Every finding on record at Complete Care at Wayne Hills Rehab & Resp Center

Based on observations, interview, and review of other pertinent documents on 6/11/26 and 6/12/26, it was determined that the facility failed to: a) ensure appropriate Enhanced Barrier Precautions (EBP, infection-control measures used in nursing homes to prevent the spread of multidrug-resistant organisms (MDROs)) were followed when Licensed Practical Nurse (LPN #1) was observed to not change gloves before performing closed tracheal suctioning (a sterile, self-contained device that allows healthcare providers to remove airway secretions without disconnecting the patient from a mechanical ventilator), a secondary high-contact task, and artificial airway, such as a tracheostomy), b) failed to ensure LPN #1 changed gloves after accessing a gastrostomy tube, a high-contact task, and before touching the privacy curtains and the window blinds in both Resident #4's and Resident #6's rooms, and c) failed to demonstrate completion of scheduled environmental disinfection of the residents' privacy curtains, in room medical equipment, and terminal room cleanings (a rigorous process, distinctly different from routine daily cleaning) for residents on EBP due to Candida Auris (C. Auris, an emerging, multidrug-resistant fungus (a type of yeast) that presents a serious global health threat) and CRAB (Carbapenem-Resistant Acinetobacter baumannii), an MDRO targeted by the Centers for Disease Control and Prevention (CDC). This deficient practice was evidenced for 2 of 6 residents observed for infection control. This deficient practice was evidenced by the following:A review of the CDC, Clinical Safety: Hand Hygiene for Healthcare Workers, February 27, 2024, Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with: Handwashing with water and soap (e.g., plain soap or with an antiseptic). Antiseptic hand rub (alcohol-based foam or gel hand sanitizer).Cleaning your hands reduces: The potential spread of deadly germs to patients.The risk of healthcare personnel colonization or infection caused by germs received from the patient.Know when to clean hands: Immediately before touching a patient. Before performing an aseptic (free from contamination caused by harmful microorganisms, such as bacteria, viruses, and fungi) task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal.1. A review of Resident #6's admission Record (AR), an admission record summary, revealed that the resident was admitted to the facility with the following diagnoses but are not limited to, anoxic brain damage a severe, (life-threatening condition that occurs when the brain is completely deprived of oxygen, leading to brain cell death within minutes ), chronic respiratory failure (a long-term condition where the respiratory system fails to properly oxygenate the blood or remove excess carbon dioxide), resistance to multiple antimicrobial drugs, tracheostomy (a surgical procedure that creates an opening in the neck into the trachea (windpipe)) status, gastrostomy status, and functional quadriplegia. A review of Resident #6's Care Plan Report (CP), revised on 5/14/24, revealed the resident was positive for C. Auris. Interventions included, but were not limited to, EBP to be maintained, monitor lab work per MD order, and staff to wear PPE (Personal Protective Equipment, specialized gear, such as gowns, gloves and masks, worn to minimize exposure to hazards that cause workplace injuries or illnesses) during interactions and during ADLs (Activities of Daily Living) when caring for the resident. On 6/11/26 at 11:02 AM, the surveyor observed care on the South Wing, a Subacute/Ventilator (a medical life-support machine that mechanically assists or fully controls breathing) Unit of the facility. A loud beeping sound was heard in front of Resident #6's room. The surveyor observed LPN #1 near the room. LPN #1 stated the loud beeping sound indicated that the resident's gastrostomy feeding was completed and the tube need to be flushed with water. On 6/11/26 at 11:05 AM, surveyor observed LPN #1 water to flush the resident's tube. LPN #1 used hand sanitizer, donned (to put on Personal Protective Equipment (PPE), such as Gown, Mask/Respirator, Goggles/Face Shield, and Gloves) on PPE; mask, gown, gloves, and went in the room, drawing the privacy curtain between the two beds. LPN #1 proceeded to flush the resident's gastrostomy tube with water. LPN #1 then suctioned the resident's tracheostomy, wearing the same gloves used to access the gastrostomy tube, before fixing the resident's blanket, closing the window blinds, and opening the privacy curtain.2. A review of Resident #4's AR showed the resident was admitted to the facility with the following diagnoses, but were not limited to, acute (condition that comes on suddenly, has severe symptoms, and typically lasts for a short period of time) and chronic respiratory failure, type 2 Diabetes Mellitus (a chronic metabolic disorder characterized by persistently high blood sugar (glucose) levels), resistance to multiple antimicrobial drugs, muscle weakness, anoxic brain damage, and tracheostomy status. A review of Resident #4's CP, revised on 5/20/26, revealed that the resident required EBP related to indwelling medical devices (feeding tube, tracheostomy tube) and infection or being colonized (the presence and multiplication of microorganisms (like bacteria or fungi) on or in a host without causing disease, tissue invasion, or an immune response) with MDRO, C. Auris. Interventions included, but were not limited to, EBP will be in place for the duration of stay in the facility; PPE must be changed before caring for another resident. On 6/11/26 at 11:20 AM, the surveyor observed LPN #1 in front of their medication cart outside of Resident #4's room. LPN #1 donned their PPE and went in the room with the two cups with water to flush the resident's gastrostomy tube. After flushing the feeding tube with water, LPN #1 then pushed back the privacy curtain and adjusted the window blinds.On 6/11/26 at 12:29 PM, the surveyor interviewed LPN #1, Resident #4's and Resident #6's assigned nurse. LPN #1 stated both residents were on EBP since they were infected with CRAB and their C. Auris infection was colonized. The surveyor asked LPN #1 when staff should change gloves and wash their hands while caring for residents on EBP due to C. Auris and CRAB. LPN #1 stated that after touching the residents' gastrostomy tubes she failed to change her gloves before touching the curtain or blinds. On 6/11/26 at 2:11 PM, the surveyor interviewed the Housekeeping Supervisor (HS). The HS stated there is a weekly schedule to change and wash the privacy curtains, as well as needed, when they are soiled or dirty. The HS further stated devices and equipment, like wheelchairs and transfer lifts, are also cleaned but did not give a frequency for this. The HS stated resident rooms are cleaned. The HS provided sample resident room housekeeping cleaning checklists. The surveyor requested completed forms, but none were provided.On 6/11/26 at 2:34 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), the IP, and the Regional Nurse (RN). The ADON stated facility currently had a total of 19 residents with C. Auris and 11 with CRAB and that all residents were colonized. The ADON further stated all the colonized residents with C. Auris and CRAB were on EBP and located in the Ventilator/Subacute Unit. The ADON stated the changing of gloves should occur after direct contact with a C. Auris and CRAB patient and before touching another object, such as a blood pressure machine, the side of the bed, the curtain, the sinks. The ADON further stated gloves should be changed as well as after touching a contaminated site and before touching an uncontaminated site. On 6/12/26 at 10:00 AM, during entrance conference with the LNHA, ADON, IP, and the Regional Nurse, the surveyor requested documentation of the environmental disinfection and cleaning of resident rooms. The facility provided Isolation Room Cleaning Procedures and a summary of C. Auris training given to housekeeping staff. The survey did not receive documentation environmental disinfection tasks were completed.A review of the facility's policy titled MDRO Infection, with a revised/reviewed date of 10/14/25, revealed under Policy: This facility implements facility-wide strategies for preventing the spread of infections with multidrug-resistant organisms .under Policy Explanation and Compliance Guidelines: . 15. Care considerations related to Candida auris: . a. Candida auris is a yeast (fungus) that has become resistant to antifungal medications commonly used to treat Candida infections .d. It is spread by direct contact. A review of the facility's policy titled Enhanced Barrier Precautions, with a revised/reviewed date of 10/1/25, revealed under Policy Explanation and Compliance Guidelines: 1. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds .and/or indwelling medical devices (e.g urinary catheters, feeding tubes, tracheostomy/ventilator tubes, .) even if the resident is not known to be infected or colonized with a MDRO . ii. Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply 6.Examples of MDROs targeted by CDC include: .d. Carbapenemase-producing carbapenem-resistant Acinetobacter bauminnii e. Candida auris. A review of the facility's policy titled Standard Precautions, with a reviewed date of 3/2021, revealed under Standard Precautions include the following practices: 1. Hand Hygiene: a. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) OR using alcohol based hand rubs (gels, foams, rinses) that do not require access to water; b. Hands shall be washed with soap and water whenever visibly soiled with dirt, blood, or body fluids, or after direct or indirect contact with such, and before eating and after using the rest room. c. In the absence of visible soiling of hands, alcohol-based hand rubs are preferred for hand hygiene; d. Wash hands after removing gloves .2. Gloves: .b. Wear gloves when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact .e. Change gloves, as necessary, during the care of a resident to prevent cross contamination from one body site to another; g. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments.A review of the facility's policy titled Transmission-Based (Isolation) Precautions, with a revised/reviewed date of 10/14/25, revealed under Policy Explanation and Compliance Guidelines: .6. High touch objects and environmental surfaces (e.g., bed rails, over-bed table, bedside commode, lavatory surfaces in resident bathrooms) should be cleaned and disinfected with an EPA-registered disinfectant for healthcare use at least daily and when visibly soiled.N.J.A.C. 8:39-19.4(a)(1), (l)

Complaint #2687290 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 1/29/26, it was determined that the facility failed to a) implement adequate interventions to address the resident's risks for fall, and b) thoroughly assess and monitor a resident following a fall incident on 11/27/25, and after the identification of swelling and ecchymosis [bruise] on the resident's right hand on 12/01/25. According to Facility Reportable Event (FRE), a Licensed Practical Nurse (LPN #1) on the 11- 7 shift on 12/03/25, noticed bruising on the resident's bilateral lower extremities. According to an employee statement, Resident #1 was observed exhibiting signs of pain, and when staff assessed the resident on 12/03/25, the resident flinched like they were in pain. The nursing supervisor's statement indicated she observed bruising on the resident's right and left thigh, their lower back, and that the resident appeared to be in pain. Resident #1 was then sent to the hospital where they were diagnosed with bilateral femur fracture [fracture of both legs]. This deficient practice was identified for 1 of 4 residents reviewed (Resident # 1). The evidence was as follows: A review of the admission Record (AR) for Resident #1, revealed that the resident was admitted to the facility with diagnoses that included but was not limited to acute respiratory failure, muscle weakness, schizoaffective disorder, seizures and functional quadriplegia. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 11/28/25 revealed that Resident # 1 had a Brief Interview Mental Status (BIMS) score of 9 out of 15, indicating that the resident was moderately cognitively impaired. A review of the Facility Reportable Event (FRE) dated 12/05/25, which the facility submitted to the New Jersey Department of Health (NJDOH), stated that while CNA #1 was providing care to Resident #1 on 11/27/25 at 2:40 PM, the resident was squirming and holding the side rail while being turned in bed; and that their lower legs fell off the bed while their torso remained on the bed. According to the FRE, Certified Nursing Assistant (CNA) #1 and a Registered Nurse (RN) #1 repositioned the resident back to bed and assessed the resident. There was no documented evidence that the facility provided interventions to address the fall. The FRE included that on 12/03/25, during the 11-7 shift, Licensed Practical Nurse (LPN) #1 noticed bruising on the resident's bilateral lower extremities. The facility did not address the right hand swelling and bruise on the FRE, and there was no corresponding documentation about the origin of the right-hand injury. The surveyor reviewed the hospital emergency department's x-ray result of the resident's two legs dated 12/4/25 at 4:35 AM, which stated that Resident #1 sustained Acute fractures of the distal shafts of the bilateral femur (fracture of both legs), and that an X-ray of the resident's right hand was done due to: pain, bruising and unsure of trauma. The X-ray result further stated, suspicious for subtle fracture the base of the proximal phalanx (a fracture closest to the hand) of the right third finger. A review of the Nursing Comprehensive assessment dated [DATE], under Mobility, revealed that the resident's mobility was very limited and that the resident was unable to make frequent or significant changes independently. Functional Abilities section revealed the resident was dependent on others for care and for Activities of Daily Living (ADL). The baseline care plan stated that the resident had an ADL deficit. A review of Resident #1's care plan initiated on 11/22/25, included a focus area on risk for falls. The care plan indicated three levels of risks for fall which included: high, moderate or low. The facility did not specify Resident #1's level of risk and did not specify the number of staff needed to assist the resident with repositioning in bed during care. The surveyor reviewed a progress Note (PN) dated 11/24/25 at 1:18 PM, which stated that Resident #1 required total care with 2 assist for repositioning. Another PN dated 11/26/26 at 2:29 PM, stated that the resident required 2 assist with care and repositioning. The facility did not include 2 assist requirement in the resident's baseline care plan. An undated employee statement from CNA #1 which was signed by the Assistant Director of Nursing (ADON) did not indicate that the resident had 2 persons helping with their repositioning during care on 11/27/25. The surveyor conducted telephone interview with RN #1 regarding the 11/27/25 incident. She confirmed that she did not assist CNA #1 with repositioning of the resident in bed during the care of Resident #1. She stated that she assessed the resident after the fall and noted no pain. RN#1 did not provide further information regarding follow up interventions to address the resident's fall and did not provide information about the required level of care for the resident. According to the facility's Investigational Summary and Conclusion, the facility stated that they determined the bilateral femur fractures they identified on 12/03/25 resulted from the resident's fall that occurred on 11/27/25. There was no evidence that the facility monitored the resident for pain and injury following the fall on 11/27/25. There were no interventions put in place on 11/27/25 to protect the resident from further fall and injury. The DON during an interview with the surveyor on 1/29/26 at 12:52 PM, she provided no explanation for why the facility's investigational conclusion summary linked the resident's bilateral leg fractures which facility identified on 12/03/25, to the fall that occurred on 11/27/25. The DON did not provide information of how the facility protected Resident #1 from further injury following the fall on 11/27/25 and did not provide information regarding the swelling and bruising on the resident's right hand. The facility's Incident and Accident policy with an implemented date of 9/1/24 and revised date of 10/20/25, under the Policy Explanation .facility will assure that appropriate and immediate interventions are implemented and corrective actions taken to prevent reoccurrences . the policy also stated that they would conduct root cause analysis to ascertain contributing factors . NJAC8:39-33.2 (d)

Complaint #2687290Based on interviews, medical record reviews, and review of other pertinent facility documents on 1/29/26, it was determined that the facility failed to conduct thorough investigations into incidents on 11/27/25 and 12/1/25. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1).The evidence was as follows: A review of Resident #1's admission Record (AR) revealed that the resident was admitted to the facility with diagnoses that included but was not limited to muscle weakness and functional quadriplegia.A review of Resident #1's comprehensive Minimum Data Set (MDS), an assessment tool dated 11/28/25, revealed that Resident # 1 had a Brief Interview Mental Status (BIMS) score of 9 out of 15, which indicated the resident was moderately cognitively impaired.A review of the resident's care plan revealed a focus care area of right hand swelling and bruise, with an initiated date of 12/01/25. A review of Progress Note (PN) dated 11/27/25 at 1:49 PM, written by Registered Nurse (RN) #1, revealed that during incontinent care, the resident was being turned in bed and both of the resident's lower extremities slid off the bed and touched the floor while their upper body remained on the side of the bed.A review of RN #1's statement indicated that the resident was not injured and did not have any signs of pain after the 11/27/26 fall. On 1/29/26 at 12:05PM, the surveyor conducted an interview with the Unit Manager LPN (UM/LPN) about facility process for conducting investigations. She stated that facility process is that the assigned nurse to report the incident to the nursing supervisor who would then obtain witness statements and start the investigation. She further stated that the expectation is that on the day of the incident, all witness statements are obtained, signed and dated by the staff that provided the statements. On 1/29/26 at 12:52 PM, the surveyor conducted an interview with the Director of Nursing (DON), who stated that the incident that occurred on 11/27/25 did not have a separate investigation from the incident that occurred on 12/03/25. The DON also confirmed that the swelling and bruise that was identified on the resident's right hand on 12/01/25, did not have a separate investigation as to how or when the injury occurred. NJAC 8:39-4(f)

