Meadow Lakes

F-F678

On [DATE REDACTED] at 9:22 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the QAPI program. The surveyor asked the LNHA to identify all the current QAPI plans. The LNHA stated that call bell response was identified from the resident council, and from grievances and the LNHA provided the surveyor with the QAPI plan which was reviewed in the presence of the LNHA. The Problem Statement revealed: Staff are to answer call lights.; The SMART Goal revealed: To respond residents need and request expeditiously and appropriately at all times.; The Root Cause/s: What are the contributing factors that cause the problem? Staff not mindful of the call lights and Staff forget to turn off the call lights

after answering their needs.; What is the importance of this goal? To respond resident's needs appropriately

in a timely manner.; Barrier/s: What difficulties will you encounter implementing your goal?

The surveyor asked the LNHA since the date of the goal is [DATE REDACTED], where is the measurable progress documented. The LNHA reviewed the QAPI in the presence of the surveyor and stated, I don't see the SMART goal is measurable. When asked what SMART meant the LNHA stated, we are not making it measurable.

When asked what the remaining QAPI plans were, the LNHA stated, that the facility identified that the staff were not all completing the online education system. When asked to provide the QAPI, the LNHA stated they were in the middle of it. When asked about a specific and measurable goal, the LNHA stated she did not have a document to show the surveyor, but the performance had improved from 40 to 70%.

The LNHA stated the facility had a QAPI on the inconsistent availability of the resident weights. The surveyor asked if the goal was specific and measurable and the LNHA stated, I don't have it, maybe the Dietitian, had it?

The LNHA stated there was a QAPI with falls with major injury. The surveyor asked if falls with major injury was an adverse event? The LNHA stated, yes, and it went into the internal risk management system. The surveyor asked if adverse events were reviewed in QAPI and she stated, no, I don't see it here, I cannot show it to you.

The surveyor asked the LNHA if hand hygiene during meals and standing and cutting resident meals has been identified as a concern per surveyor observations. The LNHA stated, that has not been identified as an issue or had any concerns regarding that brought to her attention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 315022 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315022 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow Lakes 300 Meadow Lakes East Windsor, NJ 08520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 The surveyor then asked if the LNHA was aware of staff placing two incontinence briefs residents as observed during the survey. The LNHA stated, no, the Aides (Certified Nurse Aides) never brought it to my Level of Harm - Minimal harm or attention. The surveyor asked was placing a double incontinent brief on a resident, okay? The LNHA stated, potential for actual harm no, I expect the primary nurses to be checking from time to time. The surveyor asked the LNHA if there were any audits or documents to show that care was monitored, and she stated, No. Residents Affected - Many

On [DATE REDACTED] at 12:07 PM, the survey team interviewed a Registered Nurse (RN) regarding when on [DATE REDACTED] 6:00 PM, staff observed Resident #18 sitting in recliner not breathing, no pulse, no respiration . Resident expired at 6:00 PM. The RN stated that the resident was found unresponsive and she had confirmed that she was the RN supervisor that day. The surveyor asked the RN if her Cardiopulmonary Resuscitation (CPR) training was up to date. The RN proceeded to look at her phone and looked up her CPR certification and stated, it is expired, I thought it was due in September. The surveyor requested all the CPR education for the nursing staff.

On [DATE REDACTED] at 1:56 PM, during an interview with the LNHA, the surveyor asked if she had been aware that

the RN's CPR certification was expired. The LNHA confirmed the RN's CPR certification was expired and was unable to provide a list of all the CPR certifications of the nurses because only the former Director of Nursing had access to it.

On [DATE REDACTED] at 1:59 PM, the surveyor asked the Director of Nursing (DON) how the facility would ensure that there was a CPR certified staff member on each shift. The DON stated that the RN was incorrectly listed as having a current CPR certification.

NJAC 8:,d+[DATE REDACTED]XXX,d+[DATE REDACTED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 315022 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315022 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow Lakes 300 Meadow Lakes East Windsor, NJ 08520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27193 potential for actual harm Based on observation, interview, record review and document review, it was determined that the facility Residents Affected - Some failed to a.) follow appropriate infection control protocols during a wound treatment observation. This deficient practice was identified for 1 of 2 residents (Resident # 54) reviewed with wounds, b.) perform hand hygiene (HH) between serving food, removing dirty dishes, and when assisting residents. The deficient practice was identified in 1 of 1 dining room meal observation, for 3 of 4 residents (Resident #27, #29 and #46) reviewed for dining and was evidenced by the following:

1. On 3/14/25 at 10:30 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform a wound treatment to the sacral area of Resident #54, two certified Nursing Aides (CNA) assisted the LPN during the wound treatment.

