Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for a.) 3 of 7 linen carts in 2 of 3 nursing units (North and [NAME] units), b.) 4 of 7 resident rooms (Rooms 10, 17, 18, and 20), and c.) 1 of 2 central baths (South unit) observed during environmental tour. This deficient practice was evidenced by the following: 1.On 3/24/26 at 11:20 AM, Surveyor #1 (S #1) observed during [NAME] unit tour two linen carts parked in between room [ROOM NUMBER] with posted sign for respiratory isolation and room [ROOM NUMBER] with posted sign for contact precaution. S #1 observed 1of 2 linen carts cover was ripped and there were clean linen supplies inside the ripped linen cart. On 3/25/26 at 8:20 AM, S #1 observed the North unit linen cart that was parked in between room [ROOM NUMBER] with posted sign for EBP (enhanced barrier precaution) and room [ROOM NUMBER]. Both S #1 and the Certified Nursing Aide (CNA) observed the four shelves linen cart top shelf was missing and the second top shelf was broken or damage with folded clean linen on it. The CNA confirmed that the gowns and linens were considered clean inside the damaged shelf linen cart, and the linen cart cover was ripped. There were total of three linen carts that was parked in between Rooms 46 to 53, and 1 of 3 linen cart cover was ripped. On 3/25/26 at 8:30 AM, S #1 in the presence of the Director of Nursing (DON) observed the [NAME] unit linen cart, which was parked between rooms [ROOM NUMBERS], which was observed also by the surveyor on 3/24/26, in the same location, the linen cart cover on top was ripped and left open to air in the hallway. The DON confirmed that they were considered clean linens and gowns inside the linen cart with ripped cover. At that same time, S #1 notified the DON of the above concerns that the ripped linen cart cover in the [NAME] unit was observed for two days, and the DON responded that the linen carts were brand new. S #1 then asked if they were brand new as to why they were ripped, and should it be left open if there were clean linen supplies, and she did not respond. On 3/25/26 at 8:40 AM, S #1 went back to the North unit, and observed on the other side, from Rooms 31 to 39, in the presence of the Life Enrichment Director (LED), observed the ripped linen cart cover with clean linens (inside a bag) and clean gowns (not bagged) parked in the hallway. The LED had no response when asked as to why the linen cart cover was ripped. S #1 observed 1 of 2 linen carts with ripped cover. 2. On 3/25/26 at 8:55 AM, S #1 observed room [ROOM NUMBER]'s ceiling vent in the toilet room with accumulation of grayish and whitish substances. There were two residents inside room [ROOM NUMBER] who were in their respective beds. On that same date and time, outside room [ROOM NUMBER], S #1 showed the picture that was taken inside the toilet room and asked the DON what those grayish and whitish substances in the ceiling vent were, and the DON did not respond. 3. On 3/26/26 at 8:25 AM, S #1 asked the Licensed Nursing Home Administrator (LNHA) to accompany S #1 to the South unit central bath and the LNHA stated that the shower room was being used by the dementia residents. Both S #1 and the LNHA observed the 1st big cubicle where there were equipment stocked, the ceiling air vent with grayish substances; the middle cubicle shower cubicle ceiling vent blackish to grayish substances, and the last cubicle also a shower cubicle on the right side, the ceiling vent with brownish grayish substances. S #1 asked what those in the air vents were, and he did not respond. On 3/26/26 at 8:44 AM, the LNHA informed S #1 in the presence of the survey team that those found in the South central bath were not dust. The LNHA further stated, just needed to be painted those ceiling vents. At that same time, S #1 and Surveyor #2 (S #2) with the LNHA and Regional Director of Operations (RDoO) went back to the South central bath. S #1 asked LNHA and the RDoO if they were not dust, should it be like that, and the LNHA responded that it was aesthetic. On 3/26/26 at 10:57 AM, the survey team met with the LNHA, DON, Regional Director of Clinical Services (RDoCS) and RDoO, and S #1 notified them of the above findings and concerns with environmental tour of West, North, and South units. On 3/26/26 at 12:38 PM, the survey team met with the DON, RDoCS, RDoO, and the LNHA provided a copy of the purchase order #SGR326154 for three linen carts that was created on 3/25/26, and pictures of painted air vents for room [ROOM NUMBER] and South central bath, both were after surveyor's inquiry. A review of the facility's Homelike Environment Policy that was provided by the RDoCS, with a revised date of February 2021, revealed, residents are provided with a safe, clean.and homelike environment.Under policy interpretation and implementation.2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect.homelike setting. These characteristics include: a. clean, sanitary and orderly environment. A review of the facility's Departmental (Environmental Services)-Laundry and Linen Policy that was provided by the RDoCS, with a revision date of January 2014, revealed, the purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen.Washing Line and other soiled items.7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. 4. On 3/26/26 at 12:30 PM, during environmental rounds, Surveyor #2 (S #2) observed the following concerns on the South nursing unit: room [ROOM NUMBER]: The wall behind the bed near the window had chipped paint and exposed wallboard. The windowsill also had chipped paint. room [ROOM NUMBER]: The wall behind the bed near the window had chipped paint and exposed wallboard. room [ROOM NUMBER]: The wall behind the bed near the window had chipped paint and exposed wall board. The windowsill also had chipped paint. On 3/27/26 at 2:10 PM, S #2 reviewed the above findings with the Maintenance Director in the presence of the LNHA and RDoO. The Maintenance Director acknowledged the identified concerns and confirmed that the conditions did not promote a homelike environment. The Maintenance Director further stated that he conducted weekly or biweekly rounds on the nursing units; however, these rounds do not routinely include resident rooms. He indicated that staff submit repair requests through an electronic TELS (maintenance) system, and repairs were addressed based on those submissions. A review of the facility's Homelike Environment Policy, dated as revised February 2021 reflected .The Residents are provided with a safe, clean, comfortable and homelike environment . On 3/30/26 at 12:30 PM, no further information was provided by the LNHA. NJAC 8:39-31.4(a)(f)
Every finding on record at Spring Grove Rehabilitation and Healthcare Center
New Providence, New Jersey · CCN 315005
24 findings across 5 inspections, in the inspector's own words, 5 of them at actual harm or above.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Inspection of March 30, 2026