Complaint # 2687290 Based on interviews, medical record reviews, and review of other pertinent facility documents on 1/29/26, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH), an injury of unknown origin by not reporting a bruise and swelling on the resident's right hand the facility found on 12/1/2025. This deficient practice was identified for 1of 4 residents reviewed (Resident #1) A review of Resident #1's admission Record (AR) revealed that the resident was admitted to the facility with diagnoses that included but was not limited to muscle weakness and functional quadriplegia (unable to move arms and legs).A review of Resident #1's comprehensive Minimum Data Set (MDS), an assessment tool, dated 11/28/25 revealed that resident #1 had a Brief Interview Mental Status (BIMS) score of 9 out of 15, which indicated that the resident was moderately cognitively impaired.A review of Resident #1's care plan dated 12/01/25, revealed a focus care area of swelling and bruising to the resident's right hand.A review of the facility's Reportable Event (FRE) which the facility submitted to NJDOH on 12/05/25, did not address the bruise and swelling on the resident's right hand.On 1/29/26 at 12:52PM, the surveyor conducted an interview with the Director of Nursing (DON) who revealed that the facility could not provide any documented evidence that the identified swelling and bruise on the resident's right hand was reported to NJDOH when they identified the injury on 12/01/25.A review of the facility's policy on Abuse, Neglect and Exploitation with a revised date of 9/01/25 under Reporting Response revealed that the facility will have written procedures that include reporting all alleged violations to the Administrator, state agency, adult protective services and all other required agencies within specific time frames: a) Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious body injury or b) Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serios body injury. NJAC 8:39-9.4(f)

Complaint # 2624450, 2661339 Based on interview, record review, and review of pertinent facility documentation on 11/12/25, it was determined that the facility failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs) received the necessary assistance with breakfast in accordance with their assessed needs. This deficient practice was identified for 1 of 3 residents reviewed for ADLs (Resident #2).The evidence was as follows: A review of the admission Record (AR) revealed that Resident #2 was admitted to facility with diagnoses that include but were not limited to; functional quadriplegia, dementia, and severe protein calorie malnutrition. A review of the Resident #2's comprehensive Minimum Data Set (MDS), an assessment tool dated 10/17/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 of 15, indicating that the resident's cognition was severely impaired. A review of the resident's individualized care plan included a focus area initiated 10/15/25, that the resident had an ADL self-care performance deficit related to weakness and paraplegia. Interventions included total dependence of two staff for eating initiated on 10/15/25. On 11/12/25 at 2:48 PM, the surveyor conducted an interview with the Director of Nursing (DON), who stated that the residents who required assistance with meals were identified on the Certified Nursing Assistance's (CNA) assignment sheet. The DON further stated that the CNAs, nursing staff, and the DON provided assistance to the residents during meals. On 11/12/25 at 3:38 PM, the surveyor conducted an interview with the Director of Social Services (DSS), who stated that Resident #2's Representative (RR) recently came to her with a concern. The DSS stated that she could not recall the date, but the time was approximately noon, when the RR informed her that they observed Resident #2's untouched breakfast tray at the resident's bedside. The DSS stated at that time, she accompanied the RR to Resident #2's room and confirmed the resident's breakfast tray was untouched. The DSS stated that the resident required assistance from staff with eating, and the resident was not provided the assistance. The DSS stated that she promptly contacted the Food Service Director and a new breakfast tray was delivered to the resident and the staff assisted Resident #2 with their breakfast tray. NJAC 8:39- 17.4(d)

Based on interview, record review and, review of other pertinent facility documents on 11/12/25, it was determined that the facility failed to ensure that a resident received wound care as ordered by the physician. This deficient practice was identified for 2 of 2 residents reviewed for wound care (Resident #1 and Resident #2).The evidenced was as follows: 1.A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to; anoxic brain damage, stereotyped movement disorder, muscle spasm, and depressive disorder. A review Resident #1's quarterly Minimum Data Set (MDS) an assessment tool dated 9/4/25, revealed that the resident's cognition was severely impaired. A review of the Care Plan dated on 6/9/25, included a focus area that Resident #1 had actual skin breakdown; [The resident had] actual skin breakdown upon admission to facility including pressure ulcers to his left hip and right elbow. [The resident] was also admitted with multiple arterial injuries/ wounds to right foot. [Resident #1] is severely contracted, has impaired mobility, incontinence of bowel and bladder, ect and is at risk for further breakdown. A review of Resident #1's September 2025 Treatment Administration Record (TAR) included blank spaces indicating that ordered treatments were not completed as follows: A physician's order (PO) dated 9/11/25, for medihoney wound burn dressing, external gel (wound dressing) apply to left hip topically every day shift for wound #18 pressure ulcer cleansed with normal saline solution (NSS) pat dry, apply honey to wound bed and cover with gauze and border gauze was blank for the day shift on 9/15/25. A PO dated 6/23/25, for skin prep wipes; apply to right elbow topically every day shift for wound care was blank for the day shift on 9/4/25 and on 9/5/25. A PO dated 8/9/25, for left hip cleanse open area with NSS pat dry, apply collagen and active with NSS damp gauze and cover every day and evening shift for wound #18 pressure ulcer improving was blank for the day shift on 9/4/25 and 9/5/25. A PO dated 6/4/25, for weekly skin assessment every day shift on every Thursday for monitoring was blank for the day shift on 9/4/25. A PO dated 8/1/25, for Xeroform oil emulsion gauze external pad (bismuth tribromophenate-petrolatum); apply to left toe topically every day shift every two days for wound #25 arterial ulcer cleanse area with NSS pat dry. Apply Xeroform and cover with boarder gauze was blank for day shift on 9/4/25. A PO dated 9/12/25, for Xeroform petrolat patch two-by-two (2x2) external pad (bismuth tribromophenate-petrolatum); apply to right shoulder topically every day shift for skin tear cleanse sight shoulder skin tear with NSS and apply Xeroform to the base of the wound and cover with dry dressing daily was blank for the day shift on 9/15/25 and 9/25/25. A review of Resident #1's October 2025 TAR included blank spaces indicating that the ordered treatments were not completed as follows: A PO dated 10/22/25, to cleanse right elbow with normal saline, pat dry, apply Xeroform and cover with border gauze daily every day shift every two days for skin tear was blank for the day shift on 10/28/25. A PO dated 9/11/25, for medihoney wound burn dressing external gel (wound dressing); apply to left hip topically every day shift for wound #18 pressure ulcer cleanse with NSS, pat dry apply honey to wound bed and cover with gauze and bordered gauze was blank for the day shift on 10/28/25. A PO dated 9/11/25, to cleanse right distal foot with NSS, pat dry, apply betadine dampened gauze, cover with dry gauze every day shift every two days for wound #28 arterial ulcer was blank for the day shift on 10/28/25. A PO dated 10/9/25, for skin prep wipes miscellaneous (ostomy supplies); apply to left fifth toe topically every day shift for arterial ulcer cleanse area with NSS, pat dry, apply skin prep, let dry was blank for the day shift on 10/28/25. A PO dated 9/12/25, for Xeroform petrolat patch 2x2 external pad (bismuth tribromophenate-petrolatum); apply to right shoulder topically every day shift for skin tear cleanse right shoulder skin tear with NSS apply xeroform to the base of the wound and cover with dry dressing daily was blank on the day shift on 10/28/25. A PO dated 9/24/25, to offload bilateral feet with pillow every shift was blank for the day shift on 10/28/25. A PO dated 9/24/25, to offload bilateral feet with pillow every shift was blank for the night shift on 10/28/25. A review of Resident #1's November 2025 TAR revealed blanks for: A PO dated 10/31/25, to cleanse right distal foot with normal saline solution, pat dry, apply A&D ointment daily LOA (location of application) was blank for the day shift on 11/6/25. A PO dated 11/5/25, cleanse right hand with NSS. Pat dry apply bacitracin and cover with band aid daily, every day shift for post biopsy was blank for the day shift on 11/6/25. A PO dated 9/11/25, for medihoney wound burn dressing external gel (wound dressing); apply to left hip topically every day shift for wound #18 pressure ulcer cleanse with NSS, pat dry apply honey to wound bed and cover with gauze and bordered gauze was blank for the day shift on 11/6/25. A PO dated 10/9/25, for skin prep wipes miscellaneous (ostomy supplies); apply to left fifth toe topically every day shift for arterial ulcer cleanse area with NSS, pat dry, apply skin prep, let dry was blank for the day shift on 11/6/25. A PO date 6/4/25, for weekly skin assessment, every day shift every Thursday for monitoring was blank for the day shift on 11/6/25. A PO dated 9/2/25, for Xeroform petrolat patch 2x2 external pad (bismuth tribromophenate-petrolatum); apply to right shoulder topically every day shift for skin tear cleanse sight shoulder skin tear with NSS apply Xeroform to the base of the wound and cover with dry dressing daily was blank for the day shift on 11/6/25. A PO dated 9/24/25, to offload bilateral feet with pillow every shift was blank for the day shift on 11/6/25. On 11/12/25 at 2:48 PM, the surveyor conducted an interview with the Director of Nursing (DON), who stated that wound treatments were performed by the facility nursing staff. The DON further stated that an external wound care company conducted weekly wound assessment, and the facility nurses were responsible for receiving the treatment orders, implementing and documenting them accordingly. 2.A review of the admission Record (AR) revealed that Resident #2 was admitted to facility with diagnoses that include but were not limited to; functional quadriplegia, dementia and sever protein calorie malnutrition. A review of Resident #2's comprehensive MDS dated [DATE], revealed that the resident had BIMS score of 3 out of 15 indicated severe cognitive impairment. A review of the Care Plan dated 10/21/25, included a focus area that Resident #2 had Actual skin breakdown upon admission; [the resident] has actual skin breakdown upon admission including multiple pressure ulcers to sacrum/ right and left ischium, also trauma wound to right leg. Interventions included to provide treatment as ordered. A review of Resident #2's November 2025 TAR included blanks for the following: A PO dated 10/31/25, for betadine external solution (povidone-iodine); apply to right anterior lower leg topically every day shift for wound care paint with betadine was blank on the day shift on 11/6/25. A PO dated 10/31/25, for medihoney wound burn dressing external gel (wound dressing); apply to right ischium topically every day shift for wound care cleanse right ischium with NSS, pat dry apply medihoney, apply gauze, cover with bordered foam dressing daily and as needed was blank for the day shift on 11/6/25. A PO dated 10/31/25, for Triad Hydrophilic wound dress external paste (wound dressings) apply to sacrum topically every day and evening shift for PPX (preventive prophylaxis treatment) cleanse sacrum with normal saline, pat dry, apply triad twice a day was blank for the day shift on 11/6/25. On 11/12/25 at 2:48 PM, the surveyor conducted an interview with the DON, who stated that wound treatments were performed by the facility nursing staff. The DON further stated that an external wound care company conducted weekly wound assessment, and the facility nurses were responsible for receiving the treatment orders, implementing and documenting them accordingly. A review of the facility's undated policy titled Documentation of Medical Record revealed that under Policy explanation and Compliance Guidelines included that the Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. NJAC 8:39-11.2(b)

Based on observations, document review, interviews, and policy review, the facility failed to ensure cold storage areas were clean, the freezer temperature was within standards, expired foods were disposed of properly, the ice machine was cleaned, and the food thermometer was cleaned between use for one of one kitchen and one of two food pantries affecting 84 of 104 residents who consumed food in the facility. This failure had the potential to lead to foodborne illnesses and cross contamination.Findings include: During an observation on 11/30/25 at 8:00 AM, alongside the Dietary Manager (DM), the upright meat cooler had a container of raw meat on an upper shelf- leaking blood throughout, on the right side of the rack. The left side of the white rack had dried pink liquid. The DM stated it was cleaned weekly but should be cleaned right away. The DM moved the leaking meat to the lower shelf in a contained metal pan, along with other raw meat. The DM confirmed it should not have been leaking like that. During an observation on 11/30/25 at 8:06 AM, alongside DM, the upright ice cream freezer had an internal temperature of 20 degrees Fahrenheit (F), verified by the DM. The ice cream containers were observed to be soft, not fully frozen. The DM stated the temperature should have been zero degrees. The three-door upright freezer across from the ice cream freezer had two thermometers. One read eight degrees F, and the other read 12 degrees F. This was confirmed by the DM. The food was observed to be fully frozen. At 8:09 AM, the walk-in freezer was observed to have dirty, rusty racks throughout. The surface was observed to be a non-cleanable surface. The DM stated the rust had been there a while and the racks should have been cleaned weekly. During an observation on 12/02/25 at 8:02 AM, alongside Administrative Assistant (AA) 2, the East Pantry Refrigerator had an 8-ounce whole milk carton, dated 11/30/25, and a mighty shake carton marked with a discard date of 11/12/25. AA2 confirmed the items were expired. The freezer had a pre-packaged container of pulled chicken salsa verde, dated with a best if used by date of 07/25/25. There was a pre-packaged container of gyro slices, with a best by date of 09/14/25. AA2 confirmed they were expired. During an observation on 12/02/25 at 8:33 AM, alongside the DM, the ice machine was dirty along the hard white plastic center piece, inside of the ice machine. It contained a dark brown substance along the bottom edge. The DM confirmed it was dirty and that it had last been cleaned 10/31/25. He stated the ice machine was cleaned monthly. Review of the 2025 Ice Machine Cleaning/ Sanitizing Schedule, provided by the facility, revealed a blank space for November. The most recent date the machine was cleaned was 10/31/25. During an observation on 12/02/25 at 8:42 AM, alongside the DM, the ice cream freezer was eight degrees F, and the ice cream was noted to be soft, not fully frozen. The freezer across from the ice cream freezer was observed at eight degrees F, and the food in the freezer remained frozen. During an observation of lunch preparation and interview on 12/02/25 at 9:08 AM, the Dietary Assistant (DA) 2 was observed to place the thermometer under running water and wipe it with a dry towel. DA2 was observed to place the thermometer into the green beans for temperature, without sanitization. When asked about the process of sanitizing the thermometer, she went to retrieve alcohol pads. At 9:18 AM, DA2 took the thermometer out of the holder without sanitizing it and took the temperature of the green beans. She placed the thermometer back into the holder directly, without sanitizing. She took the thermometer out of the holder again, sanitized it and took the temperature of the mechanical green beans. She placed the thermometer back into the holder directly, without sanitizing. The DM confirmed the staff should have cleaned the thermometer with alcohol pads before taking the temperature and then should have sanitized again after. During an interview on 12/02/25 at 9:47 AM, the Registered Dietitian (RD) stated she conducted monthly kitchen sanitation audits. She stated she did not include the hall pantries in her audit. She was unsure how often the ice machine should have been cleaned. She was unsure of the thermometer sanitization process. Review of the facility's policy titled, Monitoring of Cooler/Freezer Temperature, dated 09/01/25, revealed, All frozen storage must be maintained at or -4 degrees F, unless otherwise specified by law . Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date . Review of the facility's policy titled, Ice Machines and Portable Ice Carts, dated 09/01/25, revealed Ice machine(s) or carts will be cleaned at any time contamination may have occurred or when visibly soiled.Review of the facility's policy titled, Record of Food Temperatures, dated 09/01/25, revealed Food temperatures will be verified using a thermometer which is both clean, sanitized . NJAC 8:39-17.2(g)

Based on observation, interviews, record review, and policy review, the facility failed to ensure medications were administered in accordance with infection control measures for one (Resident (R) 108) of six residents reviewed in a total sample of 27. This failure placed residents at risk of cross-contamination.Findings included.Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R108 was admitted to the facility on [DATE] with a diagnosis of cerebral palsy (brain disorder at birth), respiratory failure, and was ventilator dependent. During an observation on 12/02/25 at 8:59 AM, Registered Nurse (RN) 1 entered R108's room with medications that were placed in four different medication cups for administering through a gastrostomy tube (G-tube-a tube inserted into the stomach to allow for nutrition and medications). RN1 then placed the four cups on an overbed table. She did not use a barrier, nor did she clean the table prior to placing the cups on the table.During an interview on 12/02/25 at 9:06 AM, RN1 was asked why she did not place a barrier down on the table prior to placing the medication cups. RN1 acknowledged that a barrier was not placed or the table cleaned prior to medication pass.During an interview on 12/02/25 at 10:39 AM, the Director of Nursing (DON) was told about the observation. The DON stated, She should have used a barrier as the disposable barriers are located in the cart.Review of the facility policy titled, Medication Administration, dated 09/01/25 revealed, . Medications are administered by licensed nurses, or other staff who are legally authorized to do in this state as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection . NJAC 8:39-19.4

