Electronically Signed

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 000 INITIAL COMMENTS F 000 STANDARD SURVEY: 11/19/15 CENSUS: 113 F 282 SS=D SAMPLE: 23 483.20(k)(3)(ii) SERVICES BY QUALIFIED PERSONS/PER CARE PLAN The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care. F 282 12/4/15 This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review it was determined that the facility failed to follow the resident's plan of care. This deficient practice was identified for 2 of 20 residents, Resident #16 and #7 reviewed for implementation of Care Plans and was evidenced by the following: 1. During the initial tour on 11/16/15 at approximately 10:30 a.m., the Unit Manager (UM) stated that Resident #16 was alert and oriented, and able to make his/her needs known to staff. Resident #16 was observed lying in bed listening to music. The resident greeted the surveyor. According to the medical record, Resident #16 was admitted to the facility with diagnoses that included Renal Failure and Bacteremia. A review of Resident #16's plan of care dated 11/1/15, revealed that Resident #16 was at risk Plan of for F282 1) Resident #16 to be transferred as per Care Plan and CNA in-serviced. Resident #7 had bed moved to proper position against wall as per the Care Plan. 2) Residents Care Planned for fall precautions were reviewed to ensure interventions were in place as per their Care Plans. 3) All nursing staff in-serviced about making sure interventions of Care Plan are in place and proper techniques are used for residents as per their Care Plan. 4) DON or designee to review Care Plans as they are updated with staff to ensure interventions are implented and followed. LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) 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. 12/03/2015 Facility : NJ61536 If continuation sheet Page 1 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 282 Continued From page 1 F 282 for falls. According to the interventions listed on the plan of care, two staff members and a mechanical lift were to be used for transfers. A review of an Interdisciplinary Review of the Resident Fall note dated 6/21/15 at 4:00 p.m., revealed that Resident #16 was lowered to the floor by a Certified Nursing Assistant (CNA) while being transferred alone from the wheelchair to the toilet. The CNA did not use a mechanical lift as identified on the resident's plan of care. When interviewed on 11/18/15 at 10:00 a.m., the UM stated that the CNA did not use a mechanical lift during the transfer and did not follow the resident's plan of care. The UM stated that it was the CNA's responsibility to review the resident's plan of care prior to providing care. On 11/18/15 at 1:00 p.m., the Director of Nurses (DON) stated that the CNA did not use a mechanical lift which resulted in the resident falling to the floor. 2. During the initial tour on 11/16/15 at 9:50 a.m., the Registered Nurse/Unit Manager (RN/UM) for the Subacute Unit (SAU) stated that Resident #7 was recently transferred from another unit. Resident #7's SAU room did not have a name plate and the resident's bed was in the "normal" position. The surveyor found Resident #7's medical chart on the prior unit on 11/17/15 at 12 noon. Resident #7 was moved on 11/6/15 to the SAU. The surveyor observed, at 12:35 p.m., Resident #7's prior room still had some of his/her belongings and that the bed was against the wall. The surveyor reviewed Resident #7's Plan of Care for falls on 11/17/15 at 12:15 p.m. On 7/14/15, the intervention of placing the bed Facility : NJ61536 If continuation sheet Page 2 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 282 Continued From page 2 F 282 against the wall was initiated. On 11/18/15 at 12:20 p.m., the surveyor interviewed Resident #7's day nurse regarding the position of the bed. The nurse stated s/he was not aware that the resident's bed should be against the wall. The day nurse stated that Resident #7's move to the SAU was to be temporary. On 11/18/15 at 1:40 p.m., the surveyor discussed the issue with the Administrator and Director of Nurses (DON). The DON agreed that the Care Plan was not followed. F 323 SS=D N.J.A.C. 8:39-35.2(f) 483.25(h) FREE OF ACCENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. F 323 12/4/15 This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review it was determined that the facility failed to use a mechanical lift during a transfer which resulted in a fall without injury. This deficient practice was identified for 1 of 11 residents, Resident #16, reviewed for falls. In addition, the facility failed to complete a thorough investigation for Resident #16's fall. This deficient practice was Plan of for F323 1) CNA that improperly transferred resident was in-serviced about properly following Care Plan and using proper equipment. 