14 findingsBased on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity during the medication (med) administration observation. This deficient practice was identified in 1 of 4 residents (Resident #43) observed during the med pass observation. This deficient practice was evidenced by the following: On 3/26/26 at 8:42 AM, the surveyor observed the Registered Nurse (med RN) assigned to Resident #43 prepare medications (meds) for administration to the resident. The surveyor observed the medRN enter the resident's room with the meds. The medRN stated that the resident was not in bed but was receiving care and being assisted in the lavatory. The surveyor observed the medRN enter the lavatory and administer meds to Resident #43 while they were seated on the toilet. The medRN then returned to the med cart.The surveyor asked the medRN if it was common practice to administer meds to a resident while they were in the lavatory and seated on a toilet. The medRN stated that they had known the resident for a long time and that they like to get their meds right away.The surveyor concluded the observation.The surveyor reviewed the electronic medical record (EMR) for Resident #43 which revealed the following:A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; acute embolism and thrombosis (a clot inside a blood vessel that breaks off and travels elsewhere in the body and blocks a smaller vessel), dementia (a decline in mental or cognitive ability), and difficulty walking.A review of the comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 2/6/26, under Section C-Cognitive Pattern, reflected a brief interview for mental status (BIMS) score of 0 out of 15, which indicated that the resident's cognitive status was severely impaired.A review of the resident's comprehensive care plan (CCP) did not reveal any focus, goal, or intervention for administering meds while the resident was in the lavatory or seated on a toilet.On 3/27/26 at 12:37 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations (RDoO), and Regional Director of Clinical Services (RDoCS) for the above concerns. The surveyor asked the DON if it was appropriate to administer meds to a resident while they were seated on a toilet. The DON stated, no, it was not.On 3/30/26 at 10:37 AM, the facility met with the LNHA, RDoO, RDoCS, and the DON stated that education was provided to the staff and the medRN regarding proper med administration and resident dignity. The DON provided education attendance sheets.The LNHA did not provide any further pertinent information.A review of the facility's Administering Medications Policy, dated April 2019, reflected, under 21.residents.otherwise unavailable to receive med.the nurse will return to the missed resident.The policy did not reflect any mention of administration of meds while seated on a toilet.A review of the facility's undated Dignity Policy, reflected, under 12. Demeaning practices and standards of care that compromise dignity are prohibited. Under 13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity.N.J.A.C. 8:39-4.1(a)12,16
Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to adequately monitor target behavior for the use of psychotropic medications (meds) specifically an antianxiety and antidepressant meds and ensure an antianxiety medication was ordered for an appropriate diagnosis or indication for 1 of 5 residents (Resident #1), reviewed for unnecessary meds. This deficient practice was evidenced by the following: On 3/24/26 at 11:33 AM, the surveyor observed Resident #1 seated in their bed while on nebulizer treatment. A review of Resident #1's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic obstructive pulmonary disease (COPD), muscle weakness, difficulty walking, and need for assistance with personal care. A review of Resident #1's March 2026 electronic Medication Administration Record (eMAR) included the following physician's orders (PO): -Duloxetine HCl (hydrochloride) capsule (cap) delayed release particles 30 mg (milligram), give 1 cap by mouth one time a day for depression-Start Date 2/27/26. - Trazodone HCl oral tablet (tab) 50 mg, give 50 mg by mouth at bedtime (HS) for insomnia-Start Date 2/27/26. -Clonazepam oral tab 0.5 mg, give 1 tab by mouth every 14 hours as needed (PRN) for insomnia/anxiety no stop date by MD-Start Date 3/20/26. There was no behavior monitoring documented for the use of duloxetine, trazodone, and clonazepam in the month of March. A review of Resident #1's most recent comprehensive Minimum Data Set (cMDS), with an Assessment Reference Date (ARD) of 3/5/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that Resident #1's cognition was intact. Further review of the MDS reflected that the resident received an antianxiety and antidepressant meds. The cMDS did not indicate any active diagnosis that the antianxiety and antidepressant meds were ordered for. A review of Resident #1's comprehensive care plan (CP) reflected the following focus area:- I use antianxiety medication (med) that was initiated on 2/26/26, with interventions that included but were not limited to administer antianxiety med as ordered. Observe effectiveness and side effects (s/e). - I have depression and anxiety r/t (related to) admission to nursing facility that was initiated on 2/26/26, with interventions that included but were not limited to administer meds as ordered. Monitor and document s/e and effectiveness. Further review of the CP revealed that there was no documented evidence that the target behavior were identified for use of the psychotropic meds (are drugs that affect the mind, emotions, and behavior) that included antianxiety and antidepressant. A review of the late entry physician's History and Physical (H&P) on 2/27/26 and Physician Progress Note (PPN) from 3/4/26 to 3/23/26, revealed that Resident #1's assessment included diagnosis but were not limited to COPD and anxiety/depression. There was no documented evidence that the PPN included diagnosis or indication for insomnia. A review of the psychiatric DNP (Doctor of Nursing Practice) visit included the following:2/27/26 visit-initial evaluation of resident with history of depression and anxiety.No acute distress noted. Periods of anxiety. Denies persistent depression.No severe agitation or overt aggression. Reports did not sleep well last night, resident reported took PRN clonazepam at home.Clinical signs and target symptoms: anxiety, depression.Psychotropic meds being monitored include:Clonazepam 0.5 mg by mouth q (every) 14 hour PRN anxietyDuloxetine 30 mg by mouth daily (depression)Melatonin 3 mg by mouth HS PRN sleepTrazodone 50 mg by mouth HS PRN On 3/25/26 at 9:03 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that the diagnosis and indication of meds should be based on the physician(s) documentations in their visit notes and H&P. The LPN/UM confirmed that the behavior monitoring should be in the eMAR. At that same time, the surveyor notified the LPN/UM of the concern that there was no adequate monitoring or target behavior for the use of the psychoactive meds and the concern that the indication for the use of PRN clonazepam was not clarified for insomnia/anxiety. The surveyor further asked the LPN/UM how the nurse would know and identify for what reason the PRN clonazepam was being administered for if the indication was for both insomnia and anxiety and if the indication should had been clarified, and the LPN/UM had no response. On 3/26/26 at 10:57 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations (RDoO), Regional Director of Clinical Services (RDoCS) of the above findings and concerns with regard to Resident #1's psychoactive meds and there was no adequate behavior monitoring and the indication of use for clonazepam was not clarified. On 3/26/26 at 12:38 PM, the survey team met with the LNHA, RDoO, RDoCS, and the DON stated that the order for clonazepam was clarified after surveyor's inquiry. The RDoCS stated that the behavior monitoring was entered as an order after surveyor's inquiry. The DON added that the behavior monitoring was now in the eMAR after surveyor's inquiry. A review of the facility's Psychotropic Medication Use Policy with a revised date of February 2025, included the following Policy Statement, Residents do not receive psychotropic meds that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Policy Interpretation and Implementation .2. Meds in the following categories are considered psychotropic meds and are subject to prescribing, monitoring, and review requirements specific to psychotropic meds: a. Anti-psychotics; b. Anti-depressants; c. Anti-anxiety meds.5. Psychotropic meds are never used to sedate or alter a resident's behavior for discipline or for the convenience of the staff .Monitoring and Adverse Consequences. 2. Residents receiving psychotropic med are monitored and the response to treatment is documented. The LNHA did not provide any additional information. NJAC 8:39-4.1(a)6