Based on observation, record review, interviews, and policy review, the facility failed to ensure a physician order and consent was obtained for bed rail use for one of one resident (Resident (R) 65) reviewed for bed rails out of 27 sample residents. This failure had the potential to affect safety for all residents who had bed rails. Findings include: Review of the admission Record located under the Profile tab of the electronic medical record (EMR) revealed an admission date on 08/15/24 with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness) affecting left dominant side. Review of the admission Nursing Comprehensive Assessment, dated 08/15/24, and located under the Assessments tab of the EMR, revealed the resident was assessed for bed rail usage, to include proper fit, no gaps between the rails and mattress, and alternatives attemptedReview of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/11/25 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R65 was moderately cognitively impaired. Review of the Orders located under the Orders tab of the EMR revealed no orders for the bed rails. Review of the Care Plan located under the Care Plan tab of the EMR revealed no care plans related to the bed rails.Review of R65's EMR revealed no consents in place for bed rails. During an observation on 11/30/25 at 10:11 AM, R65 was observed to have bilateral bed rails used for mobility. During an interview on 12/03/25 at 8:21 AM, the Rehab Director stated they used the bed rails for residents at fall risk, and they used the Enabler bars for residents who could assist with rolling themselves. During an interview on 12/03/25 at 11:54 AM, the Director of Nursing (DON) stated R65 had Enabler bars and acknowledged there were no orders or consents in place for R65, prior to this date. Review of the facility's policy titled, Bed Rails, dated 09/01/25, revealed, Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted . Upon receiving informed consent, the facility will obtain a physician's order for the use of the bed rail . NJAC 8:39-27.1(a)

Based on observation, interview, record review, and policy review, the facility failed to protect a resident's right to dignity while receiving medication through a gastrostomy tube (G-tube-a tube inserted into the stomach for nutrition and medication) for one (Resident (R) 108) of one resident observed for G-tube medications out of a total sample of 27. This failure placed residents at risk of a diminished quality of life and embarrassment. Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R108 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy (a neurological disorder that affects movement, muscle control, and posture due to brain damage), respiratory failure, and dependence on respirator (ventilator) status.Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/28/25 revealed R108 could not be understood and was assessed by staff to be severely impaired in cognition. During an observation on 12/02/25 at 8:59 AM, Registered Nurse (RN) 1 prepared the morning medications for R108 which were to be administered via a G-tube. RN1 entered the room but did not shut the door or pull the curtain to maintain R108's dignity/privacy. R108 was observed lying in bed and wearing a hospital gown. There was no sheet or blanket that covered R108. RN1 lifted R108's hospital gown which revealed his abdomen, the G-tube and R108's brief. RN1 administered the medications to R108 without shutting the door or pulling the curtain.During an interview on 12/02/25 at 9:06 AM, RN1 stated, I should have pulled the curtain or shut the door.During an interview on 12/02/25 at 10:00 AM, the Director of Nursing (DON) was informed of the observation with RN1. The DON stated, She should have either shut the door or pulled the curtain. That is a dignity issue.Review of the facility policy titled, Promoting/Maintaining Resident Dignity, dated 09/01/25, revealed, . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances residents' quality of life by recognizing each resident's individuality .Maintain resident privacy . NJAC 8:39-4.1(a)

Based on interview, record review, and policy review, the facility failed to provide information on the risks and benefits of the use of a wander guard for one (Resident (R)10) of one resident reviewed for elopement in a total sample of 27. This failure placed the residents and/or representatives at risk of not being informed.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a complex mental illness causing disruptions in thought, mood, and behavior) and dementia.Review of the Elopement Care Plan, revised on 02/10/24 and located in the Care Plan tab of the EMR revealed, [R10] is an elopement risk/wanderer. Periods of impaired safety awareness. Interventions included but were not limited to: Wander guard in place to right ankle, dated 05/23/23 and revised on 09/09/25.Review of the Assessments tab and the Miscellaneous tab of the EMR did not show documentation that R10 or his representative were informed of the risks and benefits of the wander guard.Review of the annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/23/25 revealed R10 had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated R10 was severely cognitively impaired. R10 had delusions (false beliefs that persist despite evidence to the contrary) and used a wander/elopement alarm.During an observation on 11/30/25 at 3:08 PM, R10 was observed in his bed with a wander guard on his right ankle.During an interview on 12/03/25 at 11:00 AM, the Director of Nursing (DON) was asked if R10 had eloped in the last year. She stated, No.During an interview on 12/03/25 at 12:12 PM, the Assistant Director of Nursing (ADON) stated there was no information provided to the representative on the risks and benefits of the wander guard.Review of the facility policy titled, Elopements and Wandering Residents, dated 09/01/25, revealed, . The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks . NJAC 8:39-4.1(a)

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure beds and baseboard heaters were maintained in a safe manner for three of 27 residents (Resident (R) 10, R54, and R13) whose environments were reviewed. This failure had the potential to cause injury.Findings include:1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE] with diagnoses that included dementia.Review of the annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/23/25 revealed R10 had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated R10 was severely cognitively impaired.During an observation on 11/30/25 at 10:56 AM, the footboard and headboard of R10's bed revealed exposed plywood which was rough, and the veneer had peeled away revealing sharp edges.2. Review of the admission Record located in the Profile tab of the EMR revealed R54 was admitted to the facility on [DATE] with diagnoses that included dementia.Review of the comprehensive MDS located in the MDS tab of the EMR with an ARD of 09/25/25 revealed R54 had a BIMS score of five out of 15, which indicated R54 was severely cognitively impaired.During an observation on 11/30/25 at 10:58 AM, the footboard and headboard of R54's bed revealed exposed plywood which was rough, and the veneer had peeled away revealing sharp edges.During an interview on 11/30/25 at 11:08 AM, Licensed Practical Nurse (LPN) 4 was shown the beds and confirmed that the veneer was peeling off and they had sharp edges.During an interview on 11/30/25 at 11:12 AM, the Director of Nursing (DON), the Maintenance Director (MD), and Unit Manager (UM) 1 all observed the beds with peeling veneer and sharp edges and confirmed that they needed to be replaced right away.3. Review of the admission Record located in the Profile tab of the EMR revealed R13 was admitted to the facility on [DATE] with diagnoses that included mild dementia with agitation.Review of a significant change MDS located in the MDS tab of the EMR with an ARD of 09/25/25 revealed R13 had a BIMS score of 14 out of 15 which indicated R13 was cognitively intact.During an observation on 12/01/25 at 8:48 AM, the baseboard heating element was pulled away from the wall and was actively putting out heat. The gray metal covering of the heating element was peeling away causing significant sharp edges. R13 stated, It's been like that since I moved into this room.During an interview on 12/01/25 at 8:49 AM, UM1 observed the heating element and confirmed that it was a safety hazard. During an interview on 12/01/25 at 8:57 AM, the Administrator was asked who was responsible for ensuring resident equipment was safe and homelike. The Administrator stated, Maintenance is.Review of the facility policy titled, Safe and Homelike Environment, dated 09/01/24, revealed, . In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk . NJAC 8:39-4.1(11)

Based on record review, interview, facility document review, and policy review, the facility failed to provide a notice of transfer to the resident, the representative, and Ombudsman; failed to ensure notices contained information related to the appeals process; and/or failed to record the reason for discharge in a language that could be understood for two of four resident (Resident (R) 8 and R28) reviewed for discharge requirements out of a total sample of 27. These failures had the potential to cause confusion for residents and representatives trying to make informed decisions when residents were transferred to the hospital.Findings include:1. Review of R8's admission Record located under the Profile tab in the electronic medical record (EMR) indicated R8 was originally admitted to the facility on [DATE] with diagnoses of dependence on respirator (ventilator) status, type two diabetes mellitus, and acute and chronic respiratory failure.Review of R8's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 07/21/25 revealed R8 was severely cognitively impaired.Review of R8's Nursing Progress Note, dated 09/16/25 and located under the Progress Note tab in the EMR, revealed, Around 01:50 AM, . Resident was found on the floor, next to the lower position bed. Resident was assessed immediately . Superficial lacerations on the forehead, and 2.5cm [centimeters] abrasion on the right forehead noted. UM [unit manager] and MD [medical doctor] notified. MD orders send Resident to [name of emergency room] for further evaluation .Review of R8's EMR in its entirety and of the facility's binder labeled Transfers, located at the nursing station, revealed no documentation that the facility provided a notice of transfer to R8 and the resident's representative or that the notice was given to the Ombudsman.During an interview on 12/02/25 at 10:14 AM, the Administrative Assistant (AA) 1 stated there should have been a notice of transfer for R8 when she was transferred to the hospital on [DATE]. AA1 stated, The nurses usually fill this [notice of transfer] out and then I fax this to the Ombudsman and send a copy to Admissions. I believe Admissions sends the families a copy of this. AA1 confirmed that there was not a notice of transfer for R8.During an interview on 12/03/25 at 8:50 AM, Licensed Practical Nurse (LPN) 1 stated, I really can't remember if I did the transfer notice or not [for R8]. LPN1 stated she should have filled out a transfer notice and put it on the desk for the unit clerk.2. Review of R28's Face Sheet located under the Profile tab in the EMR indicated R28 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, type two diabetes mellitus, and tracheostomy status.Review of R28's quarterly MDS located under the MDS tab in the EMR with an ARD of 10/30/25 revealed R28 was severely cognitively impaired.Review of R28's Nursing Progress Note, dated 11/23/25 and located under the Progress Note tab in the EMR, revealed, . VS [vital signs] obtained BP [blood pressure] 52/30. [name of MD] team contacted. order to transfer resident to ER [emergency room] . Review of R28's Notice of Transfer dated 11/22/25 indicated the reason for transfer was Hypotension, AMS [altered mental status]. The notice of transfer did not have the name or contact information of an entity that the resident representative could contact about appealing the facility's decision to discharge R28 from the facility. During an interview on 12/02/25 at 11:40 AM, the Administrator confirmed that the notice of transfer did not include any entity information other than the Ombudsman to contact in cases when the resident and/or the resident representative wanted to appeal the decision to be discharged when sent to the hospital.During an interview on 12/03/25 at 8:50 AM, LPN1 confirmed the language on the notice of transfer for R28 contained medical terms for the reason of transfer and was not in a language that the resident representative would understand.Review of the facility's policy titled, Transfer and Discharge (including AMA [Against Medical Advice]), dated 03/10/25, indicated, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include the following at the time it is provided: . d. An explanation of the right to appeal the transfer or discharge to the State. e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. f. Information on how to obtain an appeal form. g. Information on obtaining assistance in completing and submitting the appeal hearing request. NJAC 8:39-4.1(a)

Based on record review, interview, and policy review, the facility failed to ensure the accuracy of the Minimum Data Set (resident assessment) related to an antipsychotic medication for one of 27 residents (Resident (R) 75) reviewed creating an inaccurate assessment of the resident's psychological status.Findings include:Review of the admission Record located in the electronic medical record (EMR) under the Profile tab revealed R75 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia and schizophrenia.Review of the Physician's Orders located in the EMR under the Orders tab revealed R75 was prescribed quetiapine fumarate (an antipsychotic medication) 50 milligrams (mg) by mouth two times a day for schizophrenia on 09/16/25. Review of the Medication Administration Record (MAR) located in the EMR under the Orders tab, for the month of October 2025, revealed R75 received the antipsychotic medication twice a day as prescribed.Review of the MAR located in the EMR under the Orders tab, for the month of November 2025, revealed R75 received the antipsychotic medication twice a day as ordered until 11/20/25 when she was hospitalized . Upon return to the facility, on 11/24/25, the medication was reduced to one time a day.Review of the quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/06/25 revealed R75 was not identified to be taking any antipsychotic medication. During a telephone interview on 12/02/25 at 10:21 AM, the Director of Clinical Reimbursement, responsible for completing the MDS assessments, confirmed that the antipsychotic should have been coded on the MDS as R75 was taking the medication.Review of the facility's policy titled, MDS 3.0 Completion, dated 09/01/25, revealed, Residents are assessed, using a comprehensive assessment process in order to identify care needs and to develop an interdisciplinary care plan. NJAC 8:39-33.2(d)

Based on observation, record review, and interviews, the facility failed to develop and implement a comprehensive care plan for three of 27 residents (Resident (R) 11, R8, and R65) reviewed. Specifically, the facility failed to develop an individualized activity care plan for R11 creating the potential for individual interests to not be identified; failed to develop an individualized care plan for R8 related to her seizure disorder creating the potential for staff to not respond as needed; and failed to develop an individualized care plan for R65's preference for daily showers creating the potential for showers to be missed.Findings include:1. Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R11 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, anxiety disorder, and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 09/04/25 revealed a Brief Interview for Mental Status (BIMS) without a score, which indicated R11 was unable to complete the assessment.Review of the 09/09/25 revised comprehensive Care Plan located under the Care Plan tab in the EMR revealed R11, has impaired communication due to diagnosis of anoxic brain damage. Rec [recreation] will visit [R11] daily for social dignity and stimulation. Maintain eye contact with [R11] if possible.Review of the Activity Participation records for October and November 2025, provided by the Activity Director (AD), noted R11 received room visits every morning and afternoon. Each room visit (RV) was coded with a 1, which indicated R11 was not actively involved.During observations on 11/30/25 at 10:17 AM, 12/01/25 at 9:05 AM, and 12/02/25 at 10:53 AM, R11 was in his room, in bed, unable to communicate verbally. R11 was observed to track with his eyes but was unable to consistently blink once for yes or twice for no, when asked.During an interview on 12/01/25 at 11:43 AM, the AD confirmed that she developed the activity care plans. When asked to explain what social dignity and stimulation entailed for R11, the AD said that the activity assistant would go in each morning, say good morning, state the date, weather, holiday, put up a decoration on the wall if applicable, and leave a facility newspaper. When asked what individualized activity plan was in place for R11 who was non-verbal, the AD said the activity assistant would show the resident pictures, provide sensory stimulation, or turn on the resident's television. When asked who provided information about R11's interests prior to the anoxic brain injury which left him non-verbal, the AD said no-one had been contacted for information regarding R11 and what he enjoyed prior to his injury. The AD confirmed that R11 had active involvement from his mother and brother; however, neither had been contacted for information to assist with developing an individualized care plan for R11.During an interview on 12/01/25 at 11:56 AM, the Activity Assistant (Act A) 1 confirmed that he provided the one-to-one interactions with R11. Act A 1 described showing pictures to R11 of animals and offering a smell and tell which was conducted with various smells on cotton balls and telling the resident what the smells were. When asked if he documented the reaction, if any, from R11 during the smell and tell or pictures, Act A 1 said, no. When asked if he contacted R11's family members to obtain prior interests, Act A 1 said, no.2. Review of R8's admission Record located under the Profile tab in the EMR indicated R8 was initially admitted to the facility on [DATE] with diagnoses of dependence on respirator (ventilator) status and seizures.Review of R8's H&P [History and Physical] located under the Progress Note tab in the EMR and dated 10/01/25 indicated, . Seizures: Continue with Keppra [seizure medication] . Review of R8's quarterly MDS located under the MDS tab in the EMR with an ARD of 10/07/25 revealed R8 was severely cognitively impaired.Review of R8's Care Plan located under the Care Plan tab in the EMR revealed there was no plan of care for R8's seizures.The MDS Coordinator was unavailable for interview during the survey.During an interview on 12/03/25 at 12:15 PM, the Assistant Director of Nursing (ADON) confirmed R8 did not have a care plan for seizures. The ADON stated, Yes, there should have been a care plan for seizures.3. Review of R65's admission Record located under the Profile tab of the EMR revealed an admission date of 08/15/24 with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness) affecting left dominant side. Review the Care Plan, dated 10/21/24 and located under the Care Plan tab of the EMR, revealed a focus area of ADLS [activities of daily living]; I require total care for my ADLS including with bathing. Interventions included Provide me with total bed bath every day.Date initiated: 10/21/24. Review of R65's annual MDS with an ARD of 09/11/25 and located under the MDS tab of the EMR revealed a BIMS score of 11 out of 15, which indicated R65 was moderately cognitively impaired. Review of the November 2025 Documentation Survey Report, revealed Shower/ Bathing/ Personal Care was documented as NA [not applicable] on 11/04/25, 11/06/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25, 11/14/25, 11/17/25, 11/19/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/25/25, and 11/27/25. No showers or baths were listed as being completed according to the care plan. During an interview on 11/30/25 at 10:06 AM, R65 stated he was not getting daily baths. During an interview on 12/01/25 at 11:23 AM, the Certified Nurse Aide (CNA) 5 stated R65's bathing schedule was Mondays and Wednesdays. She stated it would be documented in the medical record. During an interview on 12/01/25 at 12:58 PM, the Director of Nursing (DON) stated she was aware the care plan had daily baths listed for R65. She stated they had been doing audits to ensure the CNA documentation was getting done but had not been checking the documentation for accuracy. Review of the facility's Comprehensive Care Plan policy, dated 02/02/25, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care . Qualified staff responsible for carrying out interventions specified in the care will be notified of their roles. NJAC 8:39-11.2(e) thru (i)NJAC 8:39-27.1(a)

