disease and

osteoarthritis.

A review of the resident's personalized care plan revealed the resident had an actual fall on 7/30/18, with an intervention for Physical and Occupational Therapy screens.

The surveyor reviewed the Significant Change Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) dated 8/15/18. The MDS indicated a brief interview for mental status (BIMs) score of 14, which reflected the resident was alert and cognitively intact. The

III. Systematic Changes:

All licensed staff will be re-educated by the Staff Development Coordinator on the Nursing Communication to Therapy Policy/Procedures including the use of the nursing communication form post resident falls. All resident falls will be added to the daily agenda discussed in the daily morning meeting to ensure

communication and the timely completion of NCT forms. The NCT policy and procedure will be given a new line item and emphasized in the licensed nursing staff new hire orientation material.

IV. Quality Assurance Monitoring:

The DON or designee will conduct audits of the fall incident/ accident reports weekly over 4 weeks, then monthly to prevent reoccurrence and maintain compliance.

The results of the audits will be presented to Quality Assurance Committee quarterly for review and recommendations.

(3)

F 658 Continued From page 2 F 658 Significant Change MDS indicated Resident #92

had a fall incident with a major injury.

On 9/13/18 at 12:09 p.m., the Director of Nursing (DON) provided a copy of the 7/30/18 Fall Incident/Accident Report packet which reflected the resident had a fall incident with fractures to the right 7th and 8th ribs.

The 7/30/18 Fall Incident/Accident Report packet included a Nursing Communication to Therapy (NCT) form dated 7/30/18 and signed by a Licensed Practical Nurse (LPN). There was no documented evidence that the 7/30/18 NCT request for Rehab screen was acted upon by the Rehab Department.

Further review of the 7/30/18 Fall

Incident/Accident Report packet revealed there was a second NCT form dated 8/8/18 and signed by an LPN. The reason for the second therapy request was due to the 7/30/18 fall. Review of the 8/8/18 NCT form reflected the resident was evaluated by Physical Therapy and was deemed a candidate for Physical Therapy. Further review of the NCT form revealed it was signed by the Physical Therapist and dated 8/9/18.

On 9/14/18 at 10:02 a.m., the surveyor interviewed the Director of Rehab (DOR) who informed the surveyor that as the standard of practice, whenever a resident had a fall incident, Rehab had to screen the resident the same day.

She further stated, that she was not sure why Resident #92 was not screened on 7/30/18 when there was an NCT form initiated.

On that same day and time, the DOR informed the surveyor that it wasn't until 8/9/18 that the

(4)

F 658 Continued From page 3 F 658 Physical Therapist screened and evaluated the

resident. The DOR stated she would get back to the surveyor with an explanation as to why the resident was screened a week after the 7/30/18 fall incident and not on the same day.

On 9/14/18 at 10:46 a.m., the Licensed Practical Nurse/Unit Manager (LPN/UM) informed the surveyor that he was not sure why the 7/30/18 NCT request for a Rehab screen was not done.

On that same day and time, the DOR in the presence of the LPN/UM, stated the Rehab Department did not receive the 7/30/18 NCT request for a Rehab screen s/p fall. She further stated that the only NCT request for a screen that Rehab Department received was on 8/8/18.

On 9/14/18 at 1:20 p.m., the surveyor informed the Administrator and the DON of the above concern.

On 9/17/18 at 11:31 a.m., the Vice President/Clinical Operations informed the surveyors that upon investigation, the 7/30/18 NCT request for Rehab screen s/p fall for Resident #92 was not done because "it fell through the cracks."

On that same day at 12:29 p.m., the surveyor asked the DON for a copy of the Nursing

Communication to Therapy Policy and Procedure.

On 9/17/18 at 1:18 p.m., the DON informed the surveyor that there was no Policy and Procedure with regard to Nursing Communication to Therapy.

NJAC 8:39-11.2 (b)

(5)

F 677 SS=D

ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

F 677 11/1/18

Based on observation, interview, record and policy review, it was determined that the facility failed to provide nail and oral care to a resident who was dependent on the staff for hygiene for 1 of 2 residents (Resident #63) reviewed for care.

This deficient practice was evidenced by the following:

On 9/11/18 at 10:15 a.m., the surveyor observed Resident #63 awake in bed, positioned on their back. The resident responded appropriately to the surveyor when spoken to. The resident's lips were dry and cracked, and their fingernails on both hands were long, jagged and extended beyond the fingertips.The resident kept their left hand in a fisted position and their nails rested against the palm of the left hand.

The surveyor reviewed the Medical Record which reflected Resident #63 was admitted to the facility with diagnoses which included: Cerebral Palsy, Chronic Obstructive Pulmonary Disease and Schizoaffective disorder. The 7/21/18 quarterly Minimum Data Set (MDS), an assessment tool, indicated the resident had moderate cognitive impairment and was totally dependent on staff for personal hygiene.

On 9/11/18 at 11:50 a.m., with the resident's

The CNA involved is no longer with the facility. All residents dependent of staff for personal care including nail care and oral hygiene will be audited to ensure that residents receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

All residents dependent of staff for personal care including nail care and oral hygiene will be audited to ensure that residents receive the necessary services to maintain good nutrition, grooming, personal, and oral hygiene. Audit sheets will be kept on file for validation and reference.