Based on interview and record review, it was determined that the facility failed to accurately complete portions of the Minimum Data Set (MDS), an assessment tool to facilitate the plan of care, to accurately reflect the residents' status as of the Assessment Reference Date (ARD) for 2 of 23 residents reviewed (Residents #1 and #4). The deficient practice was evidenced by the following: 1.On 3/24/26 at 11:33 AM, Surveyor #1 (S #1) observed Resident #1 seated in their bed while on nebulizer treatment. A review of Resident #1's admission Record (AR) or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic obstructive pulmonary disease (COPD), muscle weakness, difficulty walking, and need for assistance with personal care. A review of Resident #1's March 2026 electronic Medication Administration Record (eMAR) included the following physician's orders (PO): -Nifedipine oral capsule (cap) 20 mg (milligram), give 1 cap by mouth every 8 hours for hypertension (HTN)-Start date 2/26/26. -Duloxetine HCl (hydrochloride) cap delayed release particles 30 mg, give 1 cap by mouth one time a day for depression-Start Date 2/27/26. -Trazodone HCl oral tablet (tab) 50 mg, give 50 mg by mouth at bedtime (HS) for insomnia-Start Date 2/27/26. -Clonazepam oral tab 0.5 mg, give 1 tab by mouth every 24 hours as needed (PRN) for insomnia.-Start Date 2/27/26 and was discontinued (dc'd) on 3/3/26. The medication (med) was administered on 3/1, 3/2, and 3/3/26. -Clonazepam oral tab 0.5 mg, give 1 tab by mouth every 24 hours as PRN for insomnia for 14 days.-Start Date 3/3/26 and was dc'd on 3/17/26. The med was administered on 3/4, 3/5, 3/6, 3/7, 3/9, 3/11, 3/12, 3/13, 3/15, 3/16, and 3/17/26. -Tramadol HCL oral tab 50 mg, give 50 mg by mouth every 6 hours PRN for pain-Start date 2/27/26 and was dc'd on 3/3/26. The med was administered on 3/2 and 3/5/26. -Tramadol HCL oral tab 50 mg, give 50 mg by mouth every 6 hours PRN for sever pain-level 5-10-Start date 3/3/26. The med was administered on ¾, 3/5, 3/6, 3/7, 3/9, 3/11, 3/12, 3/13, 3/14, 3/15, 3/16, 3/17, 3/18, 3/20, 3/21, 3/22, and 3/23/26. A review of Resident #1's comprehensive care plan (CP) reflected the following focus area for anxiety, depression, and pain. A review of the late entry physician's History and Physical (H&P) on 2/27/26 and Physician Progress Note (PPN) from 3/4/26 to 3/23/26, revealed that Resident #1's assessment included diagnosis but were not limited to; HTN, DJD (degenerative joint disease) and anxiety/depression. A review of Resident #1's most recent comprehensive Minimum Data Set (cMDS), with an ARD of 3/5/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that Resident #1's cognition was intact. The cMDS reflected that the resident received antianxiety and antidepressant medications (meds), and pain meds. The cMDS did not indicate any active diagnosis that included anxiety, depression, and DJD even though the resident received antianxiety, antidepressant, hypertensive, and pain meds. On 3/25/26 at 9:03 AM, S #1 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that the diagnosis and indication of meds should be based on the physician(s) documentations in their visit notes and H&P, and the list of meds. The LPN/UM further stated that she was unsure about the MDS listing for diagnoses and she was not responsible for MDS. On 3/25/26 at 10:15 AM, S #1 interviewed the Registered Nurse/MDS Coordinator (RN/MDSC) who informed S #1 that she followed the RAI (Resident Assessment Instrument) Manual for MDS. She stated that she gathered information to answer Section I -active diagnosis of the MDS from the physician's H&P, physicians' notes, hospital records, and the nurses' notes. At that same time, S #1 notified the RN/MDSC of the above concerns with regard to the diagnosis that was not coded in Section I for HTN, anxiety, depression, and DJD when the resident was being medicated and meds were adjusted. The RN/MDSC stated that she would have to get back to S #1. On 3/25/26 at 11:48 AM, the RN/MDSC informed S #1 that after surveyor's inquiry, she modified the cMDS with an ARD of 3/5/26, to include the diagnosis that were not coded. She further stated that the reason that the MDS was inaccurate because she had to do all MDSs by herself and her focus was to submit the MDSs for billing purposes. She acknowledged that the MDS was inaccurate and should have included the active diagnosis. On 3/26/26 at 10:57 AM, S #1 notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations (RDoO), Regional Director of Clinical Services (RDoCS) of the above findings and concerns with regard to Resident #1's MDS accuracy. On 3/26/26 at 12:38 PM, the survey team met with the LNHA, RDoO, RDoCS, and the DON stated that the MDS was modified. The LNHA did not provide any additional information. 2. On 3/27/26 10:10 AM, Surveyor #2 (S #2) reviewed the medical record for Resident #4. A review of the AR revealed the resident had diagnoses which included, but were not limited to; unspecified dementia without behavioral disturbance, major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, Parkinson's disease without dyskinesia, metabolic encephalopathy, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, type 2 diabetes mellitus, atrial fibrillation, essential hypertension, chronic kidney disease, and iron deficiency anemia. A review of the resident's quarterly MDS with an ARD of 3/5/26, included the resident had a BIMS score of 5, indicating cognitive impairment consistent with documented diagnoses of dementia and metabolic encephalopathy. Further review of the MDS revealed that Section N-Medications were not coded accurately to reflect the refusal of meds. A review of the resident's CP revealed that the resident had a focus CP for psychosis, depression, dementia-related behaviors, and use of psychotropic medications. Interventions included administering medications as ordered, monitoring and documenting side effects and effectiveness each shift, and addressing medication refusal through redirection, education, and physician notification as clinically indicated. A review of the Order Summary Report included the following PO: Mirtazapine 30 mg tab, give 1 tab by mouth at HS, related to major depressive disorder, single episode, unspecified. Quetiapine fumarate 25 mg tab, give 1 tab by mouth two times a day for adjunct treatment for major depressive disorder and psychotic episodes related to dementia. A review of the eMAR for the seven days prior to the 3/5/26 MDS assessment revealed the resident refused meds on multiple occasions, including 3/2/26, 3/3/26, 3/4/26, and 3/5/26. These refusals were consistently documented in the eMAR, including entries noting the resident refused, and entries in which staff recorded the resident stated he did not want his med. This documented pattern of refusal, the 3/5/26 MDS did not accurately reflect this information. On 3/27/26 at 10:52 AM, S #2 interviewed the RN/MDSC who stated she had been on vacation and that the Social Worker (SW) had completed that section of the MDS. The RN/MDSC further stated that she did open and close the quarterly assessment but did not complete the section reflecting med refusal. When asked whether the MDS was accurate, the RN/MDSC stated it was not accurate and that she would go in and modify it. On 3/30/26 at 11:12 AM, the LNHA, in the presence of the DON, acknowledged that the MDS had been modified for med refusal following surveyor inquiry. NJAC 8:39-33.2(d)
Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to correctly document administration of medications (meds) during the medication (med) administration observation. This deficient practice was identified for 2 of 4 residents observed during the med pass observation (Resident #43 and Resident #69). This 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.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/26/26 at 8:34 AM, the surveyor observed the Registered Nurse (medRN) assigned to Resident #69 prepare meds for administration to the resident. The surveyor observed the medRN access the resident's electronic medication administration record (eMAR) and marked off each med on the eMAR as they prepared it in a dose cup, then checked a box that indicated the meds were administered before entering the resident's room. The medRN then administered the due meds to the resident. The medRN then continued to the next resident. On 3/26/26 at 8:34 AM, the surveyor observed the medRN to Resident #43 prepare meds for administration to the resident. The surveyor observed the medRN access the resident's eMAR, and observed the medRN marked off each med on the eMAR as they prepared it in a dose cup, then checked a box that indicated the meds were administered before entering the resident's room. The medRN then administered the due meds to the resident. The surveyor asked the medRN if it was common practice to sign for med administration before they were administered. The medRN stated not really, I just hit the button.The surveyor concluded the observation. The surveyor reviewed the electronic medical record (EMR) for Resident #43 which revealed the following:A review of the admission Record (AR) (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; acute embolism and thrombosis (a clot inside a blood vessel that breaks off and travels elsewhere in the body and blocks a smaller vessel), dementia (a decline in mental or cognitive ability), and difficulty walking. A review of the comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 2/6/26, under Section C-Cognitive Pattern, reflected a brief interview for mental status (BIMS) score of 0 out of 15, which indicated that the resident's cognitive status was severely impaired. A review of the resident's eMAR, revealed that Resident #43 had scheduled and received four meds during the observation. The surveyor reviewed the EMR for Resident #69 which revealed the following:A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to, type 2 diabetes (a condition where the body does not use insulin properly resulting in high blood sugar) and gastro-esophageal reflux disease (a digestive condition where stomach acid frequently flows back into the esophagus). A review of the quarterly Minimum Data Set (qMDS) with an ARD of 2/20/26, under Section C, reflected a BIMS score of 9 out of 15, which indicated that the resident's cognitive status was moderately impaired. A review of the resident's eMAR, revealed that Resident #69 had scheduled and received four meds during the observation. On 3/27/26 at 12:37 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations (RDoO), and Regional Director of Clinical Services (RDoCS) for the above concerns. The surveyor asked the DON if it was appropriate to sign or indicate that meds were administered before they were administered to the resident. The DON stated, no, meds should be signed for after administration and before moving to the next resident. On 3/30/26 at 10:37 AM, the survey team met with the LNHA, RDoO, RDoCS, and the DON stated that education was provided to the staff and the medRN regarding proper med administration and signing for meds. The DON provided education attendance sheets. The LNHA did not provide any further pertinent information. A review of the facility's Administering Medications Policy, dated April 2019, reflected under 23, the individual administering the med initials the resident's MAR on the appropriate line after giving each med and before administering the next one. NJAC 8:39-29.2(a)(d)
Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident with a Stage 3 pressure ulcer received care and services consistent with professional standards of practice, by failing to, a.) document the required daily wound care treatment on the electronic Treatment Administration Record (eTAR), and b.) to follow up on the wound care consultant's recommended change in treatment. This deficient practice was identified for 1 of 1 resident (Resident #7) reviewed for pressure ulcer treatment and wound care documentation, and 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.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/24/26 at 11:25 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that Resident #7 was seen by wound care weekly and that wound care was completed daily to the sacrum. On 3/25/26 at 10:48 AM, the surveyor observed Resident #7 seated in her wheelchair in the day area, participating in activities. The surveyor reviewed the medical record for Resident #7.A review of the admission Record or face sheet (an admission summary), revealed the resident had diagnoses which included, but were not limited to; quadriplegia (C5-C7 incomplete), type 2 diabetes mellitus without complications, muscle wasting and atrophy, essential hypertension, depression, neuromuscular dysfunction of bladder, hyperlipidemia, anemia, thyrotoxicosis with diffuse goiter, cervical disc disorder with myelopathy, and arthropathy. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 2/3/26, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident was assessed as having a pressure ulcer/injury, with the MDS triggering for pressure ulcer. A review of the resident's individual comprehensive care plan included a focus area that the resident had a Stage 3 pressure ulcer on the sacrum related to immobility and incontinence. Interventions included: administering treatments as ordered and monitoring for effectiveness, reporting abnormal findings to the practitioner, documenting findings and interventions, monitoring and documenting wound healing, maintaining a low air loss mattress, monitoring and treating pain as needed, and monitoring dressing placement every shift. A review of the Order Summary Report, dated as of 3/25/26, included the following physician orders (PO):A PO dated 1/31/26, for daily wound care to the sacrum: Clean with normal saline solution (NSS), apply triad paste and cover with border dressing, one time daily for pressure ulcer.A PO for weekly skin checks on Monday, Wednesday, and Friday, Evening shift, to be completed by two nurses with a signed completion form, for preventative measures. A review of the March eTAR revealed no nursing signature on 3/18/26 to indicate that the ordered daily wound care treatment was completed. There was no progress note (PN), weekly skin assessment, or alternative documentation confirming whether the treatment occurred on that date. A review of the evaluations list showed a Weekly Skin Check dated 3/18/26 documented as complete on 3/18/26; however, no documentation existed specific to confirmation that the wound care treatment order was performed on 3/18/26. A review of the PN showed a Health Status Note dated 3/25/26 at 12:39, entered only after surveyor's inquiry, which stated: Late entry for 3/20/26 - Doctor opted not to change dressing for sacrum wound. No physician documentation providing a rationale was present prior to this late entry, and no evidence existed that the physician was notified of or reviewed the consultant's recommendation in real time. A review of the PN further showed that additional notes, including documentation of the physician's decision, were created on 3/25/26 after the surveyor raised concerns. No contemporaneous documentation existed prior to surveyor inquiry to indicate that the physician had reviewed or was aware of the consultant's recommendation. Further review of Resident #7's medical records revealed a wound care consultant's assessment, dated 3/20/26, revealed an evaluation of a Stage 3 pressure ulcer/injury at the coccyx. The wound measured 0.4 cm (centimeter) length by 0.7 cm width by 0.2 cm depth, with granulation tissue and no signs of infection. The consultant documented that the wound was stable and recommended changing the treatment to collagen powder. The recommended wound orders included: cleanse wound with NSS, apply collagen powder as the primary dressing, and cover with bordered gauze daily and as needed. There was no documentation indicating that nursing notified the physician of the consultant's recommendation, nor any documentation that the physician reviewed, accepted, or declined the recommended change in treatment. The resident's ordered treatment