The LPN prepared the over bed table and gather the needed supplies to complete the treatment. The LPN placed the supplies on the overbed table.

At 10:45 AM, the surveyor observed the LPN removed the soiled dressing, dispose of the soiled dressing, removed the soiled gloves and placed them in the trash can inside the room. The LPN then, without first performing HH, donned (put on) a clean pair of gloves and cleaned the wound with [name redacted] Wound solution (topical wound care product that contains hypochlorous acid) soaked gauze pads and patted the wound dry. The LPN did not wash her hands or used Alcohol Based Hand Rub (ABHR) to cleanse her hands

after removing the soiled dressing. The LPN then donned gloves, applied the treatment inside the wound, then attempted to pack the wound with the Calcium Alginate (absorbent wound dressing) packing that was not cut to size. With the gloved hand the LPN attempted to retrieve a pair of scissors from her pants pocket.

The LPN then could not reach the scissors and asked the CNA to assist. The CNA with her gloved hand reached for the scissors and gave them to the LPN. The LPN picked up the scissors and cut the Calcium Alginate. The LPN was about to insert the Calcium Alginate to pack the clean wound when the surveyor asked the LPN if the scissors were clean or had they been disinfected. The LPN then, donned a clean pair of gloves, disinfected the scissors, cut the Calcium Alginate to size and packed the wound. The LPN then applied a foam dressing for optimum coverage and protection. The LPN did not disinfect the overbed table

after disposing of the unused supplies into the trash can. The LPN then signed the resident's Treatment Administration Record (TAR) for completion of the wound treatment.

On 3/14/25 at 11:30 AM, the surveyor reviewed the observed treatment with the LPN. The LPN confirmed that she missed some steps during the wound care. The LPN stated that she should have washed her hands

after removing the soiled dressing prior to applying a clean pair of gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 315022 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315022 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow Lakes 300 Meadow Lakes East Windsor, NJ 08520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The surveyor reviewed Resident #54's electronic medical record. The admission Face Sheet reflected that Resident #54 had diagnoses which included but were not limited to; difficulty in walking, personal history of Level of Harm - Minimal harm or other malignant neoplasm of bronchus and lung, pressure ulcer of sacral region, stage 4 (deep wound potential for actual harm reaching the muscles, ligament and bone). A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/01/24, reflected that the resident was at Residents Affected - Some high risk for developing pressure ulcers and had a stage 4 pressure ulcer to the sacral area. A review of the Care Plan initiated 2/5/25 reflected a problem for alteration in skin impairment related to overall decline. The goals were the resident's skin alterations will continue to improve without complications. The interventions included: wound care treatment as ordered, monitor for pain and provide incontinence care as needed. A

review of Physician's Orders sheet (POS) for March 2025, reflected an order dated 3/13/25 for the sacral wound to be cleansed with [name redacted] wound solution -Remove Zinc with mineral Oil-.Apply Collagen wound powder to wound bed-Pack with Calcium Silver alginate-apply Zinc to periwound and cover with bordered gauze dressing every day and as needed.

A review of the facility's policy titled, Clean Dressing last revised 1/28/25, revealed the following:

Policy: The licensed nurse will use clean techniques for all dressing changes unless otherwise ordered by

the physician. The policy did not address the steps to follow

for packing a wound. A review of the treatment observation document attached to the facility policy reflected that staff were to wash their hands, after setting the clean field, after disinfecting the over bed table and after removal of the soiled dressing.

31654

38079

2. On 3/12/25 at 11:49 AM, two surveyors observed the lunch meal in the dining room and observed the following:

The remote kitchen was adjacent to the dining room and the surveyors observed through an open door that there was one dietary staff (DS) serving food in the kitchen and two CNAs were assisting residents in the dining room.

On 3/12/25 at 12:04 PM, the DS entered the dining room wearing gloves and served soup to the residents.

The DS returned to the kitchen and failed to remove her gloves or perform HH. The surveyor then observed CNA #2, was assisting Resident #29 at the lunch meal, CNA #2 then Resident #29 got up in the middle of assisting Resident #29 and without first performing HH, walked to the back table and picked up the utensil for Resident #46 and handed it to the resident. CNA #2, without first performing HH, then returned to assist Resident #29.