All licensed staff will be re-educated by the Staff Development Coordinator or designee on grooming, personal, and oral hygiene.

Infection Control Nurse or ADON will conduct weekly grooming, personal and oral hygiene audits over 3 weeks, then monthly. Results of audits will be presented to the QAPI committee

(6)

F 677 Continued From page 5 F 677 permission , the surveyor observed the Certified

Nursing Assistant (CNA) provide a bed bath to resident #63. The CNA did not clean, clip or file the resident's nails, nor did she provide oral care.

After providing perineal care, the CNA applied Vitamin A and D ointment to the resident's lips without changing her gloves. The surveyor observed that the CNA did not provide oral care and/or, nail care.

On 9/11/18 at 12:20 p.m., the surveyor interviewed the CNA. The surveyor asked the CNA why she did not change her soiled gloves after she provided perineal care. The CNA stated,

" I'm sorry, I should have." The surveyor asked the CNA, why she didn't give Resident #63 oral hygiene care or nail care. The CNA stated that the resident didn't have a toothbrush or swabs in their drawer, and that she should have cleaned and trimmed the resident's nails. At that same time, the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN stated the CNA should have provided nail care on either bath and/or, shower days and as needed. Both the CNA and the LPN confirmed that nail care had not been done for awhile. The CNA stated she would clip and clean the resident's nails after lunch.

On 9/14/18 at 12:00 p.m., the surveyor interviewed Resident #63. The resident stated that their nails, "felt so much better" as they smiled at the surveyor.

On 9/14/18 at 1:30 p.m., the survey team met with the Administrator and Director of Nursing (DON) and discussed the above observations and concerns. The DON stated she would be inservicing all staff on ADL [activities of daily

quarterly for further review and

recommendations. Any negative findings will immediately be reported to the DON for follow up.

(7)

F 677 Continued From page 6 F 677 living] care.

Review of the facility's undated policy titled, "Nail Care" showed that staff should perform hand hygiene, carefully brush nails with nailbrush to remove dirt or clean with orange stick, and trim and file nails for smoothness as needed.

Review of the facility's undated policy titled, "Oral Care" showed that all residents will receive appropriate oral care, including denture care if applicable, twice each day or more frequently if needed. In addition, if the resident is unable to perform oral self care, staff should provide privacy, wash hands, don gloves and personal protective equipment, place emesis basin in front of resident, and proceed to brush teeth.

NJAC 8:39-27.2 F 755

SS=E

Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

§483.45 Pharmacy Services

The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in

§483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility

F 755 11/1/18

(8)

F 755 Continued From page 7 F 755 must employ or obtain the services of a licensed

pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate

reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Based on observation, interview, and record review it was determined that the facility failed to reconcile controlled narcotics stored in the narcotic back up supply box (Pyxis) located within the first-floor medication storage room since June, 2018.

This deficient practice was identified for 1 of 1 medication storage room inspected and was evidenced by the following:

On 9/12/18 at 9:09 a.m., the Licensed Practical Nurse/Unit Manager (LPN/UM) informed the surveyor that the facility utilized the Pyxis for controlled and emergency medications for all residents.

On that same day and time, the LPN/UM stated that the facility performed End of Shift Count of controlled medications(controlled medication reconciliation in the Pyxis) on a daily basis. The LPN/UM stated that this is done once a day on

Reconciliation of all controlled

medications in the automatic medication (Pyxis) dispensing unit was preformed and no discrepancies were noted. The automatic medication dispensing unit narcotic policy and procedure was reviewed and revised to establish an in place system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The narcotic counts will continue to be reconciled daily between two nurses. When reconciliation has been finished, the end of shift digital report will be printed and signed, then placed in the medication dispensing record binder. The binder will be located at the first floor nurses station.

Reconciliation of all controlled

(9)

F 755 Continued From page 8 F 755 the 3-11 shift with the nursing Supervisor and

another nurse. He further stated, that the controlled narcotic reconciliation report was printed on a daily basis and placed in a binder as the standard of practice.

At that time, the LPN/UM was unable to provide the binder for printed daily controlled narcotic reconciliation to show that it was done routinely.

The LPN/UM stated that he would get back to the surveyor with further information.

On 9/12/18 at 10:15 a.m., the LPN/UM informed the surveyor that upon investigation and

coordination with the Director of Nursing (DON), it was revealed, that the controlled narcotic

reconciliation accountability had not been done from June 2018 through September 2018, until the surveyor's inquiry.

At that same day and time, the LPN/UM stated,

"what was supposed to happen, didn't happen for the months of June 2018, July 2018, August 2018 and September 2018." He further stated that,

"the 3-11 supervisor failed to do what she had to do and it doesn't look good at all."

On 9/12/18 at 10:28 a.m., the LPN/UM and an RN in the presence of the surveyor, counted the controlled medications in the Pyxis. There were no discrepancies.

On 9/12/18 at 11:12 a.m., the surveyor attempted to conduct a phone interview with the 3-11 Registered Nurse (RN) nursing supervisor but she was unavailable.

On 9/12/18 at 11:15 a.m., the surveyor interviewed the Pharmacy Consultant. The

medications in the automatic medication dispensing unit was preformed and no discrepancies were noted.