Based on interviews, record review, and policy review, the facility failed to ensure the Fall Care Plan was updated to include interventions to prevent falls after a resident had a fall with major injury for one (Resident (R) 13) of five residents reviewed for falls in a total sample of 27 residents. This failure placed the residents at risk for unmet care needs.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R13 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a complex mental illness with a major mood disorder) and ataxic gait (abnormal walking characterized by clumsy, staggering, and an uncoordinated walk).Review of the Medical Diagnosis list located in the Diagnosis tab of the EMR revealed, Displaced Fracture of Head of Left Radius, Subsequent Encounter for Closed Fracture with Routine Healing, dated 09/11/25.Review of a significant change Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/25/25 revealed that R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R13 was cognitively intact. In addition, R13 had one fall with no injury, one fall with injury, and one fall with a major injury since the previous assessment.Review of the Fall Care Plan, revised 10/30/25 and located in the Care Plan tab of the EMR revealed, Fall Risk: [R13] is at risk for falls r/t [related to] Psychoactive drug use and use of antihypertensive medication. [R13] sustained a fall on 06/13/25 during 7am-3pm shift, no major injuries, 08/14/25 sustained a fall, no injuries, 10/30/25 [R13] sustained a fall, no injuries. It did not document a fall with major injury or updated interventions following the fall. Review of the Pain Care Plan, revised on 09/11/25, revealed [R13] has pain r/t left wrist s/p fall. During an interview on 12/03/25 at 10:23 AM, the Unit Manager (UM) 1 was asked why the Fall Care Plan was not updated/revised to include the fall with fracture on 09/11/25. The UM stated, I am not that good at Care Plans, but I did do a Pain Care Plan for the fractured wrist. UM1 was asked since R13's other falls were listed on the Problem/Focus area why was this fall not listed as a Problem/Focus. UM1 confirmed that the 09/11/25 fall with fracture should have been listed as a Problem/Focus on the Care Plan.Review of the facility policy titled, Comprehensive Care Plans, dated 02/25/25, revealed, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . NJAC 8:39-11.2(e)

Based on observation, interviews, record review, and policy review, the facility failed to provide activities to meet the interests or needs of two of 27 residents (Resident (R) 11 and R8) reviewed. The failures created the potential for in-room visits to occur without the residents' individual interests or choice.Findings include:.1. Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R11 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, anxiety disorder, and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 09/04/25 revealed a Brief Interview for Mental Status (BIMS) without a score, which indicated R11 was unable to complete the assessment.Review of the 09/09/25 revised comprehensive Care Plan located under the Care Plan tab in the EMR revealed an R11 has impaired communication due to diagnosis of anoxic brain damage. Rec [recreation] will visit [R11] daily for social dignity and stimulation. Maintain eye contact with [R11] if possible.Review of the Activity Participation records, provided by the Activity Director (AD), for the months of October and November 2025 noted R11 received room visits every morning and afternoon. Each room visit (RV) was coded with a 1, which indicated R11 was not actively involved.During observations on 11/30/25 at 10:17 AM, 12/01/25 at 9:05 AM, and 12/02/25 at 10:53 AM, R11 was in his room, in bed, unable to communicate verbally. R11 was observed to track with his eyes but was unable to consistently blink once for yes or twice for no, when asked. The roommate's television was on. R11 was not observed to have a radio at his bedside, nor was his television on during the observations; only his roommates' television was on.During an interview on 12/01/25 at 11:43 AM, the AD confirmed that she developed the activity care plans. When asked to explain what social dignity and stimulation entailed for R11, the AD said that the activity assistant would go in each morning, say good morning, state the date, weather, holiday, put up a decoration on the wall if applicable, and leave a facility newspaper. When asked what individualized activity plan was in place for R11, who was non-verbal, the AD said the activity assistant would show the resident pictures, provide sensory stimulation, or turn on the resident's television. When asked who provided information about R11's interests prior to the anoxic brain injury which left him non-verbal, the AD said no-one had been contacted for information regarding R11 and what he enjoyed prior to his injury. The AD confirmed that R11 had active involvement from his mother and brother; however, neither had been contacted for information to assist with developing an individualized care plan for R11. When asked if R11 had been identified to enjoy a particular type of music, the AD said she did not know. The AD acknowledged that R11 is a very young man, but did not know what he enjoyed prior to his incident.During an interview on 12/01/25 at 11:56 AM, Activity Assistant (Act A) 1 confirmed that he provided the one-to-one interactions with R11. Act A 1 described showing pictures to R11 of animals and offering a smell and tell which was conducted with various smells on cotton balls and telling the resident what the smells were. When asked if he documented the reaction, if any, from R11 during the smell and tell or pictures, Act A 1 said, no. When asked if Act A 1 contacted R11's family members to obtain prior interests, Act A 1 said, no. When asked if he had provided music to the resident, Act A 1 said, no. No other individualized one-to-one activities were reported to have been offered to R11.2. Review of R8's admission Record located under the Profile tab in the EMR indicated R8 was originally admitted to the facility on [DATE] with diagnoses including dependence on respirator (ventilator) status, type two diabetes mellitus, and acute on chronic respiratory failure.Review of R8's Care Plan located under the Care Plan tab in the EMR indicated a Focus dated 04/18/25, I am not doing the activities I used to enjoy Being [sic] cognitively unable to do them, Decreased physical ability. The intervention indicated, Provide me with tv, music, & or visits to assist me in socialization & dignity.Review of R8's Recreation Quarterly Assessment located under the Assessment tab in the EMR and dated 08/04/25 indicated, Rec [recreation] makes social visits for dignity. There was no documentation to reflect the facility had spoken to R8's family to ascertain which TV shows R8 liked to watch or type of music R8 liked.Review of R8's quarterly MDS located under the MDS tab in the EMR with an ARD of 10/07/25 revealed R8 was coded as being severely cognitively impaired.Review of R8's Activity Calendar dated for the months of August through November 2025 indicated RV [room visits] were held with R8. There was no documentation to reflect what activities occurred during these room visits.During an interview on 12/01/25 at 11:44 AM, the AD stated, We just document on the records that they have room visits but not what we do. When asked if she talked with the family to find out what the resident's likes and dislikes were, the AD stated, I have spoken to the sister, but I really don't document each time we talk.Review of the undated facility policy, Meaningful Resident Activities indicated, To provide meaningful activities are provided [sic] as appropriate to the residents [sic] cognitive, physical, and social abilities on a regular basis to enhance their quality of life in and [sic] environment that is near normal as possible and involve the resident in a person-centered care approach. NJAC 8:39-7.4

Based on observation, record review, and interview, the facility failed to ensure a resident's room was free of accident hazards for one of 27 sampled residents (Resident (R)8). Specifically, the facility failed to respond timely to a water leak which reached electrical cords to the ventilator, bed, and enteral feeding pump of the resident. This failure had the potential to cause injury or equipment failure. Findings include:Review of R8's admission Record located under the Profile tab in the electronic medical record (EMR) indicated R8 was originally admitted to the facility on [DATE] with the diagnoses of dependence on respirator (ventilator) status and acute and chronic respiratory failure.Review of R8's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 07/21/25 revealed R8 was severely cognitively impaired. R8 had ventilator assistance for breathing and a tube feeding.During an observation on 12/02/25 at 12:45 PM, water from the back of the bathroom sink spilled over into a trash can and then into R8's room. The bathroom was noted to be beside the A bed, by the door. Water was noted to be on the floor underneath the A bed and flowed underneath R8's bed, by the window, where electrical cords from the ventilator, bed, and feeding pump were lying. The surveyor immediately notified Licensed Practical Nurse (LPN) 1 who came into R8's room to assess the situation and then proceeded to obtain the Maintenance Director (MD)'s phone number.At 1:00 PM, when nursing had been unable to reach the MD by phone, there was an overhead page for the MD to come to R8's room. LPN1 directed a Certified Nurse Aide (CNA) to get towels and try to get some of the water off the floor. The CNA laid towels at the bathroom door and then proceeded to go to R8's side of the room and put towels down. At 1:06 PM, the Housekeeping Supervisor (HSKP Sup) came into the room and called the MD on her cell phone. The HSKP Sup stated the MD was not answering the phone in his office and went to see if she could find him. Water was still observed running from the back of the sink and overspilling into the trash can onto the floor.At 1:18 PM, the MD came to R8's room, assessed the sink, and stated there was a valve on the back of the sink where a hose came off. The MD confirmed the water was under R8's bed and the electrical cords to the ventilator, bed, and feeding pump were laying in the puddled water. At 1:30 PM, The MD stated, Everything has been fixed, and the floor is dry. There is no more water under either bed in the room.During an interview on 12/02/25 at 2:45 PM, the Director of Nursing (DON) stated, My expectation was for maintenance to come immediately to the resident's room and stop the water from running out of the bathroom into [R8's] room and for the nurses and CNAs to ensure [R8] was safe.On 12/03/25 at 10:30 AM, the Administrator was asked for a policy to ensure safety of a resident when the electrical cords from the ventilator, bed, and feeding pump cords were laying in water.At 12:30 pm, the Administrator returned to the conference room and stated he was unable to find the requested policy pertaining to that situation. NJAC 8:39-5.1(a)NJAC 8:39-27.1(a)

Based on observation, interview, and document review, the facility failed to post the daily staffing report. This deficient practice has the potential to affect all 104 residents and visitors by not accurately informing them of the available nursing staff to care for the residents.Findings include:During an observation on 11/30/25 at 8:00 AM, the New Jersey Department of Health Nursing Home Resident Care Staffing Report was located on a table in the lobby, visible to the public, and noted to have a posting date of 11/28/25. The next posting behind the 11/28/25 one was dated 11/25/25.During an interview on 11/30/25 at 8:30 AM, the Director of Nursing (DON) stated, On the weekends it is not done. The staffing coordinator is the one responsible for placing the staff posting in the lobby, and she does that when she works.During an interview on 12/01/25 at 1:30 PM, the Staffing Coordinator (SC) stated, I do these postings Monday through Friday and then on the weekends, they are not done. I have it on my computer, and I could send it over, but I don't know if the supervisors would know the routine.Review of the facility's policy titled Nurse Staff Posting Information, dated 03/06/25, indicated, . The Nurse Staffing Sheet will be posted on a daily basis . NJAC 8:39-41.2

Complaint #: NJ00183653 Based on observation, interviews, and review of pertinent facility documents on 07/14/2025, 07/15/2025, and 07/18/2025, it was determined that the facility failed to implement their abuse policy and procedure to ensure all residents were protected from abuse when a cognitively impaired resident (Resident #1) was discovered tied to their wheelchair by their roommate (Resident #3) on 01/15/2025, and the incident was not reported and Resident #1 remained with their roommate until 01/16/2025. This deficient practice was identified for 1 of 7 residents reviewed for abuse (Resident #1). A review of the Facility Reportable Event (FRE), dated 01/17/2025, revealed that Resident #1's Representative (RR #1) reported observing Resident #1 tied to their wheelchair on 01/15/2025. Interview with the Certified Nursing Aide (CNA #1) revealed that on 01/15/2025, when she went to provide incontinence care on Resident #1 prior to bed, she observed Resident #1 tied to their wheelchair by a bedsheet. CNA #1 immediately removed the restraint, and asked who tied the resident up? The resident's roommate (Resident #3) responded, I tied [them] up because [they] keeps roaming in the room touching stuff. CNA #1 did not report the incident to anyone, and Resident #1 remained in the same room as Resident #3 until 01/16/2025, when the Director of Nursing (DON) reviewed RR #1's email and moved Resident #1. The facility's failure to implement their abuse policy including protecting Resident #1 from abuse, and immediately reporting and investigating all allegations of abuse, placed all residents at risk for abuse. This posed the likelihood of serious physical and psychosocial harm, or impairment which resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 01/15/2025, during the 3:00 PM to 11:00 PM shift, after Resident #1 was observed tied to their wheelchair by Resident #3, and CNA #1 did not report the incident leaving the two residents in the same room. The facility was notified of the IJ on 07/15/2025 at 7:30 PM. The facility submitted an acceptable Removal Plan (RP) on 07/17/2025 at 11:01 AM. The survey team verified the implementation of the RP on-site during the continuation of the survey on 07/18/2025 at 1:30 PM. The evidence was as follows:A review of the facility's policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation with an implementation date of 09/1/2024, included Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment [.] immediately to the Administrator of the facility. Compliance Guidelines.4. Identification. b. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment [.] which can include [.] resident to resident altercations. 7. Protection: The facility will protect residents from harm during an investigation.Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation.When suspicion of abuse/neglect/exploitation occur, the following procedure will be initiated [.] 1. The Licensed Nurse will: a. Respond to the needs of the resident and protect him/her from further incident. c. Notify the Administrator or designee. The surveyor reviewed the closed medical record for Resident #1. According to the admission Record face sheet (an admission summary), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: acute and chronic respiratory failure with hypoxia (body does not get enough oxygen), generalized muscle weakness, Alzheimer's Disease, and insomnia (sleep disorder with trouble sleeping). According to the quarterly Minimum Data Set (MDS), an assessment tool dated 02/06/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating the resident was severely cognitively impaired. A review of the Facility Reported Event (FRE) dated 01/17/2025, revealed the following: On 01/16/2025 at 2:30 PM, the DON received an email from RR #1, who stated that Resident #1 was tied to their wheelchair with a blanket during the previous evening shift. RR #1 stated that Resident #1 indicated that it was a [race and gender redacted] who tied them up. The facility interviewed the resident's Licensed Practical Nurse (LPN #1), who stated that RR #1 reported to her on 01/15/2025, that Resident #1 was playing with pants, twisting and making knots, and had shoulder pain. LPN #1 stated that she checked on Resident #1, who was in their wheelchair at bedside, twisting clothes, and she provided the resident with as needed pain medication. The facility interviewed CNA #1, who stated at the beginning of her shift, Resident #1 was observed at bedside in their wheelchair fidgeting with a cloth talking loudly but seemed pleasant. CNA #1 stated at bedtime, she went to provide incontinence care to Resident #1, and the resident was observed in their wheelchair with the flat [bed] sheet tied around them to the back of their chair. CNA #1 stated that she asked out loud who tied [them] to the chair? CNA #1 stated that Resident #1's roommate (Resident #3) replied, I tied [them] up because [they] keeps roaming in the room and touching stuff. The resident [Resident #1] was calm, smiling, and free from pain. The facility indicated that the Social Worker (SW) interviewed Resident #3, who stated that their roommate (Resident #1) was pacing around the room, touching belongings and disturbing [Resident #3]. Resident #3 stated that they proceeded to help [Resident #1] to the wheelchair, took a bedsheet, wrapped around [Resident #1] and the wheelchair. The SW indicated when she asked Resident #3 why they tied Resident #1 up, Resident #3 stated they did not want the resident to fall. The FRE did not indicate that after CNA #1 untied Resident #1, that she reported the incident to anyone, and Resident #1 remained in the same room as Resident #3. The conclusion indicated that CNA #1 was suspended pending investigation, and later cleared of abuse, but she was re-educated on types of abuse, reporting abuse, and preventing and protecting residents from abuse. The conclusion also indicated that Resident #1's room was changed (on 01/16/2025). During an interview on 07/14/2025 at 1:45 PM, Resident #3 was observed lying on their bed watching television. Resident #3 stated that they did not want their roommate (Resident #1) to sit on Resident #3's bed, that [tying up Resident #1] was not done out of anger; just wanted [their] roommate to leave [them] alone. Resident #3 stated that the nurse and other facility staff had spoken to them already about the incident, and the resident questioned why the incident was being brought up. During a telephone interview on 07/14/2025 at 2:00 PM, the surveyor attempted to interview CNA #1, but when questioned about the incident, CNA #1 hung up the telephone. The surveyor attempted to call again, and CNA #1 did not answer. On 07/14/2025 at 2:04 PM, the surveyor attempted to conduct a telephone interview with LPN #1, who did not answer. During a telephone interview on 07/15/2025 at 11:57 AM, RR #1 stated that they visited Resident #1 on 01/15/2025, and saw a blanket tied around the resident and the wheelchair with the knot at the back of the wheelchair. RR #1 stated that they told a nurse (could not recall who), and that nurse (unknown) untied Resident #1 right away. A review of the visitor's screening log indicated that RR #1 checked into the building on 01/15/2025 at 8:03 PM, and the log was blank for their checkout time. A review of CNA #1's employee file revealed that she resigned from the facility effective 06/23/2025. During an interview on 07/15/2025 at 12:38 PM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA), stated that the Business Manager provided her with an email from RR #1. The email indicated that RR #1 observed Resident #1 tied to their wheelchair with a sheet. The DON stated that she obtained statements from LPN #1 and CNA #1, and CNA #1 stated that she observed Resident #1 tied to their wheelchair and she untied the resident. The DON stated that when CNA #1 asked who tied the resident up, their roommate (Resident #3) stated that they did. The DON acknowledged that CNA #1 should have immediately reported the incident to the LNHA and herself on 01/15/2025. The DON also acknowledged that Resident #1 should have immediately been separated from Resident #3. The DON stated leaving Resident #1 with Resident #3 was considered abuse, because more harm could have happened being left in the room with their abuser. The facility submitted an acceptable Removal Plan (RP) on 07/17/2025 at 11:01 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice to include: Resident #1 no longer resides in facility, but they were assessed post incident; Resident #3 was evaluated post incident by psychiatric (psych) services and hourly monitoring was discontinued after psych determined they were not a threat to self or others; Resident #3 was educated about not abusing other residents and acknowledged understanding. On 07/16/2025, the DON and Social Services Director interviewed residents with a BIMS score of 12 or above for potential abuse. On 07/16/2025, all abuse policies and procedures were reviewed, the DON and/or designee re-educated all staff on the facility's Compliance with Reporting Allegation of Abuse/Neglect/Exploitation and Abuse, Neglect, Exploitation policies, and in the event of any future resident-to-resident abuse, the perpetrating resident will immediately be placed on one-to-one supervision until primary care, nursing, and psych evaluations can be completed. The survey team verified the implementation of the RP on-site during the continuation of the survey on 07/18/2025 at 1:30 PM. NJAC 8:39-4.1(a)(5)