2) Care Plans were reviewed for residents Facility : NJ61536 If continuation sheet Page 3 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 323 Continued From page 3 F 323 evidenced by the following: During the initial tour on 11/16/15 at approximately 10:30 a.m., the Unit Manager (UM) stated that Resident #16 was alert and oriented, and able to make his/her needs known to staff. At this time, Resident #16 was observed lying in bed listening to music. The resident greeted the surveyor. According to the medical record, Resident #16 was admitted to the facility with diagnoses that included Renal Failure and Bacteremia. A review of an Interdisciplinary Review of the Resident Fall note dated 6/21/15 at 4:00 p.m., revealed that Resident #16 was lowered to the floor by a Certified Nursing Assistant (CNA) while being transferred alone from the wheelchair to the toilet. According to this note, Resident #16 did not sustain any injuries from the fall. A review of Resident #16's most recent Minimum Data Set (MDS), an assessment tool, dated 8/19/15 revealed that the resident had some cognitive deficits. The MDS revealed that Resident #16 required assistance from two staff members for moving from side to side while in bed, and for moving from the bed, and into a chair. The MDS also revealed that Resident #16 required the use of a mechanical lift for transferring from the bed, and into a chair or toilet. A review of an Incident Report dated 6/21/15 at 4:00 p.m. revealed that a CNA was helping Resident #16 off the toilet and the resident's legs slowly gave out. According to the note the resident was lowered to the floor by the CNA. A review of Resident #16's plan of care dated 11/1/2015, revealed that Resident #16 was at risk for falls. According to the interventions listed on the plan of care two staff member and a mechanical lift were to be used for transfers. to ensure proper interventions and equipment were in place as per recommended by the C Team. 3) Nursing staff in-serviced to properly follow Care Plan for interventions and to provide statements to accompany incidents. When resident is alert and oriented, interview will be conducted as well regarding incidents. 4) DON or designee will review incidents as they occur to ensure that statements are taken and interviews conducted with residents when able. Facility : NJ61536 If continuation sheet Page 4 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 323 Continued From page 4 F 323 F 371 SS=D When interviewed on 11/18/15 at 10:00 a.m., the UM stated that the CNA did not use a mechanical lift during the transfer. The UM stated that the CNA did not follow the resident's plan of care. The UM stated that it was the CNA's responsibility to review the resident's plan of care prior providing care to residents. On 11/18/15 at 1:00 p.m., the Director of Nurses (DON) stated that the CNA did not use a mechanical lift which resulted in the resident falling to the floor. A review of the Incident Report, in the presence of the DON, lacked documentation of an interview from Resident #16 and/or, a written statement from the CNA. The DON stated s/he was responsible for completing the incident reports. The DON stated that s/he did not obtain a written statement from the CNA, nor did s/he interview the resident about the fall. The DON stated that s/he should have obtained a written statement from the CNA and interviewed Resident #16. N.J.A.C. 8:39-27.1(a) 483.35(i) FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions F 371 12/4/15 This REQUIREMENT is not met as evidenced by: Facility : NJ61536 If continuation sheet Page 5 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 371 Continued From page 5 F 371 F 425 SS=E During the tour of the kitchen on 11/16/15 9:30 a.m., in the presence of the Food Service Director (FSD), the following was observed: 1. The stove and oven had a heavy build up of grease and burnt food particles and black substances. 2. The convection oven was heavily stained with grease and burnt food particles and black substances. 3. There were 7 1/4 pans nesting with water on the pot drying rack. When interviewed at this time, the FSD stated that the pans should have been positioned sideways. The FSD stated that the food service workers were responsible for cleaning the kitchen appliances. The FSD also stated that s/he was responsible for ensuring that the food service workers kept the kitchen and appliances clean. The FSD stated that s/he could not offer any explanation as to why this was not done. N.J.A.C. 8:39-17.2(g) 483.60(a),(b) PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.75(h) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. Plan of for F371 1) The areas noted were cleaned thoroughly to remove any evidence of grease and/or food particles. Pans were dried completely. 2) Kitchen was inspected to ensure other equipment was not dirty and that pots and pans were dried in a proper fashion to avoid nesting water. 3) Staff schedules was altered to make sure certain areas of kitchen and equipment are cleaned more often to prevent any type of grease build up. Staff in-serviced about proper drying procedures to stack air drying pots and pans sideways. 