All nursing unit managers, nursing supervisors, and the ADON were in-serviced by the DON on automatic medication dispensing unit policy and procedure revision and to ensure strict adherence to the protocol. The Pharmacy Consultant will continue to conduct monthly audits for accountability and sustained compliance with 483.45(a)(b) (1)-(3). Findings will be reported to the DON for follow up and any discrepancies will have immediate resolution.

The DON or designee will audit the automatic medication (Pyxis) dispensing unit daily over 4 weeks, then monthly to prevent reoccurrence and maintain compliance. The results of the audits will be presented to QAPI Committee quarterly for review and

recommendations. The DON will submit findings to the QAPI Committee quarterly on an ongoing basis.

(10)

F 755 Continued From page 9 F 755 Pharmacy Consultant informed the surveyors that

a daily printed reconciliation for the Pyxis controlled narcotics was kept in a binder in the DON's office. The Pharmacy Consultant further stated a history of the Pyxis report indicated that a reconciliation was being done on a daily basis.

In addition, she stated that she personally checked the Pyxis at least once a month, which, was part of her responsibility as a Pharmacy Consultant.

On that same day at 11:28 a.m., the DON informed the Pharmacy Consultant in the presence of the surveyor, that there was no printed daily reconciliation for the Pyxis controlled narcotics.

At that time, the Pharmacy Consultant in the presence of the DON and LPN/UM, attempted to show the surveyor the history report of daily reconciliation count for the controlled narcotics in the Pyxis. The Pharmacy Consultant was unable to locate the report needed, and was unable to provide documented evidence the daily controlled narcotic reconciliation was being performed.

On that same day and time, the LPN/UM informed the Pharmacy Consultant that the daily controlled narcotic reconciliation was not being done from June 2018 through September 2018.

On 9/12/18 at 1:35 p.m., the Administrator informed the surveyors in the presence of the DON that staff failed to follow the facility's Policy regarding the controlled narcotic reconciliation daily count for the Pyxis.

A review of the Automated Med Dispense Backup Narcotic Policy and Procedure dated 6/2017,

(11)

F 755 Continued From page 10 F 755 provided by the DON, indicated the "Narcotic

count will be reconciled every day between the 7-3 Unit Manager/Supervisor and the 3-11 Supervisor."

NJAC 8:39-29.4 (k) F 758

SS=D

Free from Unnec Psychotropic Meds/PRN Use CFR(s): 483.45(c)(3)(e)(1)-(5)

§483.45(e) Psychotropic Drugs.

§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:

(i) Anti-psychotic;

(ii) Anti-depressant;

(iii) Anti-anxiety; and (iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a

F 758 11/1/18

(12)

F 758 Continued From page 11 F 758 diagnosed specific condition that is documented

in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in

§483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Based on observation, interview, and record review it was determined that the facility failed to provide supportive rationale and adequate documentation to support the continued use of Risperdal, an anti-psychotic medication. This deficient practice was identified for 1 of 5 residents (Resident #47) reviewed for antipsychotic use.

The deficient practice was evidenced by the following:

On 9/14/18 at 9:12 a.m., the surveyor observed Resident #47 seated in a wheelchair in their bedroom.

A review of the resident's Face Sheet (an admission summary), revealed the resident was admitted to the facility on 7/2/18 with diagnoses which included dementia with behavioral

Resident #47 was re-assessed and re-evaluated by the Primary Physician and there were no negative outcomes noted.

Resident #47 was accessed and evaluated by a Psychiatrist on 9/15/18 with recommendations for GDR that were carried out. The Administrator and DON immediately re-in-serviced the residents primary physician on facility policy as it relates to F758.

All residents receiving psychoactive medications will be audited by the DON and Pharmacy Consultant to ensure the medical records provide supportive rationale and adequate documentation regarding the following:

(13)

F 758 Continued From page 12 F 758 disturbances and anxiety.

A review of the resident's personalized care plan, dated 7/2/18, revealed the resident was care planned for the use of psychoactive medication.

Care plan interventions dated 7/19/18 indicated to a) monitor for effectiveness in treating targeted behavioral symptoms with a monthly

psychoactive summary, b) monthly medical record medication review to be completed by the consultant pharmacist, with concerns addressed by nursing and/or physician, and c) Psychiatrist consult and follow up as ordered.

The surveyor reviewed the Comprehensive Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) dated 7/9/18, reflected the resident's cognition was moderately impaired. The MDS further identified that Resident #47 had received an antipsychotic medication for 7 days on a routine basis.

A review of the Physician's Progress Notes from 7/6/18 through 9/13/18 failed to reveal

documented evidence of justification for the continued use of antipsychotic medication and/or, any behaviors exhibited by the resident.

On 9/14/18 at 11:01 a.m., the Licensed Practical Nurse/Unit Manager (LPN/UM) informed the surveyor that Resident #47 was alert but cognitively impaired. He stated the resident had no behavioral problems and was on a toileting program. He further revealed, the resident was on Risperdal 0.5 milligram (mg) tablet (tab) at bedtime (hs), an antipsychotic medication, since admission on 7/2/18.

On that same day and time, the LPN/UM stated

1. Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.

2. Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

3. Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a

diagnosed specific condition that is documented in the clinical record; and 4. PRN orders for psychotropic drugs are limited to 14 days. Except as provided in

¿483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

5. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or

prescribing practitioner evaluates the resident for the appropriateness of that medication.

The DON/ADON will re-in-service all licensed staff on appropriate use of

(14)

F 758 Continued From page 13 F 758 the facility did not utilize a behavior monitoring

form. He added, that it was the facility's policy and procedure to document only when there was a behavior noted.

At that time, the LPN/UM informed the surveyor that there was no behavior exhibited by the resident since the resident's 7/2/18 admission. He stated there was no monthly summary

documentation for use of antipsychotic medication for the resident.

The LPN/UM further stated, the resident was not seen by the Psychiatrist to evaluate the use of antipsychotic medication. He indicated there was no documented evidence the Medical Doctor (MD) documented the justification for the continued use of antipsychotic medication.

On 9/14/18 at 11:41 a.m., the Registered Nurse (RN) told the surveyor, that the resident was alert with cognitive impairment and on antipsychotic medication with no targeted behaviors. She further stated, the resident had no behaviors exhibited which was why there were no targeted behaviors identified.

On that same day and time, the RN stated that nursing only monitors behaviors for the first 14 days of admission according to facility policy.

On 9/14/18 at 12:08 p.m., the Director of Nursing (DON) informed the surveyor the facility was not utilizing a Behavior Monitoring form, and that nursing staff does, "charting by exception." She further stated, she would get back to the surveyor regarding the Psychoactive Medications Policy.

On 9/14/18 at 12:18 p.m., the Pharmacy

psychoactive medications, monitoring, and documentation of behaviors in the clinical record.

The facility established a Psychoactive Committee that meets at least monthly, including the Psychiatrist, to discuss residents on psychoactive medications, recommendations were followed, and to ensure regulatory compliance.

The DON and Pharmacy Consultant will conduct audits of residents receiving psychoactive medications monthly. The results of the audits will be presented to Quality Assurance Performance Improvement Committee quarterly for review and recommendations to ensure compliance.

(15)

F 758 Continued From page 14 F 758 Consultant informed the surveyor that she

indicated in her 7/26/18 recommendations for a) Psychiatric follow up within two weeks of admission, b) monitor behavior as per facility policy, and c) place target behavior on the behavioral note and address quantitatively monthly. There was no documented evidence the 7/26/18 recommendations were followed.

On 9/14/18 at 1:20 p.m., the DON informed the surveyors, in the presence of the Administrator, that Resident #47 had no behaviors and no targeted behaviors documented. She further stated there was no Monthly Summary and/or, documented evidence the physician had documented the justification for continued use of the antipsychotic medication.

A review of the facility's Psychoactive Medication Policy provided by the DON, with a revision date of March 7, 2018, reflected, "It is the policy of this facility to identify and monitor target behaviors, potential side effects, potential trigger factors and the effectiveness of non-drug interventions for all residents prescribed psychoactive medication,"

and, "Psychiatric Consult is requested and should be completed within 2 weeks of admission for all new admits/re-admits coming in with

psychopharmacologic medications. Target behaviors are added to the sheet as indicated when the initial Psychiatric Consult is completed."

NJAC 8:39-29.3 (a) F 800

SS=D

Provided Diet Meets Needs of Each Resident CFR(s): 483.60

§483.60 Food and nutrition services.

The facility must provide each resident with a

F 800 11/1/18

(16)

F 800 Continued From page 15 F 800 nourishing, palatable, well-balanced diet that

meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on observation, interview, and record review it was determined the facility failed to provide meals which met the resident's personal preferences and followed the resident's tray ticket information. This deficient practice was identified for 1 of 24 residents reviewed, Resident # 71, and was evidenced by the following:

On 9/12/18 at 12:20 p.m., the surveyor observed Resident #71 in their room seated in a Geri chair being fed by a CNA. The resident stated that she did not like the food being served and wanted oatmeal with brown sugar and heavy cream. The CNA told the resident that she already had oatmeal for breakfast and continued encouraging the resident to eat lunch without offering to get the oatmeal per residents request.

Review of the medical record revealed Resident

#71 was admitted with Diagnoses which included Glaucoma and Schizophrenia. Resident #71 had a physician's order for a chopped diet and Gastrostomy Bolus feedings. Review of the Minimum Data Set (MDS), an assessment tool, reflected Resident #71 had moderate cognitive impairment and was dependent on staff for eating.

On 9/14/18 at 12:10 p.m., the surveyor observed the resident in the Dining Room being fed by the CNA. The resident stated they did not want the food they were being fed but wanted oatmeal with brown sugar and heavy cream. The CNA

continued to encourage the resident to eat the

Resident #71 immediately had food preferences and Meal Identification Card reviewed by the Registered Dietitian and FSD. The resident had a medical order for super cereal (oatmeal with brown sugar and heavy cream). The kitchen staff were counseled and re-educated on following residents Meal Identification Cards to ensure accuracy of the trays. The Administrator counseled the FSD on following the Meal Identification and Preference Cards policy and procedures.

The CNA was re-educated on importance of resident preferences and the facilities

Food Preference Policy and Procedures.

The Registered Dietitian and FSD audited, reviewed and updated food preferences for all residents to ensure each resident has a nourishing, palatable,

well-balanced, diet that meets his/her daily nutritional and dietary needs, taking into account changing preferences.