A.) Based on observation, interview and record review, it was determined that the pharmacy consultant failed to ensure that irregularities in medication orders in the presence of known and documented mediation allergies were identified and reported to the attending physician and director of nursing. This resulted in an Immediate Jeopardy situation for Resident #8. Resident #8 had diagnoses of [CONDITION(S)], Pulmonary Fibrosis and Chronic Obstructive Pulmonary Disease ([CONDITION(S)]) and returned from a hospital admission (opiate induced [CONDITION(S)]) on 6/13/17 with orders not to administer opiates, benzodiazepines, [MEDICATION(S)] and [MEDICATION(S)] ([MEDICATION(S)]). The resident had documented allergies to [MEDICATION(S)] and [MEDICATION(S)]. On 6/23/17 a nurse practitioner ordered and the resident received [MEDICATION(S)] and [MEDICATION(S)]. On 7/10/17 the resident returned to the hospital for a few hours due to acute [CONDITION(S)] and returned on the same meds. On 7/23/17 the resident became extremely lethargic and staff documented a potential for [MEDICATION(S)] reaction in the past and [MEDICATION(S)] was administered at the facility with no effect. The resident showed signs of a [CONDITION(S)] and [MEDICATION(S)] (a benzodiazepine) was ordered and administered. The resident remained on [MEDICATION(S)]. The resident was not transferred to the hospital due to physician orders to Do Not Resuscitate (DNR) and Do Not Hospitalize (DNH). The physician increased the dose of [MEDICATION(S)] on 7/24/17 and further increased the dose on 7/26/17. On 8/6/17 the physician discontinued the allergy for [MEDICATION(S)]. The allergy to [MEDICATION(S)] remained. From 6/23/17 to 8/6/17 the resident received medications that were ordered by the physician to be avoided and received a medication that was registered as an allergy. There was a system breakdown in the consultant pharmacist, the pharmacy and staff communication in this discovery (see F428). The facility was notified of the Immediate Jeopardy on 9/29/17 at 3:35 p.m. An acceptable POC was submitted to the team at 6:50 p.m. and the immediacy addressed by the facility was verified by the team and continued until the end of the survey. The deficient practice was evidenced by the following: 1. On 9/25/17 at 10:10 a.m. during the initial tour of the facility the Unit Manager (UM) told the surveyor that Resident #8 had diagnoses of [CONDITION(S)] and Pulmonary Fibrosis and had a [CONDITION(S)]. The UM stated that the resident had behaviors such as banging and yelling but that the resident had not had the behaviors recently, and that the resident did not have a diagnosis of Dementia. The surveyor observed Resident #8 lying in bed with their eyes open. The surveyor spoke with the resident who answered appropriately with clear speech and stated that they were tired because they did not sleep well the previous night. On 9/27/17 at 12:30 p.m. the surveyor interviewed Resident #8 who stated that they had [CONDITION(S)] and had a [CONDITION(S)] but that the cancer was not in remission and that they did not want any further medical interventions to treat the cancer. On 9/28/17 and 9/29/17 the surveyor reviewed the physician's orders, medication administration records, interdisciplinary progress notes, physician and nurse practitioner notes, consults, monthly order summaries, and hospital records for Resident #8. The printed and electronic medical record revealed the following: Resident #8 was originally admitted to the facility on [DATE] with diagnoses that included Chronic [CONDITION(S)] (CRF), Pulmonary Fibrosis, and [CONDITION(S)]. A progress note entered by a Registered Nurse (RN) on 3/3/17 revealed that new orders for [MEDICATION(S)] (an antianxiety medication) had been obtained from the physician for restlessness and shortness of breath. An admission Minimum Data Set (MDS), an interdisciplinary assessment tool, dated 3/9/17 revealed that Resident #8's Brief Interview for Mental Status (BIMS) score was 14 out of 15 indicating intact cognition, the resident did not exhibit behaviors, and that the resident self-reported mood symptoms including trouble sleeping and abnormal appetite. An initial assessment by the facility's consultant psychiatrist dated 3/15/17 revealed that the resident had a history of Colorectal Cancer, was withdrawn, had become increasingly depressed, and had mood swings with irritable mood. The psychiatrist noted that Resident #8 did not have delusions and did not have hallucinations. The psychiatrist documented a diagnosis of [CONDITION(S)] and recommended [MEDICATION(S)] (an antidepressant medication). On 6/8/17 Resident #8 was discharged to the hospital for evaluation of altered mental status. A General Medical Progress Note completed by a hospital physician on 6/12/17 revealed that the resident was diagnosed with CRF, Pneumonia, and [CONDITION(S)] (brain disease) induced by opiates (pain medications). The physician documented that Resident #8 was paranoid, did not have a diagnosis of [CONDITION(S)] on record, had a diagnosis of Major Depressive Disorder, and wrote to discontinue and avoid all opiates and benzodiazepines (a classification of medications used for anxiety). A consult completed by a hospital psychiatrist dated 6/13/17 revealed that Resident #8's cognition was fair, the resident had paranoid delusions of people trying to harm the resident, had refused medical treatment, and had not been aggressive but was irritable. The resident denied a history of mental illness and the psychiatrist had contacted the resident's sister and she corroborated that the resident had no history of mental illness except Depression, and did not have a history of [CONDITION(S)], [CONDITION(S)] or Hypomania. The psychiatrist documented the following diagnoses: [CONDITION(S)] Due to Known Condition; Major Depressive Disorder, Recurrent, Severe, with Psychotic Features; and Rule Out Opiate Induced Psychotic Disorder. The psychiatrist's treatment plan noted that the resident had a history of paranoid ideation on [MEDICATION(S)] (an opiate), directed to stop [MEDICATION(S)] (a benzodiazepine), avoid benzodiazepines, and start [MEDICATION(S)] (an antipsychotic). Resident #8 was readmitted to the facility on [DATE]. The surveyor reviewed a Transition of Care Document dated 6/13/17 completed by the hospital and sent to the facility upon readmission with discharge instructions. The document contained a synopsis of Resident #8's hospitalization . Under a section entitled Allergies, Adverse Reactions, Alerts the surveyor observed the following: [MEDICATION(S)] causes moderate [CONDITION(S)]. Onset 6/10; [MEDICATION(S)] causes moderate hives. The document listed mediations in place at time of discharge from the hospital and included: [MEDICATION(S)] 0.5 mg tablet, disintegrating, two tablets orally daily and [MEDICATION(S)] 20 mg capsule, delayed release, one capsule orally daily. The document also listed medications that had been stopped during hospitalization and included [MEDICATION(S)] patch (generic [MEDICATION(S)]), [MEDICATION(S)] Concentrate ([MEDICATION(S)]) and [MEDICATION(S)]. The facility's Admission Medication Orders for Resident #8 dated 6/13/17 listed the resident's allergies as [MEDICATION(S)], [MEDICATION(S)] and Penicillin. A readmission note by the primary physician dated 6/13/17 stated [CONDITION(S)]- [MEDICATION(S)], [MEDICATION(S)], psych eval, avoid opiates and benzos. The physician wrote an order dated 6/14/17 for No opiates, No benzodiazepines. A Psychiatric Follow Up from the facility's consultant psychiatrist dated 6/16/17 read follow up for depression, now with [CONDITION(S)]. Patient is becoming more paranoid and delusional, refusing medications. Patient refused long conversation with me. The psychiatrist recommended to increase [MEDICATION(S)] to 0.5 mg three times a day for [CONDITION(S)], continue [MEDICATION(S)] 20 mg daily for Depression, and start [MEDICATION(S)] (a benzodiazepine) 0.5 mg every eight hours as needed. The surveyor observed a handwritten telephone order dated 6/19/17 received from the primary physician and signed by an unidentified nurse that matched the recommendations given by the psychiatrist for [MEDICATION(S)] and [MEDICATION(S)]. The order for [MEDICATION(S)] had a line through it and an entry of error above it. There was no other information in the record addressing this order. Review of the June Medication Administration Record (MAR) indicated that the [MEDICATION(S)] had not been administered. The surveyor observed a handwritten telephone order dated 6/23/17 from the Nurse Practitioner (NP) taken by the Licensed Practical Nurse (LPN) for [MEDICATION(S)] (an opiate) patch 12 micrograms (mcg) every 72 hours (hr) diagnosis Pain and [MEDICATION(S)] Liquid ([MEDICATION(S)] Concentrate) 20 milligrams (mg) per milliliter (ml) by mouth as needed every four hours for moderate to severe pain. There was no nurses' note entered in the medical record that addressed the need for pain medications or the new orders for [MEDICATION(S)] and [MEDICATION(S)]. Review of the June 2017 MAR revealed that [MEDICATION(S)] patches had been applied to Resident #8 on June 23rd, 26th and 29th and that [MEDICATION(S)] Concentrate had been administered eight times from 6/23/17 to 6/30/17. Review of the July 2017 MAR revealed that [MEDICATION(S)] patches had been applied to Resident #8 every three days and the [MEDICATION(S)] Concentrate had been administered 29 times from 7/1/17 to 7/31/17. On 7/7/17 the consultant pharmacist entered a progress note that read Psych 6/16- [MEDICATION(S)] adjusted. Continue to monitor behaviors. The pharmacist did not address the resident's allergies or the use of opiates in the presence of a physician order for no opiates and no benzodiazepines. On 7/10/17 the LPN entered a progress note that Resident #8 was agitated in the morning with a concern regarding finances. Throughout the morning, the resident became increasingly paranoid and agitated, screaming at staff, kicking, and throwing items on the floor. The nurse practitioner was contacted and gave a telephone ordered to transfer to the hospital for psychiatric episode, may use restraints for transport, and give [MEDICATION(S)] (an antipsychotic) 5 mg intramuscular (IM) injection once. The progress note stated that the Director of Nursing (DON) gave the resident IM [MEDICATION(S)]. The resident left the facility with transport at 11 a.m. There was no note addressing whether restraints were used. The July MAR did not list [MEDICATION(S)] as one of the medications administered during the month. The resident returned to the facility at 7:40 p.m. the same day. Review of a physician note from the Emergency Department revealed that crisis evaluated the resident and did not feel that the resident was experiencing acute paranoia despite agitation, noted that the resident was competent to refuse treatments for cancer, that there was no indication for involuntary committal, and that the resident was stable, calm, and cooperative after initial dose of [MEDICATION(S)]. On 7/23/17 the DON entered a progress note that Resident #8 was assessed and noted to be lethargic, non-responsive to verbal and tactile stimuli. The DON further documented that Resident does have a history of reactions to [MEDICATION(S)] patch in the past so patch immediately removed to ensure it was not causing lethargy. Primary physician notified of change in condition . Writer did relay concern of history of reactions to [MEDICATION(S)] in the past although resident has had patch on for quite some time now. The DON obtained from the physician a telephone order to insert intravenous (IV) line, give [MEDICATION(S)] (a medication used to block the effects of opiates) 0.4 mg IV one dose, and discontinue [MEDICATION(S)] patch. The [MEDICATION(S)] was administered without effect and approximately three minutes after administration the resident began to show signs of a [CONDITION(S)]. The physician was notified and gave an order for [MEDICATION(S)] (a benzodiazepine) 1 mg IV one dose stat (immediately). The [MEDICATION(S)] was administered and was effective without further [CONDITION(S)] activity. On 7/24/17 the [MEDICATION(S)] patch was ordered by the primary physician to be restarted at the same (12 mcg/hr) dose. On 7/26/17 the [MEDICATION(S)] patch was increased by the primary physician to 25 mcg/hr. On 8/6/17 an unidentified nurse took a telephone order from the primary physician to discontinue the allergy to [MEDICATION(S)]/[MEDICATION(S)]. There were no nurses' notes entered for the date of 8/6/17. The physician's order for no opiates, no benzodiazepines remained active. On 8/10/17 the consultant pharmacist entered a progress note stating No new issues. Also on 8/10/17 the primary physician wrote an order to discontinue the [MEDICATION(S)] Concentrate and give [MEDICATION(S)] (an opiate) by mouth every four hours as needed for severe pain. The primary physician also wrote an order to reduce [MEDICATION(S)] to 0.5 mg by mouth every 12 hours. On 8/12/17 the primary physician increased the dosage of the [MEDICATION(S)] patch to 50 mcg/hr. On 8/22/17 the primary physician increased the dosage of the [MEDICATION(S)] patch to 75 mcg/hr. On 8/25/17 the primary physician discontinued the [MEDICATION(S)] and increased the dose of [MEDICATION(S)] to be given every four hours as needed for pain. On 9/14/17 the consultant pharmacist wrote a progress note stating to clarify and sequence the PRN (as needed) [MEDICATION(S)]. A Quarterly MDS dated [DATE] revealed that Resident #8's BIMS score was 15 out of 15 indicating intact cognition, the resident did not exhibit behaviors and did not report mood symptoms, and that the resident reported occasional pain at a level of four