4) Food Service Director or designee will make weekly rounds to ensure proper cleaning protocols are being met and that equipment and spaces are free from grease build up and dirt. FSD or designee will check on a daily basis that pans and pots are dried and stored properly. F 425 12/4/15 Facility : NJ61536 If continuation sheet Page 6 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 425 Continued From page 6 F 425 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. The facility must employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review it was determined that the facility failed to dispose expired and/or unused medications in a timely manner. This deficient practice was noted for 2 out of 3 medication rooms as evidenced by the following: 1. On 11/18/15 at 9:20 a.m., the surveyor and the Registered Nurse/Unit Manager (RN/UM) inspected the Subacute Unit medication room. The surveyor observed a plastic container in an unlocked cabinet with multiple medications. The RN/UM stated that the medications were to be returned to the pharmacy or destroyed. The surveyor observed the following medications: 24 packets of Questran, a medication used to lower cholesterol, with a delivery date of 3/11/15 for Resident #25. According to the medical record, Resident #25 was discharged on 5/9/15. Plan of for F425 1) Medications that were noted to be for residents that had been discharged from the facility were destroyed. 2) Medication rooms were inspected to make sure there were no additional medications present that should have been destroyed or returned to the pharmacy. 3) Nursing staff in-serviced about facility policy and proper return and destruction of medications. 4) DON or designee will audit medication storage on a monthly basis with Pharmacy Consultant to ensure there are no medications that need to be returned or destroyed. 12 syringes of Lovenox, a medication used to thin Facility : NJ61536 If continuation sheet Page 7 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 425 Continued From page 7 F 425 the blood, with a delivery date of 3/11/15 for Resident #26. According to the medical record, Resident #26 was discharged on 6/18/15. 10 syringes of Lovenox with a delivery date of 11/10/14 for Resident #27. According to the medical record, Resident #27 was discharged 1/2/15. An unlabeled plastic bag with 41 total packages of multiple dosages of Coumadin, a medication used to thin the blood. 2 syringes of Arixtra, a medication used to thin the blood, with a delivery date of 3/24/15 for Resident #28. According to the medical record, Resident #28 was discharged 3/29/15. 3 unlabeled syringes of Lovenox. 1 unlabeled syringe of Arixitra. 16 unopened vials of Heparin, a medication used to thin the blood, with a delivery date of 6/11/15 for Resident #29. According to the medical record, Resident #29 was discharged 6/17/15. An unlabeled plastic bag with 37 unopened vials of Heparin. 4 syringes of Arixtra with a delivery dated of 12/1/14 for Resident # 30. According to the medical record, Resident #30 was discharged 12/16/14. The surveyor discussed this issue with the Administrator and Director of Nurses (DON) on 11/18/15 at 1:40 p.m. The surveyor received the Facility : NJ61536 If continuation sheet Page 8 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 425 Continued From page 8 F 425 facility's Medication Disposal Policy on 11/19/15 at 9 a.m. The Policy noted that medications no longer needed should be either returned to the pharmacy or destroyed. Per the Administrator, medication disposal should occur as soon as the resident was discharged or when the medication was discontinued. 2. On 11/18/15 at 10:00 a.m., the following was observed on the Medici Unit. The surveyor found 24 Prochlorperazine suppositories, used to treat nausea, in a cabinet on the unit. When interviewed at this time, the Unit Manager (UM) stated that Resident #24 had died in 6/2015. Further inspection of the cabinet, revealed the following medications inside a floral cosmetic bag: 10 Nitrofurazone tablets, an antibiotic; 5 Sulfamethoxazole tablets, an antibiotic; 4 Ampicillin tablets, an antibiotic; 2 Keppra tablets, used to treat seizures; 2 Coumadin tablets, used to thin the blood; 2 Amoxicillin tablets, an antibiotic; 2 Clindamycin tablets, an antibiotic and; 1 Carbidopa/Levodopa tablet, used to treat Parkinson's. When interviewed at this time, the UM stated that the medications found inside the bag were non-returnable medications. The UM stated that it was the facility's policy and his/her responsibility to destroy non-returnable medications. F 431 SS=D N.J.A.C. 8:39-29.4(g) 483.60(b), (d), (e) DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS F 431 12/4/15 Facility : NJ61536 If continuation sheet Page 9 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 431 Continued From page 9 F 431 The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review it was determined that the facility failed to restrict non-authorized personnel access to Plan of for F431 1) Key to the medication room was Facility : NJ61536 If continuation sheet Page 10 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 431 Continued From page 10 F 431 medications in the medication rooms for 1 of 3 units. This deficient practice was evidenced by the following: On 11/18/15 at 9:15 a.m., the surveyor was at the Subacute Unit nursing station. The surveyor observed the unit secretary remove keys from a drawer at the nurse's station and enter the medication room alone. The unit secretary then left the medication room and returned the keys to the same drawer. At 9:20 a.m., the surveyor asked the Registered Nurse/Unit Manager (RN/UM) to open the medication room for inspection. The RN/UM removed the keys from the drawer at the nurse's station. The surveyor inspected the medication room and noted multiple medications located in an unlocked cabinet. The RN/UM stated the medications needed to be returned to the pharmacy and/or destroyed. removed from the unlocked drawer by the nurse's station. 