The Staff Educator or designee will re-educate nursing staff on Food Preference Policy and Procedure and Meal Identification and Preference Cards.

Resident food preferences will be added to the existing binders containing resident

(17)

F 800 Continued From page 16 F 800 chopped diet.

At the same time, the surveyor asked the Food Service Director(FSD) why the resident was not given their preference of oatmeal. The FSD stated that she would make the superceral (oatmeal with brown sugar and heavy cream) and further stated, " it would take awhile because it wasn't instant." The surveyor asked the Dietician and FSD why this preference was not being provided to the resident. No response was provided.

NJAC 8:39-17.4 (a)

diets. The Resident Care Representative will continue rounds up to 5 times weekly to ensure resident preferences are identified and communicated to FSD and RD. The FSD or designee will ensure meal cards are followed during meal service to ensure the correct diet is being served and food preference's are being honored.

The FSD or designee will check meal trays prior to delivery to ensure accuracy and that preferences are honored. FSD or designee will audit 5 randomly selected trays weekly over 4 weeks, then monthly over 3 months. Any negative findings will be reported to the Administrator. Results of audits will be submitted to the QAPI Committee quarterly for review and further recommendations.

F 804 SS=E

Nutritive Value/Appear, Palatable/Prefer Temp CFR(s): 483.60(d)(1)(2)

§483.60(d) Food and drink

Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

F 804 11/1/18

Based on observation and interview and record review, it was determined that the facility failed to ensure the safe and appetizing temperatures of

Food truck trolley insulated coverings were immediately ordered for all delivery

(18)

F 804 Continued From page 17 F 804 food and drink were appropriately served to the

residents. This deficient practice was identified by 8 of 8 residents during the 9/13/18 Resident Council group meeting, and confirmed during the lunch time meal service on 9/14/18 on 2 of 2 nursing units tested for food temperatures (first and second floors), and was evidenced by the following:

On 9/13/18 at 10:30 a.m., the surveyor conducted a group meeting with eight residents who were part of the facility's resident council. All eight residents indicated the lunch meals were always late and they had to wait at least 30 minutes before being served. All eight residents stated he food is "terrible, tasteless and cold. Trays sit in the hallway for 30 minutes or longer before being passed out."

On 9/14/18 at 11:30 a.m., the surveyor observed the Food Services Director (FSD) take tray line temperatures using a calibrated thermometer.

The temperatures were as follows;

Pureed green vegetables: 150 degrees Fahrenheit (F)

Pureed meat: 142 degrees F: The FSD asked the cook to place the pureed meat back into the oven.

Carrots: 165 degrees F

Fried chicken sticks: 145 degrees F Mashed potatoes: 170 degrees F Fish/crab cakes: 170 degrees F Roasted potatoes: 160 degrees F Milk from the milk box: 39 degrees F

The surveyor asked the FSD for the facility's temperature log for the 9/14/18 lunch service which according to the cook started at 10:50 a.m.

carts. A time study was conducted on tray delivery times and locations. Nursing units will be notified via overhead page and/or calls to the unit nurses when food trucks are delivered. RD will evaluate all menu items for proper seasoning to ensure palatability of food. Any items identified, RD will adjust recipes accordingly. FSD was counseled by Administrator for failing to follow facility policy related to food temperatures.

RD and FSD immediately checked food temps at the next meal service. FSD will hold a monthly resident food service planning meeting to identify improvements and areas of resident concern.

The Food Temperature Policy has been revised to include the recording of temperatures after delivery to unit and prior to meal service completed by the kitchen staff. Nursing units will be notified via overhead page and/or calls to the unit nurses when food trucks are delivered.

Food temperatures will be recorded at three different times daily, prior to portioning to trays on kitchen steam table, after delivery to unit and prior to resident meal service, and last tray(test tray).

RD and FSD developed an audit tool to randomly monitor the checking and recording of food temperatures when leaving the kitchen, prior to service to residents on units and last tray. Audits will

(19)

F 804 Continued From page 18 F 804 The FSD said they did not record "today's" lunch

temperatures.

The surveyor observed the food trucks were open carts which did not have an enclosure. The FSD said "hotplates" are utilized to keep the food warm.

On 9/14/18 at 11:56 a.m., two surveyors, using calibrated thermometers, obtained the following food temperatures during the noon lunch meal on the first floor:

Crab cake: 120 degrees F Pasta: 105 degrees F Sliced Carrots: 100 degrees F Apricots: 60 degrees F

Mandarin oranges: 60 degrees F Coffee: 139 degrees F

Milk: 50 degrees F

On 9/14/18 at 12:24 p.m., the surveyor, in the presence of a Certified Nursing Assistant (CNA), obtained the following food temperatures during the noon lunch meal on the second floor:

Crab cake: 113.8 degrees F Sliced Carrots: 104.6 degrees F Potatoes: 100.1 degrees F Soup: 138 degrees F Fruit: 62 degrees F

On 9/14/18 at 12:30 p.m., the surveyors taste tested lunch test trays of food on the menu for the resident's lunch. One entrée consisted of crab cakes, sliced carrots, and roasted potatoes. The carrots lacked flavor and the green pureed vegetable was tasteless.

be conducted daily by dietary staff, FSD or designee will verify daily that checks are being done,and RD or designee will monitor temps on units weekly. RD developed an audit tool to check for resident satisfaction. Resident Care Representative or designee will complete resident satisfaction audit. Results will be presented to QAPI committee on a quarterly basis for review and further recommendations.