out of ten. On 9/23/17 an unidentified nurse wrote a telephone order from the NP to discontinue the order for no opiates, no benzodiazepines. There was no nurses' note that addressed the discontinuation of the order. On 9/29/17 at 10:50 a.m. and 1:15 p.m. the surveyor interviewed the DON who stated that on 7/10/17 Resident #8 was out of control and combative and the resident called the police but accused him of being one of us. The facility scheduled transport to psychiatric crisis and the resident later returned. An order was obtained for emergency restraints and transport may have used them but they were not put on the resident while in the facility. The DON further stated that on 7/23/17 she was told by a Certified Nursing Assistant (CNA) that Resident #8 wasn't right. The DON assessed the resident and the clinical assessment seemed okay and indicated no cardiac or pulmonary signs and symptoms. The DON called the physician and told him that the resident had orders for Do Not Resuscitate (DNR) and Do Not Hospitalize (DNH). The DON informed the physician that the resident was lethargic and that the resident had been on [MEDICATION(S)] patch because the DON recalled that there was a potential for a reaction and that the [MEDICATION(S)] had been restarted and the resident had been receiving it for awhile. The physician directed the DON to give [MEDICATION(S)] IV but the [MEDICATION(S)] did not improve the resident's lethargy so the DON called the resident's sister who confirmed the resident's wishes for DNR and DNH. The DON stated that she didn't think the resident would make it through the night and that the next morning the resident was still lethargic but that night shift reported the resident had been their usual self. Later Resident #8 reported that the resident had drank vodka that they obtained from another resident but no formal investigation was completed. On 9/29/17 at 12:15 p.m., via telephone, the surveyor interviewed a medical records representative (MRR) from the facility's contracted pharmacy provider who stated that on 6/14/17 the pharmacy received readmission orders for Resident #8 that listed allergies to [MEDICATION(S)], [MEDICATION(S)] and Penicillin and also included an order for no opiates and no benzodiazepines. The MRR further stated that there was no record indicating that the facility, NP or physician were contacted regarding these discrepancies from 6/14/17 to 9/29/17. At 12:30 p.m., via telephone, the surveyor interviewed Pharmacist #1 from the facility's contracted pharmacy provider who reviewed Resident #8's pharmacy records and stated that the pharmacy had received readmission orders that listed allergies to [MEDICATION(S)], [MEDICATION(S)] and Penicillin and also included an order for no opiates and no benzodiazepines. In regards to the order for no opiates and no benzodiazepines, Pharmacist #1 stated that the pharmacy cannot track this unless there is an allergy entered for it. Pharmacist #1 stated that considering the allergy information received from the facility for Resident #8 on 6/14/17 all orders for opiates should have been questioned. Pharmacist #1 further stated that there was no record that indicated the facility, NP or physician were contacted regarding these discrepancies from 6/14/17 to 9/29/17. On 9/29/17 at 2:30 p.m. the surveyor interviewed Resident #8 who stated that they frequently have pain in the back, legs, spine, and bladder. Resident #8 stated they had allergies to [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and anything in that family and that when given these medications they would get deathly sick, confused, and hallucinate. Resident #8 stated that they had never been told that they had an allergy to [MEDICATION(S)] and stated That's the patch that I take. If I don't take the patch [my pain] is worse. It seems to help to some degree. The resident stated that they recalled the incident on 7/10/17 and that very strong people were grabbing me and holding me down . they grabbed my wrists and arms and legs so tight I got bruises on my wrists and arms, but did not get bruises on my legs. I got very angry and I wanted to punch them. On 9/29/17 at 3:15 p.m. the surveyor interviewed the NP who gave the orders for [MEDICATION(S)] and [MEDICATION(S)] Concentrate on 6/23/17. The NP stated that the phone order was initiated by a facility nurse and that the resident wasn't on the medication upon readmission and the resident wanted it restarted. She stated that she was aware of the allergy and that just because a resident is allergic to one medication doesn't mean they are allergic to others. She stated that pharmacy calls her all the time but that she couldn't recall this specific case. She further stated that this information was documented about a week later because that was the next time she was in the facility. The surveyor reviewed the NP's progress note dated 6/28/17 which stated the following in regard to Resident #8's pain and mental status: Still with neuropathic pain; Awake, alert, oriented, forgetful, occasional hallucinations; [CONDITION(S)]/lymph [CONDITION(S)] increase [MEDICATION(S)] continue [MEDICATION(S)]; Chronic Pain [MEDICATION(S)] patch, Depression/Anxiety [MEDICATION(S)] [MEDICATION(S)] psych eval. The NP did not address the resident's listed allergies or the active physician order for no opiates no benzodiazepines. On 9/29/17 at 3:39 p.m. the surveyor interviewed via telephone Pharmacist #2, the facility's consultant pharmacist, who stated that there is a difference between an allergic reaction and an adverse reaction and that in a situation like this a true allergic reaction would start immediately. Pharmacist #2 stated that allergy to a medication or class of medications would not necessarily indicate an allergy to all medications of that type. Pharmacist #2 stated that he could not speak to specifics in the case of Resident #8 because he did not have the chart in front of him. On 10/2/17 at 9:35 a.m. the surveyor interviewed the primary physician for Resident #8 who stated that Resident #8 was admitted in March of 2017 and that he was not Resident #8's physician prior to initial admission. He stated that the resident was admitted with an allergy to [MEDICATION(S)] and was using a [MEDICATION(S)] patch for pain at the time without problem so it was continued. The physician also stated that the resident had been started on [MEDICATION(S)] for anxiety after initial admission. The physician stated he was aware the resident had [MEDICATION(S)] documented as an allergy on readmission in June 2017 and that he wrote an order for no opiates and no benzodiazepines because it was a recommendation from the hospital. He further stated that, as the resident's primary physician, he could overwrite recommendations and stated that the hospital's recommendations were a snap decision given by someone that didn't know the resident. He further stated that after the resident's readmission in June 2017 the resident had complained of pain and requested to again receive the [MEDICATION(S)] patch. He stated the resident had a diagnosis of Chronic Pain Syndrome and that the medication would not have been ordered if the resident had not tolerated it previously. He stated he did not recall himself or the NP being contacted by the pharmacy for clarification. The fact that my NP and I gave the orders means that we gave the okay for these meds . This may be a documentation issue but my patient was never in danger and did not have a bad outcome. On 10/2/17 at 9:44 a.m. the DON stated that it was a new LPN who took the order for [MEDICATION(S)] and [MEDICATION(S)] Concentrate from the NP on 6/23/17 and that the DON was told by the LPN that the allergy had been discussed with the NP but was not documented. On 10/4/17 at 9:40 a.m. the surveyor interviewed consultant Pharmacist #2 at the facility. Pharmacist #2 stated that he had reviewed the chart for Resident #8 and noted the order for no opiates and no benzodiazepines. He stated that he could not attest to having seen this order before. He stated that just because someone has an allergy to opiates doesn't mean that they would have an allergy to [MEDICATION(S)] because they are a different chemical makeup and that adverse reactions are different from allergies. He further stated that because Resident #8 tolerated the [MEDICATION(S)] before and after the 6/8/17-6/13/17 hospitalization showed that there was no allergy and that stood for itself without documentation. On 10/3/17 at 12:15 p.m. and on 10/4/17 at 11:28 a.m. the surveyor interviewed the LPN. The LPN stated that Resident #8 had complained of pain and that the resident asked for the pain medications that they had been on before readmission from the hospital. The LPN stated she reviewed the resident's medical record and saw that the resident had previously been on [MEDICATION(S)]/[MEDICATION(S)] and [MEDICATION(S)]/[MEDICATION(S)] Concentrate. She called the NP who gave her the order for these medications on 6/23/17. The LPN stated she saw a red sticker on the inside front of the resident's chart with allergies including [MEDICATION(S)] allergy. She stated that she told the NP of the listed allergies and that the NP said that because the resident was on it before that it was okay to give. The LPN stated that she did not see or address with the NP the active physician order for no opiates or benzodiazepines. The LPN stated that she did not document her assessment of the Resident #8's pain or her conversations with the resident and NP. The facility was notified of the immediate jeopardy on 9/29/17 at 3:35 p.m. A plan of correction (POC) was submitted by the facility and accepted on 9/29/17 at 6:50 p.m. based on actions to be taken which included: 1. The Director of Nursing will review, revise, and date the facility's Policy and Procedure (P&P) titled Adverse Reaction, Medication, Allergy. 2. All Physicians, NPs, RNs, LPNs, and CNAs will receive education on the new P&P upon credentialing and annually. 3. The DON and UMs will audit all residents' charts to ensure that no resident is receiving a mediation that they have a documented allergy to. 4. The DON and UMs will audit all charts to ensure that any and all allergies are listed in the orders and on the resident allergy sticker located on the chart monthly. 5. The DON will work with the pharmacy customer service representative to ensure that the pharmacy has an accurate list of residents' allergies monthly. 6. The licensed nurse will review all resident allergies when new orders are obtained and physician orders are reviewed during monthly recaps. 7. The UM will print the allergy report weekly for three months and will ensure that each resident on their unit is not on any medication that is listed as an allergy and report the findings to the DON weekly. 8. The DON will report the findings of the observation of the medication pass to the Quality Assurance Committee (QAC) monthly for three months. The QAC will determine if further monitoring is necessary. N.J.A.C. 8:39-29.3(a)1,3 While the Immediate Jeopardy was abated for Resident #8, this deficient practice continued at F428 at a lower scope and severity of (D) level and was evidenced by the following: B.) Based on observation, interview, and record review, it was determined that the facility failed to a.) administer medications according to physician orders and b.) failed to identify and report irregularities in medication orders. This deficient practice was identified for 2 of 30 residents reviewed, Residents #1 and #19, and evidenced by the following: 1.) On 09/26/17 at 10:30 a.m., the surveyor reviewed the records of Resident #1 who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Vascular Dementia without Behaviors and Prostate Cancer. The surveyor observed that on 07/14/17 the physician wrote an order to discontinue [MEDICATION(S)] (a medication to treat Dementia). A review of the July 2017 eMAR revealed that the medication was given for the entire month. The surveyor observed the Consultant Pharmacist (CP) Progress Note dated 07/25/17. The CP did not note this error. On 10/04/17 at 9 a.m. the surveyor spoke with the CP regarding this discrepancy. The CP said that this was an error on his part and should have been noted. 2.) On 09/29/17 at 11:45 a.m., the surveyor reviewed the records of Resident #19 who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included [CONDITION(S)] and [CONDITION(S)]. The surveyor observed a current physician's order for [MEDICATION(S)] 5 mg, give (2) tablets, by mouth every 8 hours for [CONDITION(S)] and to withhold for systolic blood pressure (SBP) above 100 which was originally ordered on 06/14/17. A review of the July 2017, August 2017 and September 2017 eMARs revealed that this medication was given 32 times when the SBP was above 100. Additionally, the surveyor observed 10 blank dates on the eMARs. Documentation of medication administration and blood pressures were both omitted on those dates. A review of the July 2017 and August 2017 CP Progress Notes (CPPN) indicated to follow hold parameters for blood pressure medications. The September 2017 CPPN indicated no new issues. A review of the Consultant Pharmacist's Monthly Reports which are provided to the facility detailing any discrepancies noted dated 07/10/17 and 08/14/17 did not include any of these findings. A review of the facility CP Monthly Report policy indicated that the facility will receive a detailed report. These reports enable the facility to address any concerns that the CP has. On 10/04/17 at 9 a.m. the surveyor spoke with the CP regarding this discrepancy. The CP stated that his recommendation to follow the hold parameters should have been included on the CP Monthly Report but was not. NJAC 8:39-29.3(a)