of Triad paste with border dressing per the 1/31/26 PO remained unchanged. On 3/25/26 at 11:42 AM, the surveyor interviewed the Director of Nursing (DON), who confirmed the missing eTAR documentation and stated that the nurse probably forgot to sign. The DON provided a typed and signed statement of the nurse after surveyor's inquiry, that the wound treatment on 3/18/2026 was provided prior to the nurse's medication pass but that the nurse forgot to sign. On that same date and time, the DON stated her expectation that when wound care consultants made a recommendation, nursing was expected to follow up with the primary physician, who would normally be notified by the Unit Manager, and that the physician was then expected to write an order. The DON further stated that she would expect the physician to document a rationale when a consultant's recommendation was not followed. A review of the PN showed a Health Status Note dated 3/25/26 at 11:57, which stated: Wound treatment on 3/18/26 provided prior to my med pass but I forget to sign. On 3/30/26 at 11:14 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, acknowledged that the nurse had written a letter stating she completed the wound care treatment on 3/18/26 but failed to document it in the eTAR. The LNHA also acknowledged that a late entry for the physician's note regarding the wound care consultant recommendation had been documented following surveyor's inquiry. NJAC 8:39-27.1 (a)(e)
Based on observation, interview, and record review, it was determined that the facility failed to, a) ensure that an active physician order was in place for the management, care, and monitoring of a nephrostomy tube upon a resident's return from the hospital for 1 of 2 residents (Resident #10), and b) ensure that the comprehensive care plan accurately reflected the current status of a resident's indwelling urinary catheter following discontinuation of the device for 1 of 2 residents (Resident #57), reviewed for urinary catheter or UTI (Urinary Tract Infection), and was evidenced by the following: This deficient practice was evidenced by the following: 1.On 3/25/26 at 10:35 AM, Surveyor #1 (S #1) observed Resident #10 lying in bed. Enhanced Barrier Precautions (EBP) signage was posted at the door. The nephrostomy drainage bag was observed in place and functioning, and the resident appeared comfortable. On that same date and time, S #1 interviewed Resident #10, who reported having a nephrostomy tube in place for urine drainage and stated they had no issues with it. On 3/26/26 at 12:30 PM, S #1 reviewed the medical record for Resident #10. A review of the admission Record (AR) or face sheet (an admission summary) revealed the resident had diagnoses which included, but were not limited to; muscle wasting and atrophy, not elsewhere classified, multiple sites; gastrostomy infection; gastrostomy status; obstructive and reflux uropathy, unspecified; renal agenesis, unilateral; other artificial openings of urinary tract status; urinary calculus, unspecified; benign prostatic hyperplasia without lower urinary tract symptoms. A review of the resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, the MDS triggered for an indwelling catheter, including nephrostomy tubing, with a response of yes documented for the presence of an indwelling catheter including suprapubic catheter and nephrostomy tube. A review of the resident's care plan (CP) included an active problem area stating the resident had a urostomy or nephrostomy, with a dated note from 9/16/25, indicating the resident had turned over and their nephrostomy tube had come out, requiring transfer to the hospital for re-insertion. Interventions included connecting to a drainage bag as ordered and keeping it below catheter level to ensure proper drainage, applying dressing to the insertion site as ordered, monitoring and documenting any symptoms of bacteremia or septicemia and reporting abnormal findings to the physician, monitoring and documenting urine color and amount, and monitoring the insertion site for signs and symptoms of infection including redness, drainage, and heat. A review of the admission summary dated [DATE] at 10:42 PM, revealed the resident was a re-admission from the hospital. The admission note documented that a body assessment was completed and that the resident had a nephrostomy tube attached to a urine drainage bag at the left lower back. The note further documented that all admission orders were verified with the physician. A 10:00 PM entry in the same note documented the nephrostomy tubing was draining clear urine. A review of the Physician Orders (PO) and electronic Treatment Administration Record (eTAR) on 3/26/26 revealed no active physician order (PO) for the nephrostomy tube or nephrostomy care at the time of surveyor's review. Past nephrostomy orders had been in place prior to the resident's most recent hospitalization; however, no active order had been entered following resident's return from the hospital on 2/16/26. On 3/26/26 at 11:15 AM, S #1 interviewed the Director of Nursing (DON), who stated that the resident had been in and out of the hospital and that the order must not have been activated on their return. On 3/27/26 at 9:45 AM, S #1 conducted a follow-up interview with the DON, who provided an updated Order Summary Report (OSR) that included nephrostomy care orders entered by the physician following surveyor inquiry on 3/26/26. On 3/30/26 at 11:15 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON and the survey team, acknowledged that the PO for the nephrostomy tube had been entered on 3/26/26 after surveyor's inquiry. The LNHA further provided documentation of an in-service training record completed on 3/28/26 following surveyor inquiry, which addressed the requirement that nurses ensure all orders for drains, treatments, and similar devices were in place on the day of admission. 2. On 3/24/26 at 11:13 AM, Surveyor #2 (S #2) interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who informed S #2 that Resident #57 was on contact precautions (infection control measures used in healthcare settings to prevent the spread of germs transmitted by direct or indirect contact with a patient or their environment) due to ESBL in urine ((Extended-Spectrum Beta-Lactamase) in urine indicates a UTI caused by bacteria (usually E. coli or Klebsiella) that produce enzymes resistant to many common antibiotics) which was an in house infection. On 3/24/26 at 11:20 AM, S #2 observed Resident #57's door was slightly open, and the resident was lying in bed with eyes closed. At that time, S #2 observed no urinary catheter drainage bag. There was a posted sign outside the door for contact precaution and a PPE (personal protective equipment) hung that included box of surgical masks, gowns, and gloves. S #2 reviewed the medical records of Resident #57, and revealed: A review of Resident #57's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; essential (primary) hypertension (elevated blood pressure), difficulty walking, need for assistance with personal care, and ESBL in urine. A review of the most recent comprehensive Minimum Data Set (cMDS), with an assessment reference date (ARD) of 3/16/26, revealed a BIMS score of 13 out of 15, which reflected that the resident's cognitive status was intact. The cMDS also reflected that the resident was frequently incontinent of both bowel and bladder, had no indwelling catheter, and received an antibiotic within the last seven days of lookback period. A review of the Physician Progress Note (PPN) that was electronically signed on 3/20/26 at 7:00 AM, by the DO ((Doctor of Osteopathic Medicine) is a fully licensed physician in the United Stated trained to provide comprehensive medical care, including prescribing medicine, performing surgery, and practicing in all specialties), under Plan,.remove foley today.Discussed:.