(20)

F 804 Continued From page 19 F 804 On 9/14/18 at 1:20 p.m., the survey team met

with the Administrator and Director of Nursing and discussed the above observations. The

Administrator stated the facility was looking into getting enclosed food trucks.

Review of the facility's undated, "Tray Line Temperature Monitoring Policy" indicated the facility will provide foods that are the proper temperature for palatability and resident safety based on food safety guidelines.

NJAC 8:39-17.4 (a) F 812

SS=F

Food Procurement,Store/Prepare/Serve-Sanitary CFR(s): 483.60(i)(1)(2)

§483.60(i) Food safety requirements.

The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.

(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.

(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.

(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

F 812 11/1/18

(21)

F 812 Continued From page 20 F 812 Based on observation, interview and record

review it was determined that the facility failed to a) store potentially hazardous foods in a manner to prevent foodborne illness, b) ensure the three-compartment sink was accurately set-up to prevent microbial growth, and c) follow

appropriate hand hygiene protocol in a manner to prevent contamination.

On 09/11/18 at 9:00 a.m., in the presence of the Food Service Director (FSD), the surveyor observed the following:

1. The refrigerator inside the dry storage room had an open and undated package of parmesan cheese covered in saran wrap.

2. There was one box of Neapolitan ice cream (quart size) open and undated inside freezer #2 in the dry storage room.

3. In the "everyday" refrigerator in the kitchen;

there was a half block of yellow cheese which was open and undated.

The FSD stated she did not know when the above food items were opened, and that they should have been dated when opened. She discarded the above items in the presence of the surveyor.

4. The FSD asked a dietary aide (DA) to set up the three-compartment sink. The DA told the surveyor she had to follow the instructions posted on the wall because she didn't have it memorized.

The 2 different types of cheese and ice cream were immediately discarded. The 3 compartment sink was drained, refilled, and tested to ensure proper levels were attained. The female DA was educated on proper hand washing technique. The kitchen staff including cooks were in serviced on the updated Food Safety and Sanitation Policy. The Administrator counseled FSD for failing to follow food safety requirements according to facility policy and procedure.

Food storage areas were audited by the FSD to ensure foods were stored in a proper manner and dated if opened. All dietary staff we re-in-serviced by RD or designee on the 3 compartment sink, hand washing, food safety and sanitation, and hair restraints policy and procedure with return demonstration.

All dietary staff we re-in-serviced by RD or designee on the 3 compartment sink, hand washing, food safety and sanitation, and hair restraints policy and procedure with return demonstration. The dietary monthly staff departmental in-services were modified by FSD to include Tag 0812. Documentation of education will be kept for validation and reference.

The FSD will review with the administrator monthly over the next 3 months, then quarterly to review departmental educations and to review regulatory

(22)

F 812 Continued From page 21 F 812 On 9/11/18 at 9:24 a.m., the DA tested the

sanitizer section of the three-compartment sink utilizing a Quat (quaternary ammonium) test kit (measures the concentration level of the sanitizer). The surveyor observed the DA dip the test strip into and immediately out of the water.

She did not hold the test strip for 10 seconds.

When the DA showed the surveyor the test strip, she did not know what it indicated. The test strip was a rusty orange color which indicated 100 parts per million (indicated not enough sanitizer).

At that same time, the FSD intervened and the DA retested the water and held the test strip for 10 seconds. When the DA showed the surveyor the test strip a second time; it was a very dark green color which indicated the sanitizer was over 400 parts per million (indicated too much

sanitizer). The DA could not speak to what the colors on the quat test kit indicated. The DA said she was not the usual dishwasher.

At that same time, the FSD said, "we don't keep a log of the PPM's (parts per million). We check with the strip but don't record it."

5. At 10:10 a.m., the surveyor observed a male dietary aide attempting to replace the soap bottle inside the soap dispenser near the handwashing sink. At that same time, a female DA took the bottle of soap; applied soap to her hands then walked over to the sink near the cooking area to wet her hands then walked back over to the handwashing sink to wash her hands. The female DA said, "I was only wetting my hands."

On 9/12/18 at 1:30 p.m., the surveyor discussed the kitchen observations with the Administrator and Director of Nursing.

compliance.

The FSD or designee will conduct random audits weekly over 4 weeks, then monthly to ensure compliance. The results of the audits will be presented to Quality Assurance Performance Improvement Committee quarterly for review and recommendations.

(23)

F 812 Continued From page 22 F 812

On 9/14/18 at 10:35 a.m., the surveyor observed two cooks in the cooking area without a beard net.

Cook #1 was behind the stove making grilled cheese sandwiches. When the surveyor asked him if he should be wearing a beard net in the cooking area he tugged on his beard and said, "I usually wear one. Yes, I should have one on."

In the same cooking area, the surveyor observed Cook #2 making sandwiches. He said, "it just fell off." Then he retracted his statement and said he didn't think his facial hair was long enough for a beard restraint.