On 3/12/25 at 12:13 PM, the DS plated lunch plates and entered the dining room wearing the same gloves and served residents their lunch meal. At that time the surveyor observed that the HH dispenser adjacent to

the dining room panty entrance was empty. The surveyor informed the food service supervisor (FSS) who was also present and the FSS placed her hand under the dispenser and confirmed that the HH did not work.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 315022 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315022 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow Lakes 300 Meadow Lakes East Windsor, NJ 08520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 She reentered the kitchen at 12:17 PM, failed to remove gloves or perform HH and plated meals for the residents. Level of Harm - Minimal harm or potential for actual harm On 3/12/25 at 12:13 PM, On 3/12/25 at 12:23 PM, CNA #2 who was assisting a resident with feeding, stopped feeding the resident and walked over to a table with three residents and was handling their cups and Residents Affected - Some utensils (Resident #46 and #27) and used a knife cut Resident #27's food, then without first performing HH returned to assist Resident #29 with their meal.

On 3/12/25 at 12:14 PM, CNA #2 again got up from assisting Resident #29 and began removing dirty dishes from Resident #46 and without first performing HH went back to Resident #29 and used the resident's cup to offer a drink to Resident #29.

On 3/12/25 at 12:19 PM, the DS delivered three more meals, and then removed two dirty soup bowls. The DS then returned to the kitchen still wearing the same gloves and without performing HH after removing the soiled dishes. At 12:22 PM, the DS delivered two more meals while still wearing the same gloves that were used to remove dirty dishes and plate up other meals.

On 3/12/25 at 12:24 PM, CNA #2 walked over to Resident #27 and held that resident's hand while asking that resident if they wanted ice cream. CNA #2 then, without first performing HH, returned to resident #29 and continued to assist with feeding.

On 3/12/25 at 12:26 PM, the DS was observed wearing the same gloves, delivered one meal to a resident, returned to the kitchen and began placing desserts on a cart. She did not change remove her gloves or perform HH. At 12:28 PM, the DS removed her gloves and put on new gloves without first performing HH, and then passed desserts from a cart to the resident in the dining room.

On 3/12/25 at 12:32 PM, the DS returned to the pantry wearing the same gloves, proceeded to open up packages of crackers, placed the non-sealed crackers on a saucer, and served soup with the crackers to a resident in the dining room.

On 3/12/25 at 12:33 PM, CNA #2 stopped assisting Resident #29 when another resident entered the dining room, and without first performing HH she assisted the newly arrived resident to sit, and then handed them their utensils.

On 3/12/25 at 12:36 PM, the DS while wearing gloves, pushing the cart into the dining room, then simultaneously provided residents with desserts while removing dirty dishes and placed on the same cart, then placed a tea bag in water opened and then used the same gloved hands to open Jello for a resident. There was no HH performed between providing food items and removing soiled items and at 12:42 PM, the DS then walked into the kitchen while pulling up her pants wearing the same gloves. The DS did not remove her gloves or perform HH and obtained a meal for a resident, and then delivered the meal, removed more dirty dishes while wearing the same gloves.

On 3/12/25 at 12:46 PM, upon interview the DS stated she did not change the gloves because I go fast. She further stated that she did not need to perform HH because it was only her, and she was not leaving the dining room. When asked about performing HH between delivering meals and removing dirty dishes, the DS stated she did not need to change her gloves just to deliver food and that there was usually another staff member there to assist her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 315022 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315022 B. Wing 03/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Meadow Lakes 300 Meadow Lakes East Windsor, NJ 08520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 3/12/25 at 1:08 PM, the Food Service Director (FSD) stated that the kitchen staff should not be using the same gloves and should use HH between tasks. The FSD further stated that the DS had been educated and Level of Harm - Minimal harm or usually would have others to help in the dining room. potential for actual harm

A review of the facility provided policy, Hand Hygiene revised 1/22, included but was not limited to; Policy: all Residents Affected - Some associates handling food shall wash hands with soap and water at the following times (included) before handling good or clean utensils/dishes/equipment; before putting on gloves; after touching clothing; after handling soiled silverware/utensils; after handling garbage; after removing gloves; and after activities that may contaminate the hands.

On 3/14/25 at 12:58 PM, the above concerns were presented to the facility.

On 3/18/25 at 10:05 AM, the DON presented documentation that the DS had been in serviced on hand hygiene on 2/13/25.

NJAC 8:39 -19.4 (a)

Surveyor: [NAME], [NAME]

Surveyor: LAW, [NAME]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 315022