A.) Based on observation, interview and record review, it was determined that the facility failed to obtain clarification for a resident with a known and documented medication allergy and failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had documented allergies to [MEDICATION(S)] and [MEDICATION(S)]. On 6/23/17 a nurse practitioner ordered and the resident received [MEDICATION(S)] and [MEDICATION(S)]. On 7/10/17 the resident returned to the hospital for a few hours due to acute [CONDITION(S)] and returned on the same meds. On 7/23/17 the resident became extremely lethargic and staff documented a potential for [MEDICATION(S)] reaction in the past and [MEDICATION(S)] was administered at the facility with no effect. The resident showed signs of a [CONDITION(S)] and [MEDICATION(S)] (a benzodiazepine) was ordered and administered. The resident remained on [MEDICATION(S)]. The resident was not transferred to the hospital due to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician increased the dose of [MEDICATION(S)] on 7/24/17 and further increased the dose on 7/26/17. On 8/6/17 the physician discontinued the allergy for [MEDICATION(S)]. The allergy to [MEDICATION(S)] remained. From 6/23/17 to 8/6/17 the resident received medications that were ordered by the physician to be avoided and received a medication that was registered as an allergy. There was a system breakdown in the consultant pharmacist, the pharmacy and staff communication in this discovery (see F428). The facility was notified of the Immediate Jeopardy on 9/29/17 at 3:35 p.m. An acceptable POC was submitted to the team at 6:50 p.m. and the immediacy addressed by the facility was verified by the team and continued until the end of the survey. 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 wellbeing and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 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 1. On 9/25/17 at 10:10 a.m. during the initial tour of the facility the Unit Manager (UM) told the surveyor that Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM stated that the resident had behaviors such as banging and yelling but that the resident had not had the behaviors recently, and that the resident did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor spoke with the resident who answered appropriately with clear speech and stated that they were tired because they did not sleep well the previous night. On 9/27/17 at 12:30 p.m. the surveyor interviewed Resident #8 who stated that they had [CONDITION(S)] and had a [CONDITION(S)] but that the cancer was not in remission and that they did not want any further medical interventions to treat the cancer. On 9/28/17 and 9/29/17 the surveyor reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The printed and electronic medical record revealed the following: Resident #8 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note entered by a Registered Nurse (RN) on 3/3/17 revealed that new orders for [MEDICATION(S)] (an antianxiety medication) had been obtained from the physician for restlessness and shortness of breath. An admission Minimum Data Set (MDS), an interdisciplinary assessment tool, dated 3/9/17 revealed that Resident #8's Brief Interview for Mental Status (BIMS) score was 14 out of 15 indicating intact cognition, the resident did not exhibit behaviors, and that the resident self-reported mood symptoms including trouble sleeping and abnormal appetite. An initial assessment by the facility's consultant psychiatrist dated 3/15/17 revealed that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The psychiatrist noted that Resident #8 did not have delusions and did not have hallucinations. The psychiatrist documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/8/17 Resident #8 was discharged to the hospital for evaluation of altered mental status. A General Medical Progress Note completed by a hospital physician on 6/12/17 revealed that the resident was diagnosed with CRF, Pneumonia, and [CONDITION(S)] (brain disease) induced by opiates (pain medications). The physician documented that Resident #8 was paranoid, did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A consult completed by a hospital psychiatrist dated 6/13/17 revealed that Resident #8's cognition was fair, the resident had paranoid delusions of people trying to harm the resident, had refused medical treatment, and had not been aggressive but was irritable. The resident denied a history of mental illness and the psychiatrist had contacted the resident's sister and she corroborated that the resident had no history of mental illness except Depression, and did not have a history of [CONDITION(S)], [CONDITION(S)] or Hypomania. The psychiatrist documented the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The psychiatrist's treatment plan noted that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 was readmitted to the facility on [DATE]. The surveyor reviewed a Transition of Care Document dated 6/13/17 completed by the hospital and sent to the facility upon readmission with discharge instructions. The document contained a synopsis of Resident #8's hospitalization . Under a section entitled Allergies, Adverse Reactions, Alerts the surveyor observed the following: [MEDICATION(S)] causes moderate [CONDITION(S)]. Onset 6/10; [MEDICATION(S)] causes moderate hives. The document listed mediations in place at time of discharge from the hospital and included: [MEDICATION(S)] 0.5 mg tablet, disintegrating, two tablets orally daily and [MEDICATION(S)] 20 mg capsule, delayed release, one capsule orally daily. The document also listed medications that had been stopped during hospitalization and included [MEDICATION(S)] patch (generic [MEDICATION(S)]), [MEDICATION(S)] Concentrate ([MEDICATION(S)]) and [MEDICATION(S)]. The facility's Admission MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . A readmission note by the primary physician dated 6/13/17 stated [CONDITION(S)]- [MEDICATION(S)], [MEDICATION(S)], psych eval, avoid opiates and benzos. The physician wrote an order dated 6/14/17 for No opiates, No benzodiazepines. A Psychiatric Follow Up from the facility's consultant psychiatrist dated 6/16/17 read follow up for depression, now with [CONDITION(S)]. Patient is becoming more paranoid and delusional, refusing medications. Patient refused long conversation with me. The psychiatrist recommended to increase [MEDICATION(S)] to 0.5 mg three times a day for [CONDITION(S)], continue [MEDICATION(S)] 20 mg daily for Depression, and start [MEDICATION(S)] (a benzodiazepine) 0.5 mg every eight hours as needed. The surveyor observed a handwritten telephone order dated 6/19/17 received from the primary physician and signed by an unidentified nurse that matched the recommendations given by the psychiatrist for [MEDICATION(S)] and [MEDICATION(S)]. The order for [MEDICATION(S)] had a line through it and an entry of error above it. There was no other information in the record addressing this order. Review of the June Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor observed a handwritten telephone order dated 6/23/17 from the Nurse Practitioner (NP) taken by the Licensed Practical Nurse (LPN) for [MEDICATION(S)] (an opiate) patch 12 micrograms (mcg) every 72 hours (hr) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no nurses' note entered in the medical record that addressed the need for pain medications or the new orders for [MEDICATION(S)] and [MEDICATION(S)]. Review of the June 2017 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #8 on June 23rd, 26th and 29th and that [MEDICATION(S)] Concentrate had been administered eight times from 6/23/17 to 6/30/17. Review of the July 2017 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #8 every three days and the [MEDICATION(S)] Concentrate had been administered 29 times from 7/1/17 to 7/31/17. On 7/7/17 the consultant pharmacist entered a progress note that read Psych 6/16- [MEDICATION(S)] adjusted. Continue to monitor behaviors. The pharmacist did not address the resident's allergies or the use of opiates in the presence of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 7/10/17 the LPN entered a progress note that Resident #8 was agitated in the morning with a concern regarding finances. Throughout the morning, the resident became increasingly paranoid and agitated, screaming at staff, kicking, and throwing items on the floor. The nurse practitioner was contacted and gave a telephone ordered to transfer to the hospital for psychiatric episode, may use restraints for transport, and give [MEDICATION(S)] (an antipsychotic) 5 mg intramuscular (IM) injection once. The progress note stated that the Director of Nursing (DON) gave the resident IM [MEDICATION(S)]. The resident left the facility with transport at 11 a.m. There was no note addressing whether restraints were used. The July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident returned to the facility at 7:40 p.m. the same day. Review of a physician note from the Emergency Department revealed that crisis evaluated the resident and did not feel that the resident was experiencing acute paranoia despite agitation, noted that the resident was competent to refuse treatments for cancer, that there was no indication for involuntary committal, and that the resident was stable, calm, and cooperative after initial dose of [MEDICATION(S)]. On 7/23/17 the DON entered a progress note that Resident #8 was assessed and noted to be lethargic, non-responsive to verbal and tactile stimuli. The DON further documented that Resident does have a history of reactions to [MEDICATION(S)] patch in the past so patch immediately removed to ensure it was not causing lethargy. Primary physician notified of change in condition . Writer did relay concern of history of reactions to [MEDICATION(S)] in the past although resident has had patch on for quite some time now. The DON obtained from the physician a telephone order to insert intravenous (IV) line, give [MEDICATION(S)] (a medication used to block the effects of opiates) 0.4 mg IV one dose, and discontinue [MEDICATION(S)] patch. The [MEDICATION(S)] was administered without effect and approximately three minutes after administration the resident began to show signs of a [CONDITION(S)]. The physician was notified and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was administered and was effective without further [CONDITION(S)] activity. On 7/24/17 the [MEDICATION(S)] patch was ordered by the primary physician to be restarted at the same (12 mcg/hr) dose. On 7/26/17 the [MEDICATION(S)] patch was increased by the primary physician to 25 mcg/hr. On 8/6/17 an unidentified nurse took a telephone order from the primary physician to discontinue the allergy to [MEDICATION(S)]/[MEDICATION(S)]. There were no nurses' notes entered for the date of 8/6/17. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/17 the consultant pharmacist entered a progress note stating No new issues. Also on 8/10/17 the primary physician wrote an order to discontinue the [MEDICATION(S)] Concentrate and give [MEDICATION(S)] (an opiate) by mouth every four hours as needed for severe pain. The primary physician also wrote an order to reduce [MEDICATION(S)] to 0.5 mg by mouth every 12 hours. On 8/12/17 the primary physician increased the dosage of the [MEDICATION(S)] patch to 50 mcg/hr. On 8/22/17 the primary physician increased the dosage of the [MEDICATION(S)] patch to 75 mcg/hr. On 8/25/17 the primary physician discontinued the [MEDICATION(S)] and increased the dose of [MEDICATION(S)] to be given every four hours as needed for pain. On 9/14/17 the consultant pharmacist wrote a progress note stating to clarify and sequence the PRN (as needed) [MEDICATION(S)]. A Quarterly MDS dated [DATE] revealed that Resident #8's BIMS score was 15 out of 15 indicating intact cognition, the resident did not exhibit behaviors and did not report mood symptoms, and that the resident reported occasional pain at a level of four out of ten. On 9/23/17 an unidentified nurse wrote a telephone order from the NP to discontinue the order for no opiates, no benzodiazepines. There was no nurses' note that addressed the discontinuation of the order. On 9/29/17 at 10:50 a.m. and 1:15 p.m. the surveyor interviewed the DON who stated that on 7/10/17 Resident #8 was out of control and combative and the resident called the police but accused him of being one of us. The facility scheduled transport to psychiatric crisis and the resident later returned. An order was obtained for emergency restraints and transport may have used them but they were not put on the resident while in the facility. The DON further stated that on 7/23/17 she was told by a Certified Nursing Assistant (CNA) that Resident #8 wasn't right. The DON assessed the resident and the clinical assessment seemed okay and indicated no cardiac or pulmonary signs and symptoms. The DON called the physician and told him that the resident had orders for Do Not Resuscitate (DNR) and Do Not Hospitalize (DNH). The DON informed the physician that the resident was lethargic and that the resident had been on [MEDICATION(S)] patch because the DON recalled that there was a potential for a reaction and that the [MEDICATION(S)] had been restarted and the resident had been receiving it for awhile. The physician directed the DON to give [MEDICATION(S)] IV but the [MEDICATION(S)] did not improve the resident's lethargy so the DON called the resident's sister who confirmed the resident's wishes for DNR and DNH. The DON stated that she didn't think the resident would make it through the night and that the next morning the resident was still lethargic but that night shift reported the resident had been their usual self. Later Resident #8 reported that the resident had drank vodka that they obtained from another resident but no formal investigation was completed. On 9/29/17 at 12:15 p.m., via telephone, the surveyor interviewed a medical records representative (MRR) from the facility's contracted pharmacy provider who stated that on 6/14/17 the pharmacy received readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At 12:30 p.m., via telephone, the surveyor interviewed Pharmacist #1 from the facility's contracted pharmacy provider who reviewed Resident #8's pharmacy records and stated that the pharmacy had received readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacist #1 stated that considering the allergy information received from the facility for Resident #8 on 6/14/17 all orders for opiates should have been questioned. Pharmacist #1 further stated that there was no record that indicated the facility, NP or physician were contacted regarding these discrepancies from 6/14/17 to 9/29/17. On 9/29/17 at 2:30 p.m. the surveyor interviewed Resident #8 who stated that they frequently have pain in the back, legs, spine, and bladder. Resident #8 stated they had allergies to [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and anything in that family and that when given these medications they would get deathly sick, confused, and hallucinate. Resident #8 stated that they had never been told that they had an allergy to [MEDICATION(S)] and stated That's the patch that I take. If I don't take the patch [my pain] is worse. It seems to help to some degree. The resident stated that they recalled the incident on 7/10/17 and that very strong people were grabbing me and holding me down . they grabbed my wrists and arms and legs so tight I got bruises on my wrists and arms, but did not get bruises on my legs. I got very angry and I wanted to punch them. On 9/29/17 at 3:15 p.m. the surveyor interviewed the NP who gave the orders for [MEDICATION(S)] and [MEDICATION(S)] Concentrate on 6/23/17. The NP stated that the phone order was initiated by a facility nurse and that the resident wasn't on the medication upon readmission and the resident wanted it restarted. She stated that she was aware of the allergy and that just because a resident is allergic to one medication doesn't mean they are allergic to others. She stated that pharmacy calls her all the time but that she couldn't recall this specific case. She further stated that this information was documented about a week later because that was the next time she was in the facility. The surveyor reviewed the NP's progress note dated 6/28/17 which stated the following in regard to Resident #8's pain and mental status: Still with neuropathic pain; Awake, alert, oriented, forgetful, occasional hallucinations; [CONDITION(S)]/lymph [CONDITION(S)] increase [MEDICATION(S)] continue [MEDICATION(S)]; Chronic Pain [MEDICATION(S)] patch, Depression/Anxiety [MEDICATION(S)] [MEDICATION(S)] psych eval. The NP did not address the resident's listed allergies or the active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 9/29/17 at 3:39 p.m. the surveyor interviewed via telephone Pharmacist #2, the facility's consultant pharmacist, who stated that there is a difference between an allergic reaction and an adverse reaction and that in a situation like this a true allergic reaction would start immediately. Pharmacist #2 stated that allergy to a medication or class of medications would not necessarily indicate an allergy to all medications of that type. Pharmacist #2 stated that he could not speak to specifics in the case of Resident #8 because he did not have the chart in front of him. On 10/2/17 at 9:35 a.m. the surveyor interviewed the primary physician for Resident #8 who stated that Resident #8 was admitted in March of 2017 and that he was not Resident #8's physician prior to initial admission. He stated that the resident was admitted with an allergy to [MEDICATION(S)] and was using a [MEDICATION(S)] patch for pain at the time without problem so it was continued. The physician also stated that the resident had been started on [MEDICATION(S)] for anxiety after initial admission. The physician stated he was aware the resident had [MEDICATION(S)] documented as an allergy on readmission in June 2017 and that he wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He further stated that, as the resident's primary physician, he could overwrite recommendations and stated that the hospital's recommendations were a snap decision given by someone that didn't know the resident. He further stated that after the resident's readmission in June 2017 the resident had complained of pain and requested to again receive the [MEDICATION(S)] patch. He stated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he did not recall himself or the NP being contacted by the pharmacy for clarification. The fact that my NP and I gave the orders means that we gave the okay for these meds . This may be a documentation issue but my patient was never in danger and did not have a bad outcome. On 10/2/17 at 9:44 a.m. the DON stated that it was a new LPN who took the order for [MEDICATION(S)] and [MEDICATION(S)] Concentrate from the NP on 6/23/17 and that the DON was told by the LPN that the allergy had been discussed with the NP but was not documented. On 10/4/17 at 9:40 a.m. the surveyor interviewed consultant Pharmacist #2 at the facility. Pharmacist #2 stated that he had reviewed the chart for Resident #8 and noted the order for no opiates and no benzodiazepines. He stated that he could not attest to having seen this order before. He stated that just because someone has an allergy to opiates doesn't mean that they would have an allergy to [MEDICATION(S)] because they are a different chemical makeup and that adverse reactions are different from allergies. He further stated that because Resident #8 tolerated the [MEDICATION(S)] before and after the 6/8/17-6/13/17 hospitalization showed that there was no allergy and that stood for itself without documentation. On 10/3/17 at 12:15 p.m. and on 10/4/17 at 11:28 a.m. the surveyor interviewed the LPN. The LPN stated that Resident #8 had complained of pain and that the resident asked for the pain medications that they had been on before readmission from the hospital. The LPN stated she reviewed the resident's medical record and saw that the resident had previously been on [MEDICATION(S)]/[MEDICATION(S)] and [MEDICATION(S)]/[MEDICATION(S)] Concentrate. She called the NP who gave her the order for these medications on 6/23/17. The LPN stated she saw a red sticker on the inside front of the resident's chart with allergies including [MEDICATION(S)] allergy. She stated that she told the NP of the listed allergies and that the NP said that because the resident was on it before that it was okay to give. The LPN stated that she did not see or address with the NP the active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility was notified of the immediate jeopardy on 9/29/17 at 3:35 p.m. A plan of correction (POC) was submitted by the facility and accepted on 9/29/17 at 6:50 p.m. based on actions to be taken which included: 1. The Director of Nursing will review, revise, and date the facility's Policy and Procedure (P&P) titled Adverse Reaction, Medication, Allergy. 2. All Physicians, NPs, RNs, LPNs, and CNAs will receive education on the new P&P upon credentialing and annually. 3. The DON and UMs will audit all residents' charts to ensure that no resident is receiving a mediation that they have a documented allergy to. 4. The DON and UMs will audit all charts to ensure that any and all allergies are listed in the orders and on the resident allergy sticker located on the chart monthly. 5. The DON will work with the pharmacy customer service representative to ensure that the pharmacy has an accurate list of residents' allergies monthly. 6. The licensed nurse will review all resident allergies when new orders are obtained and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 7. The UM will print the allergy report weekly for three months and will ensure that each resident on their unit is not on any medication that is listed as an allergy and report the findings to the DON weekly. 8. The DON will report the findings of the observation of the medication pass to the Quality Assurance Committee (QAC) monthly for three months. The QAC will determine if further monitoring is necessary. N.J.A.C. 8:39-27.1(a)(b) While the Immediate Jeopardy was abated for Resident #8, this deficient practice continued at F281 at a lower scope and severity of (E) level and was evidenced by the following: B.) Based on observation, interview and record review, it was determined that the facility failed to follow acceptable standards of clinical practice for 5 of 30 residents reviewed, Residents #1 and #4 reviewed for physicians orders and Residents #13, #15, #19 reviewed for Registered Dietitian's (RD) recommendations. The deficient practice was evidenced by the following: According to the Standards of Peractice for Dietitians and the Academy of Nutrition and Dietetics, third addition dated 5/18/15 the Nutrition Care Process (NCP) is an accurate and efficient diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. On 09/26/17 at 12 p.m. the surveyor reviewed the records for Resident #13 who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received 100% nutrition support via a Gastrostomy Tube (GT). The surveyor reviewed the Dietitian Communication/Recommendation to Doctors dated 08/07/17 and signed by the physician, which recommended that the resident's tube feeding formula be changed to [MEDICATION(S)] AF (advanced formula) at 80 ml (milliliters) for 18 hours (hrs) for a total infusion of 1140 ml, 1728 calories, 109 grams (gm) of protein and 1166 ml of free fluids. The form did not include any mention of the additional protein supplement of 30 gms provided with the Pro Stat (Amino Acids-Protein Hydrolys Supplement) that the resident also received. A review of the Dietary Nutrition Analysis, Progress Note and Tube Feeding Assessments dated 06/16/17 estimated the resident's nutritional needs for total calories (cal) per 24 hours should be 1620 cal. The estimated protein needs were calculated at 73 grams and the estimated fluid needs were 1694 ml. On 10/02/17 at 10:30 a.m. the surveyor spoke with the RD about the recommendations dated 08/07/17. According to the RD the resident had redness to the back and sacrum while at the hospital so the RD continued the Pro Stat BID. The RD also stated she was aware that the total protein provided every 24 hours exceeded the resident's needs. On 10/02/17 at 10:40 a.m. the RD stated in retrospect, that at the time of the resident's readmission the Pro Stat should have been decreased. 2. On 09/26/17 at 10:30 a.m., the surveyor reviewed the records of Resident #1 who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor observed a Dietician Communication/Recommendation dated 07/06/17 which recommended that the resident receive Boost Plus (a nutritional supplement) three times a day. The physician signed the form on 07/14/17 and circled approved. A review of the July 2017 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/29/17 at 11 a.m., the surveyor spoke with the RD regarding this discrepancy. According to the RD, once the physician approved the recommendations, the nurse would write the order and place it in the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon further review of Resident #1's record, the surveyor observed that on 07/14/17 the physician wrote an order to discontinue [MEDICATION(S)] (a medication used to treat Dementia). A review of the July 2017 eMAR revealed that the medication was not discontinued as ordered and the nurses continued to give the [MEDICATION(S)] for the entire month. The surveyor observed that chart checks were done nightly from 07/15/17 through 07/31/17 but no one noted this error. A review of the August 2017 eMAR revealed that the medication continued to be given until 08/14/17 at which time the resident was transferred to the hospital. The surveyor reviewed the facility Review of Medication Orders policy and procedure which indicated that the 11-7 nurse will review every chart each night for the presence of physician order(s) and to review that any orders written were transcribed properly onto the resident's medication administration record. On 10/04/17 at 7:45 a.m., the surveyor spoke with the Director of Nursing (DON). She agreed that this error should have been detected during nightly chart checks but was not. 3. On 09/29/17 at 10 a.m. the surveyor reviewed the record of Resident #19 who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor observed a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed the July 2017, August 2017 and September 2017 eMARS which revealed that the medication was given 32 times when the blood pressure was above 100. Additionally, there were 10 instances when the eMARs were left blank which would indicate that the medication was not administered. On 10/02/17 at 9:10 a.m. the surveyor brought this to the attention of the DON who agreed with the surveyor's findings. 4. On 09/27/17 at 8:45 a.m., the surveyor reviewed the record of Resident #15 who was