*nursing. A review of the Health Status Note in the Progress Notes (PN), that was electronically signed by Licensed Practical Nurse #1 (LPN #1) on 3/20/26 at 11:30 AM, reflected in the Note text: Resident foley catheter removed per order, 400 ml (milliliters) output. Resident had one wet change since removal. Resident in stable condition. A review of the March 2026 eTAR revealed the following PO: -Urinary catheter care: clean area around catheter with soap and water every shift-Start date 3/12/26 at 7:00 AM. The order was discontinued (dc'd) on 3/23/26 at 10:09 PM. The above PO for urinary catheter care was plotted for Day, Evening, and Night shifts that were electronically signed by nurses from 3/12/26 to 3/23/26 Day shift. -Urinary catheter: maintain foley catheter with 14F (14 french) 10 ml balloon for urinary retention and change PRN (as needed) for obstruction every shift.-Start date 3/12/26 at 7:00 AM. The order was dc'd on 3/23/26 at 10:08 PM. The above PO for maintain foley was plotted for Day, Evening and Night shifts that were electronically signed by nurses from 3/12/26 to 3/23/26 Day shift. A review of the current CP reflected a focus, that the resident had an indwelling urinary catheter r/t (related to) neurogenic bladder that was initiated on 3/11/26. The focus was that the resident had a UTI with initiated date of 3/12/26. Further review of the CP revealed that the resident's CP was not revised to reflect the current condition of the resident that the indwelling urinary catheter was dc'd on 3/20/26. On 3/25/26 at 8:50 AM, S #2 interviewed LPN #2 regarding Resident #57's foley catheter, and she responded that the resident's catheter had been dc'd. On 3/25/26 at 9:08 AM, S #2 interviewed LPN/UM, who stated that the CP should reflect the current condition of the resident. The LPN/UM further stated, usually she update or revise the CP within 48 hours, that included the foley catheter, wounds that healed, and any changes in the medications. On that same date and time, S #2 notified the LPN/UM of the above concern that the physician had documented on 3/20/26 by the DO to discontinue (d/c) the foley and it was not until 3/23/26 in the eTAR that the foley was dc'd. S #2 also notified the LPN/UM about the CP being not revised up to this time, and she responded that she would get back to S #2. On 3/26/26 at 10:57 AM, The survey team met with the LNHA, DON, Regional Director of Operations (RDoO), and Regional Director of Clinical Services (RDoCS), and the surveyor notified them of the above findings and concerns with Resident #57's foley catheter. On 3/26/26 at 12:38 PM, the survey team met with the LNHA, RDoO, RDoCS, and the DON stated that Resident #57's CP was updated to reflect that the indwelling catheter was resolved, and the incontinent CP was added on 3/25/26, after surveyor's inquiry. A review of the facility's Catheter Care, Urinary Policy that was provided by the RDoCS, with a revision date of August 2022, revealed, the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Preparation: 1. Review the resident's CP to assess for any special needs of the resident. A review of the facility's Care Plans, Comprehensive Person-Centered Policy that was provided by the RDoCS, with a revision date of March 2022, revealed under policy statement, a comprehensive, person-centered CP that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under policy interpretation and implementation, 1. The interdisciplinary team (IDT), in conjunction with the resident and their representative or legal representative, develops and implements comprehensive, person-centered CP for each resident.11. Assessments of residents are ongoing and CP are revised as information about the residents and the resident's conditions change. A review of the facility's Medication and Treatment Orders Policy that was provided by the RDoCS, with a revision date of July 2016, reflected under policy statement, orders for meds and treatments will be consistent with principles of safe and effective order writing. Under policy interpretation and implementation.2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record.7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and time of the order. The LNHA did not provide additional information. N.J.A.C. 8:39-27.1 (a)
REPEAT DEFICIENCYBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) maintain the necessary respiratory care and services of residents in accordance with professional standards of practice and b.) follow physician orders, for 2 of 5 residents, (Resident #3 and Resident #139) reviewed for respiratory care.This 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. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 3/24/26 at 10:23 AM, Surveyor #1 (S #1) observed Resident #3 in the common room with other residents, sitting on a wheelchair listening to music. S #1 observed the resident connected to an oxygen (O2) via nasal cannula (N/C) at 2 liters/minute (L/min). The O2 tubing (dated 3/19/26) was observed laying on the floor, connected to the resident, then to the bottle of humidification (undated) and then to the O2 concentrator machine. On 3/24/26 at 10:56 AM, (33 minutes later) License Practical Nurse #1 (LPN #1) came over to the resident, picked up the O2 tubing off the floor and placed it on top of the concentrator. LPN #1 did not dispose of O2 tubing or apply a new one. On 3/24/26 at 11:02 AM, S #1 observed the resident's O2 tubing again laying on the floor while in use. S#1, in the presence of LPN #1 observed the O2 tubing touching the floor, the bottle of undated humidification. S #1 interviewed LPN #1 who confirmed the tubing should be off the floor because of infection control, and confirmed the bottle of humidification should be dated. LPN #1 proceeded to remove the O2 tubing off the floor, placed it on the concentrator, did not dispose of the tubing or replaced it with a new one. A review of Resident #3's admission Record (AR) or face sheet (an admission summary) revealed diagnoses which included but not limited to, displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, encounter for other orthopedic aftercare, unspecified dementia (decline in mental ability), unspecified severity, without behavioral disturbance, psychotic disturbance. A review of the quarterly Minimum Data Set (MDS), an assessment tool to facilitate the plan of care, with an assessment reference date (ARD) of 1/16/26, revealed a Brief Interview Mental Status (BIMS) score of 3 out of 15 indicating severe impaired cognition. A review of the resident's Care Plans (CP) revealed: At risk for respiratory complications related to history of respiratory conditions, (heart failure), and disease, date initiated 2/17/26. A review of the Physician Order Summary (POS) revealed: an order on 3/5/26 for O2 at 2 L/min via N/C to maintain SPO2 > 90% (peripheral oxygen saturation-percentage of oxygenated hemoglobin in the blood) every shift for shortness of breath, SPO2 < 90% notify Medical Doctor (MD). Furthermore, an order on 2/17/26 for change O2 tubing, humidifier, and clean filter weekly on Wednesday night shift, and as needed (PRN) for soiling or damage, every night shift, every Wednesday, date and label tubing and humidifier bottle, and PRN date and label tubing and humidifier bottle. On 3/26/26 at 10:22 AM, S #1 observed Resident #3 in the common area, participating in music exercise activity with other residents. S #1 observed the resident with O2 at 2 L/min via N/C. The O2 tubing connected to the bottle of humidifier dated 3/24/26 and O2 concentrator. The surveyor observed the O2 tubing dated 3/24/26, laying on the floor. S #1 interviewed the Registered Nurse Supervisor (RNS), who confirmed that the tubing should not be touching the floor due to infection prevention. The RNS proceeded to remove the tubing off the floor and attached the O2 tubing to the wheelchair. The RNS did not dispose of the tubing or obtain a new one. On 3/27/26 at 12:37 PM, S #1 met with the License Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Clinical Services (RDoCS), and Regional Director of Operations (RDoO) to notify them of the above concerns regarding O2 tubing and not following orders to date humidification bottle. 