Review of the facility's undated policy titled, "Food Storage" indicated that "all foods should be covered, labeled and dated and leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated."

Review of the facility's undated, "Food Safety and Sanitation" policy provided by the FSD on 9/14/18 at 12:10 p.m., specified "all staff are required to have their hair styled so that it does not touch the collar, and to wear clean aprons, clothes and shoes. Hair restraints are required and should cover all hair on the head." The policy did not address the use of bread restraints in the kitchen and/or cook areas.

On 9/14/18 at 1:20 p.m., the surveyor discussed the kitchen observations with the Administrator and Director of Nursing, who acknowledged the findings reflected the kitchen staff were not following the appropriate storage and sanitary protocols.

(24)

F 812 Continued From page 23 F 812

NJAC 8:39-17.2(g) F 814

SS=D

Dispose Garbage and Refuse Properly CFR(s): 483.60(i)(4)

§483.60(i)(4)- Dispose of garbage and refuse properly.

F 814 11/1/18

Based on observation, interview and record review it was determined the facility failed to maintain the dumpster area in a sanitary manner in order to avoid pests.

On 9/11/18 at 9:35 a.m., in the presence of a dietary aide, the surveyor observed that the lids of two dumpsters were open. In addition, there was debris which consisted of empty food wrappers, empty plastic bottles, two disposable plastic gloves, and various size plastic cups. There were two large cardboard boxes full of books on the ground next to the cardboard dumpster.

The Food Service Director (FSD) confirmed the surveyor's observation and closed the lid to one of the dumpsters. The FSD was unable to close the second lid as it was obstructed by debris. She acknowledged that the area should be clean and free of any debris and the lids to the dumpsters should be closed. The FSD further stated, "we are supposed to split between housekeeping."

On 9/14/18 at 8:45 a.m., the surveyor observed a housekeeping staff member in the parking lot

On 9/11/18 the debris which consisted of empty food wrappers, empty plastic bottles, two disposable plastic gloves, and various size plastic cups were placed back into the dumpster. The dumpster lids were immediately closed. The

Housekeeping and Dietary Directors were re-educated by the Administrator on the facility Trash Removal policy and procedures. Exterior facility rounds were completed by the Safety Committee.

Random audits will be conducted by the Housekeeping Director weekly to ensure the dumpster lids are closed, area is clear of debris, and to maintain the dumpster area in a sanitary manner. A copy of the audits will be documented and kept on file for reference and validation.

All Dietary and Housekeeping staff will be re-inserviced by department directors on procedures to ensure that the area will be kept clean and the dumpster lids kept closed. Annual in-service education will be

(25)

F 814 Continued From page 24 F 814 near the dumpster area sweeping.

On 9/14/18 at 9:30 a.m., the Maintenance Director said the dumpster area was cleaned by housekeeping daily and the dumpster was emptied three times a week. She further stated, that Housekeeping oversees the dumpster area.

The Maintenance Director acknowledged the area should be kept clean and the dumpster lids kept closed.

On 9/12/18 at 1:30 p.m., the surveyor discussed the above concerns with the Administrator and Director of Nursing.

There was no additional information provided.

Review of the facility's undated, "Trash Removal Policy" specified that "approximately 11 AM post vendor pick up, the director of housekeeping or designee will round the exterior of the building including the outside metal trash container. Any debris that is on the ground will be place back in the appropriate container for next pick up.

Exterior rounds will be not less than tree times weekly. Trash removal is three times weekly or as needed."

NJAC 8:39-17.2(g)

conducted in both departments to ensure issue will not reoccur. A copy of the audits will be documented and kept on file for reference and validation.

The Housekeeping Director or designee will conduct audit 5 times weekly for 1 month, 3 times weekly for following month, then weekly on an ongoing basis.

Any negative findings will be immediately reported to the Administrator. Results of audits will be presented to Quality Assurance Committee quarterly for review and recommendations.

F 880 SS=D

Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

§483.80 Infection Control

The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and

comfortable environment and to help prevent the development and transmission of communicable

F 880 11/1/18

(26)

F 880 Continued From page 25 F 880 diseases and infections.

§483.80(a) Infection prevention and control program.

The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual

arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:

(i) A system of surveillance designed to identify possible communicable diseases or

infections before they can spread to other persons in the facility;

(ii) When and to whom possible incidents of communicable disease or infections should be reported;

(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;

(iv)When and how isolation should be used for a resident; including but not limited to:

(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and

(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.

(v) The circumstances under which the facility

(27)

F 880 Continued From page 26 F 880 must prohibit employees with a communicable

disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and

(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.

Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.

The facility will conduct an annual review of its IPCP and update their program, as necessary.

Based on observation, interview, record review and policy review, it was determined that the facility failed to maintain acceptable infection control practices for oral care for 1 of 21 residents reviewed (Resident #63); and, for storage of urinary catheter bags for 1 of 1 residents reviewed (Resident # 56).

1. On 9/11/18 at 10:15 a.m., the surveyor observed Resident #63 awake in bed positioned on their back. The resident responded

appropriately to the surveyor when spoken to.