Based on observation, interview and record review, it was determined that the facility failed to monitor for adverse consequences for a resident with a known and documented medication allergy. This resulted in an Immediate Jeopardy situation for Resident #8. Resident #8 had [DIAGNOSES REDACTED]. The resident had documented allergies to [MEDICATION NAME] and [MEDICATION NAME]. On 6/23/17 a nurse practitioner ordered and the resident received [MEDICATION NAME] and [MEDICATION NAME]. On 7/10/17 the resident returned to the hospital for a few hours due to acute [MEDICAL CONDITION] and returned on the same meds. On 7/23/17 the resident became extremely lethargic and staff documented a potential for [MEDICATION NAME] reaction in the past and [MEDICATION NAME] was administered at the facility with no effect. The resident showed signs of a [MEDICAL CONDITION] and [MEDICATION NAME] (a benzodiazepine) was ordered and administered. The resident remained on [MEDICATION NAME]. The resident was not transferred to the hospital due to physician orders [REDACTED]. The physician increased the dose of [MEDICATION NAME] on 7/24/17 and further increased the dose on 7/26/17. On 8/6/17 the physician discontinued the allergy for [MEDICATION NAME]. The allergy to [MEDICATION NAME] remained. From 6/23/17 to 8/6/17 the resident received medications that were ordered by the physician to be avoided and received a medication that was registered as an allergy. There was a system breakdown in the consultant pharmacist, the pharmacy and staff communication in this discovery (see F428). The facility was notified of the Immediate Jeopardy on 9/29/17 at 3:35 p.m. An acceptable P[NAME] was submitted to the team at 6:50 p.m. and the immediacy addressed by the facility was verified by the team and continued until the end of the survey. The deficient practice was evidenced by the following: 1. On 9/25/17 at 10:10 a.m. during the initial tour of the facility the Unit Manager (UM) told the surveyor that Resident #8 had [DIAGNOSES REDACTED]. The UM stated that the resident had behaviors such as banging and yelling but that the resident had not had the behaviors recently, and that the resident did not have a [DIAGNOSES REDACTED].#8 lying in bed with their eyes open. The surveyor spoke with the resident who answered appropriately with clear speech and stated that they were tired because they did not sleep well the previous night. On 9/27/17 at 12:30 p.m. the surveyor interviewed Resident #8 who stated that they had [MEDICAL CONDITION] and had a [MEDICAL CONDITION] but that [MEDICAL CONDITION] was not in remission and that they did not want any further medical interventions to treat [MEDICAL CONDITION]. On 9/28/17 and 9/29/17 the surveyor reviewed the physician's orders [REDACTED].#8. The printed and electronic medical record revealed the following: Resident #8 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A progress note entered by a Registered Nurse (RN) on 3/3/17 revealed that new orders for [MEDICATION NAME] (an antianxiety medication) had been obtained from the physician for restlessness and shortness of breath. An admission Minimum Data Set (MDS), an interdisciplinary assessment tool, dated 3/9/17 revealed that Resident #8's Brief Interview for Mental Status (BIMS) score was 14 out of 15 indicating intact cognition, the resident did not exhibit behaviors, and that the resident self-reported mood symptoms including trouble sleeping and abnormal appetite. An initial assessment by the facility's consultant psychiatrist dated 3/15/17 revealed that the resident had a history of [REDACTED]. The psychiatrist noted that Resident #8 did not have delusions and did not have hallucinations. The psychiatrist documented a [DIAGNOSES REDACTED]. On 6/8/17 Resident #8 was discharged to the hospital for evaluation of altered mental status. A General Medical Progress Note completed by a hospital physician on 6/12/17 revealed that the resident was diagnosed with [REDACTED]. The physician documented that Resident #8 was paranoid, did not have a [DIAGNOSES REDACTED]. A consult completed by a hospital psychiatrist dated 6/13/17 revealed that Resident #8's cognition was fair, the resident had paranoid delusions of people trying to harm the resident, had refused medical treatment, and had not been aggressive but was irritable. The resident denied a history of mental illness and the psychiatrist had contacted the resident's sister and she corroborated that the resident had no history of mental illness except Depression, and did not have a history of [MEDICAL CONDITIONS] Hypomania. The psychiatrist documented the following Diagnoses: [REDACTED]. The psychiatrist's treatment plan noted that the resident had a history of [REDACTED]. Resident #8 was readmitted to the facility on [DATE]. The surveyor reviewed a Transition of Care Document dated 6/13/17 completed by the hospital and sent to the facility upon readmission with discharge instructions. The document contained a synopsis of Resident #8's hospitalization . Under a section entitled Allergies, Adverse Reactions, Alerts the surveyor observed the following: [MEDICATION NAME] causes moderate [MEDICAL CONDITION]. Onset 6/10; [MEDICATION NAME] causes moderate hives. The document listed mediations in place at time of discharge from the hospital and included: [MEDICATION NAME] 0.5 mg tablet, disintegrating, two tablets orally daily and [MEDICATION NAME] 20 mg capsule, delayed release, one capsule orally daily. The document also listed medications that had been stopped during hospitalization and included [MEDICATION NAME] (generic [MEDICATION NAME]), [MEDICATION NAME] Concentrate ([MEDICATION NAME]) and [MEDICATION NAME]. The facility's Admission MEDICATION ORDERS FOR [REDACTED]. A readmission note by the primary physician dated 6/13/17 stated [MEDICAL CONDITION]- [MEDICATION NAME], psych eval, avoid opiates and benzos. The physician wrote an order dated 6/14/17 for No opiates, No benzodiazepines. A Psychiatric Follow Up from the facility's consultant psychiatrist dated 6/16/17 read follow up for depression, now with [MEDICAL CONDITION]. Patient is becoming more paranoid and delusional, refusing medications. Patient refused long conversation with me. The psychiatrist recommended to increase [MEDICATION NAME] to 0.5 mg three times a day for [MEDICAL CONDITION], continue [MEDICATION NAME] 20 mg daily for Depression, and start [MEDICATION NAME] (a benzodiazepine) 0.5 mg every eight hours as needed. The surveyor observed a handwritten telephone order dated 6/19/17 received from the primary physician and signed by an unidentified nurse that matched the recommendations given by the psychiatrist for [MEDICATION NAME] and [MEDICATION NAME]. The order for [MEDICATION NAME] had a line through it and an entry of error above it. There was no other information in the record addressing this order. Review of the (MONTH) Medication Administration Record [REDACTED]. The surveyor observed a handwritten telephone order dated 6/23/17 from the Nurse Practitioner (NP) taken by the Licensed Practical Nurse (LPN) for [MEDICATION NAME] (an opiate) patch 12 micrograms (mcg) every 72 hours (hr) [DIAGNOSES REDACTED]. There was no nurses' note entered in the medical record that addressed the need for pain medications or the new orders for [MEDICATION NAME] and [MEDICATION NAME]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. On 7/7/17 the consultant pharmacist entered a progress note that read Psych 6/16- [MEDICATION NAME] adjusted. Continue to monitor behaviors. The pharmacist did not address the resident's allergies or the use of opiates in the presence of a physician order [REDACTED].>On 7/10/17 the LPN entered a progress note that Resident #8 was agitated in the morning with a concern regarding finances. Throughout the morning, the resident became increasingly paranoid and agitated, screaming at staff, kicking, and throwing items on the floor. The nurse practitioner was contacted and gave a telephone ordered to transfer to the hospital for psychiatric episode, may use restraints for transport, and give [MEDICATION NAME] (an antipsychotic) 5 mg intramuscular (IM) injection once. The progress note stated that the Director of Nursing (DON) gave the resident IM [MEDICATION NAME]. The resident left the facility with transport at 11 a.m. There was no note addressing whether restraints were used. The (MONTH) MAR indicated [REDACTED]. The resident returned to the facility at 7:40 p.m. the same day. Review of a physician note from the Emergency Department revealed that crisis evaluated the resident and did not feel that the resident was experiencing acute paranoia despite agitation, noted that the resident was competent to refuse treatments [MEDICAL CONDITION], that there was no indication for involuntary committal, and that the resident was stable, calm, and cooperative after initial dose of [MEDICATION NAME]. On 7/23/17 the DON entered a progress note that Resident #8 was assessed and noted to be lethargic, non-responsive to verbal and tactile stimuli. The DON further documented that Resident does have a history of reactions to [MEDICATION NAME] in the past so patch immediately removed to ensure it was not causing lethargy. Primary physician notified of change in condition . Writer did relay concern of history of reactions to [MEDICATION NAME] in the past although resident has had patch on for quite some time now. The DON obtained from the physician a telephone order to insert intravenous (IV) line, give [MEDICATION NAME] (a medication used to block the effects of opiates) 0.4 mg IV one dose, and discontinue [MEDICATION NAME]. The [MEDICATION NAME] was administered without effect and approximately three minutes after administration the resident began to show signs of a [MEDICAL CONDITION]. The physician was notified and gave an order for [REDACTED]. On 7/24/17 the [MEDICATION NAME] was ordered by the primary physician to be restarted at the same (12 mcg/hr) dose. On 7/26/17 the [MEDICATION NAME] was increased by the primary physician to 25 mcg/hr. On 8/6/17 an unidentified nurse took a telephone order from the primary physician to discontinue the allergy to [MEDICATION NAME]/[MEDICATION NAME]. There were no nurses' notes entered for the date of 8/6/17. The physician's orders [REDACTED]. On 8/10/17 the consultant pharmacist entered a progress note stating No new issues. Also on 8/10/17 the primary physician wrote an order to discontinue the [MEDICATION NAME] Concentrate and give [MEDICATION NAME] (an opiate) by mouth every four hours as needed for severe pain. The primary physician also wrote an order to reduce [MEDICATION NAME] to 0.5 mg by mouth every 12 hours. On 8/12/17 the primary physician increased the dosage of the [MEDICATION NAME] to 50 mcg/hr. On 8/22/17 the primary physician increased the dosage of the [MEDICATION NAME] to 75 mcg/hr. On 8/25/17 the primary physician discontinued the [MEDICATION NAME] and increased the dose of [MEDICATION NAME] to be given every four hours as needed for pain. On 9/14/17 the consultant pharmacist wrote a progress note stating to clarify and sequence the PRN (as needed) [MEDICATION NAME]. A Quarterly MDS dated [DATE] revealed that Resident #8's BIMS score was 15 out of 15 indicating intact cognition, the resident did not exhibit behaviors and did not report mood symptoms, and that the resident reported occasional pain at a level of four out of ten. On 9/23/17 an unidentified nurse wrote a telephone order from the NP to discontinue the order for no opiates, no benzodiazepines. There was no nurses' note that addressed the discontinuation of the order. On 9/29/17 at 10:50 a.m. and 1:15 p.m. the surveyor interviewed the DON who stated that on 7/10/17 Resident #8 was out of control and combative and the resident called the police but accused him of being one of us. The facility scheduled transport to psychiatric crisis and the resident later returned. An order was obtained for emergency restraints and transport may have used them but they were not put on the resident while in the facility. The DON further stated that on 7/23/17 she was told by a Certified Nursing Assistant (CNA) that Resident #8 wasn't right. The DON assessed the resident and the clinical assessment seemed okay and indicated no cardiac or [MEDICAL CONDITION] signs and symptoms. The DON called the physician and told him that the resident had orders for Do Not Resuscitate (DNR) and Do Not Hospitalize (DNH). The DON informed the physician that the resident was lethargic and that the resident had been on [MEDICATION NAME] because the DON recalled that there was a potential for a reaction and that the [MEDICATION NAME] had been restarted and the resident had been receiving it for awhile. The physician directed the DON to give [MEDICATION NAME] IV but the [MEDICATION NAME] did not improve the resident's lethargy so the DON called the resident's sister who confirmed the resident's wishes for DNR and DNH. The DON stated that she didn't think the resident would make it through the night and that the next morning the resident was still lethargic but that night shift reported the resident had been their usual self. Later Resident #8 reported that the resident had drank vodka that they obtained from another resident but no formal investigation was completed. On 9/29/17 at 12:15 p.m., via telephone, the surveyor interviewed a medical records representative (MRR) from the facility's contracted pharmacy provider who stated that on 6/14/17 the pharmacy received readmission orders [REDACTED]. At 12:30 p.m., via telephone, the surveyor interviewed Pharmacist #1 from the facility's contracted pharmacy provider who reviewed Resident #8's pharmacy records and stated that the pharmacy had received readmission orders [REDACTED]. Pharmacist #1 stated that considering the allergy information received from the facility for Resident #8 on 6/14/17 all orders for opiates should have been questioned. Pharmacist #1 further stated that there was no record that indicated the facility, NP or physician were contacted regarding these discrepancies from 6/14/17 to 9/29/17. On 9/29/17 at 2:30 p.m. the surveyor interviewed Resident #8 who stated that they frequently have pain in the back, legs, spine, and bladder. Resident #8 stated they had allergies to [MEDICATION NAME] and anything in that family and that when given these medications they would get deathly sick, confused, and hallucinate. Resident #8 stated that they had never been told that they had an allergy to [MEDICATION NAME] and stated That's the patch that I take. If I don't take the patch (my pain) is worse. It seems to help to some degree. The resident stated that they recalled the incident on 7/10/17 and that very strong people were grabbing me and holding me down . they grabbed my wrists and arms and legs so tight I got bruises on my wrists and arms, but did not get bruises on my legs. I got very angry and I wanted to punch them. On 9/29/17 at 3:15 p.m. the surveyor interviewed the NP who gave the orders for [MEDICATION NAME] and [MEDICATION NAME] Concentrate on 6/23/17. The NP stated that the phone order was initiated by a facility nurse and that the resident wasn't on the medication upon readmission and the resident wanted it restarted. She stated that she was aware of the allergy and that just because a resident is allergic to one medication doesn't mean they are allergic to others. She stated that pharmacy calls her all the time but that she couldn't recall this specific case. She further stated that this information was documented about a week later because that was the next time she was in the facility. The surveyor reviewed the NP's progress note dated 6/28/17 which stated the following in regard to Resident #8's pain and mental status: Still with neuropathic pain; Awake, alert, oriented, forgetful, occasional hallucinations; [MEDICAL CONDITION]/lymph [MEDICAL CONDITION] increase [MEDICATION NAME] continue [MEDICATION NAME]; Chronic Pain [MEDICATION NAME], Depression/Anxiety [MEDICATION NAME] psych eval. The NP did not address the resident's listed allergies or the active physician order [REDACTED].>On 9/29/17 at 3:39 p.m. the surveyor interviewed via telephone Pharmacist #2, the facility's consultant pharmacist, who stated that there is a difference between an allergic reaction and an adverse reaction and that in a situation like this a true allergic reaction would start immediately. Pharmacist #2 stated that allergy to a medication or class of medications would not necessarily indicate an allergy to all medications of that type. Pharmacist #2 stated that he could not speak to specifics in the case of Resident #8 because he did not have the chart in front of him. On 10/2/17 at 9:35 a.m. the surveyor interviewed the primary physician for Resident #8 who stated that Resident #8 was admitted in (MONTH) of (YEAR) and that he was not Resident #8's physician prior to initial admission. He stated that the resident was admitted with an allergy to [MEDICATION NAME] and was using a [MEDICATION NAME] for pain at the time without problem so it was continued. The physician also stated that the resident had been started on [MEDICATION NAME] for anxiety after initial admission. The physician stated he was aware the resident had [MEDICATION NAME] documented as an allergy on readmission in (MONTH) (YEAR) and that he wrote an order for [REDACTED]. were a snap decision given by someone that didn't know the resident. He further stated that after the resident's readmission in (MONTH) (YEAR) the resident had complained of pain and requested to again receive the [MEDICATION NAME]. He stated the resident had a [DIAGNOSES REDACTED]. He stated he did not recall himself or the NP being contacted by the pharmacy for clarification. The fact that my NP and I gave the orders means that we gave the okay for these meds . This may be a documentation issue but my patient was never in danger and did not have a bad outcome. On 10/2/17 at 9:44 a.m. the DON stated that it was a new LPN who took the order for [MEDICATION NAME] and [MEDICATION NAME] Concentrate from the NP on 6/23/17 and that the DON was told by the LPN that the allergy had been discussed with the NP but was not documented. On 10/4/17 at 9:40 a.m. the surveyor interviewed consultant Pharmacist #2 at the facility. Pharmacist #2 stated that he had reviewed the chart for Resident #8 and noted the order for no opiates and no benzodiazepines. He stated that he could not attest to having seen this order before. He stated that just because someone has an allergy to opiates doesn't mean that they would have an allergy to [MEDICATION NAME] because they are a different chemical makeup and that adverse reactions are different from allergies. He further stated that because Resident #8 tolerated the [MEDICATION NAME] before and after the 6/8/17-6/13/17 hospitalization showed that there was no allergy and that stood for itself without documentation. On 10/3/17 at 12:15 p.m. and on 10/4/17 at 11:28 a.m. the surveyor interviewed the LPN. The LPN stated that Resident #8 had complained of pain and that the resident asked for the pain medications that they had been on before readmission from the hospital. The LPN stated she reviewed the resident's medical record and saw that the resident had previously been on [MEDICATION NAME]/[MEDICATION NAME] and [MEDICATION NAME]/[MEDICATION NAME] Concentrate. She called the NP who gave her the order for these medications on 6/23/17. The LPN stated she saw a red sticker on the inside front of the resident's chart with allergies including [MEDICATION NAME] allergy. She stated that she told the NP of the listed allergies and that the NP said that because the resident was on it before that it was okay to give. The LPN stated that she did not see or address with the NP the active physician order [REDACTED]. The facility was notified of the immediate jeopardy on 9/29/17 at 3:35 p.m. A plan of correction (P[NAME]) was submitted by the facility and accepted on 9/29/17 at 6:50 p.m. based on actions to be taken which included: 1. The Director of Nursing will review, revise, and date the facility's Policy and Procedure (P&P) titled Adverse Reaction, Medication, Allergy. 2. All Physicians, NPs, RNs, LPNs, and CNAs will receive education on the new P&P upon credentialing and annually. 3. The DON and UMs will audit all residents' charts to ensure that no resident is receiving a mediation that they have a documented allergy to. 4. The DON and UMs will audit all charts to ensure that any and all allergies are listed in the orders and on the resident allergy sticker located on the chart monthly. 5. The DON will work with the pharmacy customer service representative to ensure that the pharmacy has an accurate list of residents' allergies monthly. 6. The licensed nurse will review all resident allergies when new orders are obtained and physician orders [REDACTED]. 7. The UM will print the allergy report weekly for three months and will ensure that each resident on their unit is not on any medication that is listed as an allergy and report the findings to the DON weekly. 8. The DON will report the findings of the observation of the medication pass to the Quality Assurance Committee (QAC) monthly for three months. The QAC will determine if further monitoring is necessary. N.J.A.C. 8:39-27.1(a)(b)