2. On 3/24/26 at 12:17 PM, Surveyor #2 (S #2) observed Resident #139 reclining in bed accompanied by a private duty aide. S #2 observed O2 tubing connected to a nebulizer (neb) machine (a device used to turn liquid medication into a vapor that can be inhaled from a mask or tube). S #2 observed the tubing hanging down to the floor and looped back up to a nightstand drawer. S #2 observed that the drawer contained a mask used for neb solutions or O2 use. The mask was not contained in a bag and neither the tubing nor mask were labeled with a date of use. On 3/26/26 at 1:25 PM, S #2 observed Resident #139 in bed, and the resident stated that they could not recall if they got a neb treatment today. S #2 again observed O2 tubing connected to the neb machine, hanging to the floor and looped into the drawer. S #2 observed that the drawer again contained a mask that was next to a bag but not inside it. Neither the mask nor tubing was labeled with a date. S #2 reviewed the medical record for Resident #139 which revealed the following: A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to essential hypertension (high blood pressure) and hypothyroidism (a condition where the thyroid gland does not produce enough hormones). A review of the resident's MDS revealed that it was not yet completed. A review of the Social Services Assessment, dated 3/35/26, revealed that the resident was cognitively intact. A review of the resident's Order Summary Report (OSR) revealed that the resident was receiving two medications that were given by neb. A review of the resident's CP revealed an intervention/task that reflected to administer respiratory treatments and inhalants as ordered and keep respiratory equipment clean and change disposable equipment per facility policy. On 3/27/26 at 12:37 PM, S #2 met with the LNHA, DON, RDoCS, and RDoO to notify them of the above concerns regarding the neb tubing and mask. On 3/30/26 at 10:50 AM, the survey team met with the facility administration for their responses and the DON stated they completed education on the oxygen tubing being in bags and not touching the floor. The DON provided in-services dated 3/27/26 and 3/28/26 for oxygen concerns (after surveyor inquiry). No additional information was provided. A review of the facility's Oxygen Administration Policy, dated October 2010 revealed under Purpose, the purpose of this procedure is to provide guidelines for safe O2 administration. A review of the facility's policy Departmental (Respiratory Therapy)-Prevention of Infection Policy revealed under General Guidelines #1 .water used in respiratory therapy must be dated and initialed when opened and discarded after 24 hours .Under Steps in Procedure #7, Change the O2 cannula and tubing every 7 days, or as needed . A review of the facility's Administering Medications through a small Volume (Handheld) Nebulizer, dated 10/2010, reflected, under 29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Under 30. Change equipment and tubing every seven days, or according to facility protocol. NJAC 8:39-25.2(c)3; 27.1(a)
Based on observation, interview and record review, it was determined that facility failed to provide pharmaceutical services in accordance with professional standards of nursing practice by failing to, a.) monitor and document pain levels and b.) administer the correct medication for pain according to the physician's orders. This deficient practice was identified for 1 of 23 residents (Residents #58) reviewed for medication administration. This deficiency 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.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 3/24/2026 at 11:33 AM, the surveyor observed Resident #58 lying in bed and conversant.On 3/24/26 at 1:37 PM, a review of the admission Record or face sheet (an admission summary) revealed diagnoses which included but not limited to; type 2 diabetes mellitus with diabetic chronic kidney disease, malignant neoplasm of endometrium, and bilateral primary osteoarthritis (OA) of knee.A review of the Quarterly Minimum Data Set (MDS), an assessment tool that facilitates the plan of care, with an assessment reference date of 2/6/26, revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating intact cognition; Section J (pain management) of the MDS indicated resident with occasional pain frequency, a pain scale of 2 (mild); Section N (medications) resident received scheduled and as needed (PRN) medications (meds).A review of the resident's Care Plan (CP) revealed: back pain. hand and wrist pain probably due to OA, date initiated, 11/7/17; chronic pain and/or potential for pain related to arthritis, date initiated 12/5/25 (interventions did not specify pain scale). A review of the Physician Order Summary (POS) revealed:-Monitor for pain every shift, document pain scale (0-10) every shift -Start Date 7/11/22. The order did not indicate pain scale of mild, moderate and severe.-Acetaminophen (Tylenol) tablet (tab) 325 mg (milligram), give 2 tablets (tabs) by mouth every 4 hours as PRN for mild pain (2 tabs = 650 mg.) not to exceed 3 g (grams) of all sources -Start Date 7/28/22. The order did not indicate pain scale for mild pain.-Ibuprofen oral tab 600 mg, give 1 tab by mouth every 6 hours PRN for pain, administer for moderate pain of a scale of 3 or more. Take with food or milk -Start Date 12/4/25. The order did not indicate the pain scale for or more.-Naproxen oral tab 375 mg, give 1 tab by mouth PRN for moderate to severe pain twice daily - Take with food or milk -Start Date12/4/25. The order did not indicate pain scale for moderate or severe pain.According to the electronic Medication Administration (eMAR): Ibuprofen (ordered for moderate pain scale of 3 or more) was administered on 3/7/26 with pain level of 1 (the pain scale was not above 3).On 3/25/26 at 10:21 AM, the surveyor interviewed the Registered Nurse Supervisor (RNS), on the process for PRN pain medication (med). The RNS stated that she would ask the resident what the pain was from scale of 1-10. The surveyor and the RNS reviewed the orders for Tylenol, Ibuprofen, and Naproxen, and she confirmed that the Tylenol and Naproxen orders did not indicate a pain scale for administration and will need to follow up with the Medical Doctor to clarify the orders. The surveyor asked the RNS how they determine which PRN pain med to administer the resident and she stated that the resident will tell you which med they want. The surveyor asked the RNS if that was indicated in the resident's care plan (CP) and she replied, I don't touch the CP. The surveyor and RNS reviewed the Ibuprofen that was administered on 3/7/26 with a pain scale of 1 and she stated, I cannot answer why that was given with a pain scale of 1. I would not give that. Orders are confusing because there's no scale at all. I will ask the doctor. The surveyor reviewed the resident's CP and no intervention indicating that the resident will state which pain med they preferred when having episodes of pain. The surveyor reviewed the March 2026 nursing progress notes, and no notes indicating resident verbalized which pain med they preferred for 3/6/26 and 3/7/26.On 3/26/26 at 10:03 AM, the surveyor observed resident in room, sitting on side of the bed, using an electronic device. The surveyor interviewed the resident regarding pain. The resident stated, they had arthritis on their fingers and knees and had knee replacements. The resident stated they took Motrin (Ibuprofen) for pain on their fingers PRN, resident also stated they were not aware of any other pain meds ordered and did not take Naproxen because it was not prescribed. The resident further confirmed that they did not tell the nurses which pain med to give and that the nurses dispensed what was ordered by the doctor. On 3/27/26 at 12:37 PM, the surveyor met with the License Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Clinical Services (RDoCS), and Regional Director of Operations (RDoO) and notified them