2) Other units were checked to make sure there was not access to medication rooms or their keys by unauthorized personnel. 3) Key copies were made and distributed to nurses for access to the medication rooms. Nursing staff in-serviced that only authorized staff should be allowed access to the medication rooms. 4) DON or designee to check medication rooms on a weekly basis to ensure they are locked and that there is not access to unauthorized personnel. The surveyor asked the RN/UM about the key kept in a drawer for the medication room at 9:50 a.m. The RN/UM was unaware that non-authorized personnel were not allowed to have access to the medication room without an authorized person present. The surveyor discussed this issue with the Administrator and Director of Nurses (DON) on 11/18/15 at 1:30 p.m. The surveyor was provided with the Medication Security Policy on 11/19/15 at 9 a.m. According to the Policy, only nurses are to have access to the medication room via a key and, that the key was to be kept secure. N.J.A.C. 8:39-29.4(h) Facility : NJ61536 If continuation sheet Page 11 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 456 Continued From page 11 F 456 F 456 SS=E 483.70(c)(2) ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION The facility must maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. F 456 12/4/15 This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review on 11/16/15 in the presence of facility management, it was determined that the facility failed to provide maintenance services to maintain Packaged Terminal Air Conditioner (PTAC) units in effective and optimal operating condition. This deficient practice was evidenced by the following: 1. At 11:15 a.m.- 1:45 p.m., the surveyor inspected and observed 13 of 16 PTAC units in resident rooms with clogged and dirty filters. 2. At 11:15 a.m.- 1:45 p.m., the surveyor inspected and observed in the Emerald Cafe, 1 of 1 PTAC units with clogged and dirty filters. 3. At 11:15 a.m.-1:45 p.m., the surveyor inspected and observed in the Conference room, 1 of 1 PTAC units with clogged and dirty filters. Plan of for F456 1) The filters for the PTACs noted were cleaned. 2) All PTACs in the facility were checked for dirty filters and cleaned as needed. 3) Maintenance staff in-serviced regarding properly cleaning filters for PTACs on a seasonal basis and on properly documenting the work performed to do so. 4) Maintenance Director will perform check of PTAC filters to ensure that they have been cleaned on a seasonal basis prior to heat being turned on for the Autumn/Winter and the air conditioning being turned on for the Spring/Summer. 4. At 11:15 a.m.-1:45 p.m., the surveyor inspected and observed in the Activitites room, 1 of 3 PTAC units with clogged and dirty filters. 5. At 11:15 a.m.-1:45 p.m., the surveryor inspected and observed in the Medical Records Facility : NJ61536 If continuation sheet Page 12 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES OMB NO. 0938-0391 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY NAME OF PROVER OR SUPPLIER (X4) F 456 Continued From page 12 F 456 Office, 1 of 1 PTAC units with clogged and dirty filters. At 1:50 p.m., the surveyor interviewed the Maintenance Director who stated that at this time there was no policy and procedure on the maintenance of PTAC units. The surveyor was provided with a PTAC maintenance log that indicated the PTAC filters were checked on 11/2/15 and 11/9/15, but that the inspected units were missed. NJAC 8:39-31.2(b), 31.4(e) Facility : NJ61536 If continuation sheet Page 13 of 13

CENTERS FOR MEDICARE & MEDICA SERVICES POST-CERTIFICATION REVISIT REPORT PROVER / SUPPLIER / CLIA / ENTIFICATION NUMBER 315327 Y1 MULTIPLE CONSTRUCTION A. Building B. Wing Y2 OF REVISIT 12/22/2015 Y3 NAME OF FACILITY This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of, that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form). ITEM ITEM ITEM Y4 Y5 Y4 Y5 Y4 Y5 Prefix F0282 Prefix F0323 Prefix F0371 483.20(k)(3)(ii) 483.25(h) 483.35(i) 12/04/2015 12/04/2015 12/04/2015 Prefix F0425 Prefix F0431 Prefix F0456 483.60(a),(b) 483.60(b), (d), (e) 483.70(c)(2) 12/04/2015 12/04/2015 12/04/2015 Prefix Prefix Prefix Prefix Prefix Prefix Prefix Prefix Prefix REVIEWED BY STATE AGENCY REVIEWED BY (INITIALS) SIGNATURE OF SURVEYOR REVIEWED BY CMS RO REVIEWED BY (INITIALS) TITLE FOLLOWUP TO SURVEY ON CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY? YES NO Form CMS - 2567B (09/92) EF (11/06) Page 1 of 1 EVENT : EG2T12