The resident's lips were dry and cracked and their fingernails on both hands were long, jagged and extended beyond the fingertips. The resident

Resident #63 nails were cut, filed, and trimmed at the time of observation and discovery. Resident #56 supplies were discarded and replaced with a new Foley catheter and leg bag. The CNA involved in caring for resident #63 and #56 is no longer an employee of the facility. The Indwelling Foley Catheter Maintenance policy and procedure was revised to include daily disposal.

All residents dependent on staff for personal care were audited to ensure ADL's are provided in accordance with accepted standards of practice. All residents with urinary catheters and leg

(28)

F 880 Continued From page 27 F 880 kept their left hand in a fisted position and their

nails rested against the palm of the left hand.

The surveyor reviewed the Medical Record which reflected Resident #63 was admitted to the facility with diagnoses which included: Cerebral Palsy, Chronic Obstructive Pulmonary Disease and Schizoaffective disorder.

Review of the 7/21/18 quarterly Minimum Data Set (MDS), an assessment tool, indicated the resident had moderate cognitive impairment and was totally dependent on staff for personal hygiene.

On 9/11/18 at 11:50 a.m., with the resident's permission , the surveyor observed the Certified Nursing Assistant (CNA) provide a bed bath to resident #63. The CNA did not clean, clip or file the resident's nails, nor did she provide oral care.

After providing perineal care the CNA applied Vitamin A and D ointment to the resident's lips without changing her gloves. The surveyor observed that the CNA did not provide oral care or nail care.

On 9/11/18 at 12:20 p.m., during an interview, the surveyor asked the CNA why she hadn't changed her soiled gloves after she provided perineal care. The CNA stated, " I'm sorry, I should have."

The surveyor asked the CNA why she had not given the resident oral care or nail care. The CNA stated that the resident didn't have a toothbrush or swabs in their drawer and that she should have cleaned and trimmed Resident #63's nails. During an interview with the Licensed Practical Nurse (LPN), the LPN stated the CNA should have provided nail care on either bath or shower days and, as needed. The CNA and the

bags were audited to ensure nursing staff are adhering to revised indwelling catheter. Nursing Unit

Managers/Supervisors will conduct random observation for provisions of ADL care such as nail care and oral care.

All nursing staff will be educated by the Staff Development Coordinator or designee on Foley Catheter use, management, maintenance, standard precautions, and the revised Indwelling Foley Catheter Maintenance policy and procedure. All nursing staff will be re-educated on the facilities Infection Prevention and Control Program including oral and nail care.

Infection Control Nurse or ADON will conduct weekly audits over 3 weeks, then monthly. Results of audits will be presented to the QAPI committee quarterly for further review and

recommendations. Any negative findings will immediately be reported to the DON for follow up.

(29)

F 880 Continued From page 28 F 880 LPN stated nail care had not been done for

awhile. The CNA stated she would clip and clean the resident's nails after lunch.

On 9/14/18 at 12:00 p.m., the surveyor interviewed Resident #63 who stated that their nails felt so much better and they smiled at the surveyor.

Review of the facility's undated policy titled, "Nail Care" showed that staff should perform hand hygiene, carefully brush nails with nailbrush to remove dirt or clean with orange stick and trim and file nails for smoothness as needed.

Review of the facility's undated policy titled, "Oral Care" showed that all residents will receive appropriate oral care, including denture care if applicable twice each day or more frequently, if needed. If the resident is unable to perform oral selfcare, staff should provide privacy, wash hands, don gloves and personal protective equipment, then place emesis basin in front of resident and proceed to brush teeth.

2. On 9/11/18 at 9:31 a.m., the surveyor observed Resident #56 in bed awake. The resident was alert and oriented and responded pleasantly and appropriately when spoken to. The surveyor observed the resident had a urinary catheter leg bag in place draining yellow urine. The surveyor observed resident #56's urinary catheter drainage bag inside a plastic bag hanging in the resident's bathroom. The drainage bag was observed to have urine in it. The tip of the drainage tube was uncapped. In the same plastic bag, the surveyor observed a urinal with urine in it.

(30)

F 880 Continued From page 29 F 880 The surveyor reviewed the Medical Record of

Resident #56 which reflected the resident was admitted with diagnoses that included Diabetes Mellitus and Obstructive Uropathy.

The surveyor reviewed the quarterly Minimum Data Set (MDS), an assessment tool dated 7/14/18. The MDS assessed Resident #56 as having an indwelling bladder catheter for Obstructive Uropathy. Further review of the resident's medical record revealed the resident was admitted from the hospital on 8/9/18 with a Urinary Tract Infection which resolved with a Physician's order for Bactrim DS [double strength].

On 9/14/18 at 12:35 p.m., in the presence of the Certified Nursing Assistant (CNA), the surveyor observed resident #56's urinary catheter drainage bag inside a plastic bag hanging in the resident's bathroom. The tip of the drainage tube was uncapped. The CNA stated that it should be capped and would obtain a new drainage bag.

On 9/14/18 at 1:30 p.m., the survey team met with the Administrator and Director of Nursing (DON) and discussed the above observations and concerns. The DON stated she would be inservicing all staff on ADL [activities of daily living] care and Foley Catheter Care.

Review of the facility's undated policy titled,

"Indwelling Foley Catheter Maintenance," showed that foley catheter drainage bag and leg bags are to be rinsed, drained and stored in plastic bag in resident's bathroom.

N.J.A.C. 8:39-27.2