Complaint #: 398975Based on record review, interview, and document review, the facility failed to consistently provide pain management for one of 16 sampled residents (Resident (R)16). R16 was admitted to the facility with diagnoses including pancreatic adenocarcinoma and had admitting orders for pain medications, in particular Dilaudid (an opioid pain medication used to treat moderate to severe pain), and staff failed to administer the medication as ordered. R16 had pain levels up to a 10 (on a zero to 10 scale, with 10 being the most intense pain possible). …
COMPLAINT #: 2648245 Based on interviews, review of medical records, and review of pertinent facility documents, it was determined the facility failed to a.) assess and document a resident's pain level; b.) obtain orders for pain management; and c.) re-evaluate and document the effectiveness of pain management in accordance with professional standards of practice. This deficient practice was identified 1 of 3 residents reviewed for pain management (Resident #3), and was evidenced by the following:A review of Resident #3's Closed Medical Record's admission Record revealed that Resident #3 was admitted to the facility with diagnoses which included but were not limited to acidosis, unspecified (condition in which there is too much acid in the body fluids); major depressive disorder,… …
E · No harm, potential for more than minimal, patternJune 1, 2026
Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to meet the professional standards of practice by not appropriately assessing and documenting PRN (as needed) pain medications. This deficient practice was identified for 1 of 5 residents (Resident #41) reviewed for unnecessary medications and was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health… …
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