of the concerns regarding pain management, following physician orders and CP for pain.On 3/30/26 at 10:43 AM, the survey team met with the LNHA, RDoCS, RDoO, and the DON stated the orders for pain meds were clarified with the physician (after surveyor inquiry) on 3/27/26. The DON provided a copy of the new orders for pain: Naproxen was discontinued, an order for Acetaminophen for mild pain 1-3 and Ibuprofen for moderate pain 4-6, there was no order for severe pain. The DON stated the resident did not have severe pain and would let you know. The LNHA stated that they would call doctor to clarify for a severe pain med. A review of the facility's Pain Assessment and Management Polic, dated April 2025, revealed under Assessing Pain #4. b. Characteristics of pain, including: (2) intensity (as measured on a standardized pain scale) .Under Defining Goals and Appropriate Interventions, #1. The pain management interventions: b. reflects the sources, type, and severity of pain .Under Implementing Pain Management Strategies #6. The med regimen is implemented as ordered .A review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated March 2022, revealed under Policy and Interpretation and Implementation #4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to: f. participates in determining the type, amount, frequency and duration of care .NJAC 8:39-11.2, 27.1(a)
Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted prior to the start of the current shift for 2 of 5 days during the annual re-certification survey. This deficient practice was evidenced by the following:On 3/24/26 at 8:55 AM, upon entry to the facility, the survey team observed the Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the main entrance. The NHRCSR posted was dated 3/23/26 (incorrect date) with a census of 100, for the (7:00 AM to 3:00 PM) day shift. There was no NHRCSR posted for 3/24/26.On 3/24/26 at 12:30 PM, the License Nursing Home Administrator (LNHA) provided NHRCSR dated 3/24/26, which revealed a census of 100; 2 Registered Nurses (RN); 3 License Practical Nurses (LPN); and 13 Certified Nursing Assistants (CNA); with a CNA to resident ratio of 1 to 7.7 for the day shift.On 3/27/26 at 8:07 AM, the surveyor entered the facility and observed the LNHA in the receptionist front desk area. The surveyor observed the NHRCSR posted on the desk dated 3/26/26 (incorrect date) with a census of 100. The surveyor asked the LNHA who was responsible for posting the staffing in the morning and he replied it was the Human Resources/Staffing Coordinator who was responsible for posting. According to the LNHA he stated that he was covering for the receptionist until she got there.On 3/27/26 at 8:11 AM, the Director of Nursing (DON) provided the staffing with a census of 98.On 3/27/26 at 8:16 AM, in the presence of the survey team, and the Regional Director of Clinical Services (RDoCS), the LNHA provided the NHRCSR forms dated 3/26/26 and 3/27/26 and stated, I had the NHRCSR for 3/27/26 staffing on the back of the 3/26/26 forms, we just did not put it in the front. The surveyor asked what time was visiting hours and he responded 8:00 AM-8:00 PM, and the RDoCS stated that visitation hours could also be extended. The LNHA submitted the NHRCSR dated 3/27/26 with a census of 100; 3 RNs; 4 LPNs; and 14 CNAs, with a CNA to resident ratio of 1 to 7.1. The census of 100 was inconsistent with what the DON provided earlier of census of 98.On 3/27/26 at 9:47 AM, the surveyor interviewed the LNHA who confirmed there were two discharges yesterday before midnight which did not reflect on the NHRCSR for 3/27/26. On 3/27/26 at 11:19 AM, in the presence of the DON, the surveyor interviewed the Regional Human Resources, who was covering for the Staffing Coordinator/Human Resource (SC/HR). The surveyor asked what the process was for posting. The DON stated the SC/HR would provide the NHRCSR sheets the day before and the receptionist would post it in the morning. In addition, for the weekend, the DON stated the SC/HR would include the sheets for Friday, Saturday, and Sunday and provide that to the receptionist every Friday. The surveyor asked if there were changes who would make the corrections and the Regional HR replied, He will make the changes and will change the posting in the morning before morning meeting. The surveyor asked if they were familiar with the regulation for posting and the DON confirmed, I am familiar that it has to be posted in the morning so that the public can see when they first come in. The posting has to be accurate.On 3/27/26 at 12:37 PM, the survey team met with the LNHA, DON, RDoCS, Regional Director of Operations (RDoO) and the surveyor notified them of the NHRCSR posting concerns.On 3/30/26 at 8:30 AM, the surveyor interviewed the Receptionist regarding the posting and she stated the HR will leave sheets on her desk, and she would post the NHRCSR on the receptionist area. On 3/30/26 at 10:50 AM, survey team met with the LNHA, RDoCS, RDoO, and the DON stated, We did education for posting the staffing, including those Manager on Duty (MOD). The DON provided copies of in-services completed on 3/27/26 and 3/28/26 for posting (after surveyor inquiry). No additional information was provided by the LNHA.A review of the facility's Staffing, Sufficient and Competent Nursing Policy, dated April 2025, revealed under Competent Staff #6. Direct care daily staffing numbers are posted in the facility for every shift .A review of the facility's Posting Direct Care Daily Staffing Numbers Policy, dated August 2022, revealed under Policy Interpretation and Implementation #1. Within 2 hours of the beginning of each shift the number of unlicensed nursing personnel directly responsible for resident care is posted in a prominent location .The regulation did not indicate posting within 2 hours of the beginning of each shift but indicated posting at the beginning of each shift. The facility policy did not indicate posting prior to the start of each shift.NJAC 8:39-41.2(a)(b)(c)(d)
Based on observation, interview, and record review, it was determined that the facility failed to ensure the implementation and accurate documentation of behavioral health monitoring for 2 of 5 residents reviewed, (Residents #4 and #9), reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1.On 3/24/26 at 11:00 AM, Surveyor #1 (S #1) observed Resident #4 seated in his wheelchair (w/c) in the hallway outside their room. The resident responded to yes and no questions but did not engage in further conversation and was noted to be confused at baseline. On 3/25/26 at 10:39 AM, a second observation revealed the resident seated calmly in their w/c looking out the window in the hallway. No behavioral concerns were noted during this observation. S #1 reviewed the medical record for Resident #4. A review of the resident's comprehensive care plan (CP) revealed multiple behavioral health-related problems, including psychosis, depression, dementia-related behaviors, and use of psychotropic medications (meds) requiring monitoring of effectiveness and side effects. The CP included interventions directing staff to administer meds as ordered, monitor and document side effects and effectiveness each shift, and report findings to the physician or designee as clinically indicated. A review of the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) revealed that behavior monitoring documentation was incomplete and inconsistently performed. Specifically, nine required night shift entries and two required day shift entries were missing, indicating that staff failed to consistently document behavior monitoring as required by physician order (PO). Further review of the eMAR and eTAR revealed that staff were not following the facility's designated side effect coding system. The PO required documentation using the facility's chart codes, with code 15 indicating side effect (s/e) not seen and code 13 indicating s/e noted. Instead, nurses were documented writing NO or placing markings above their initials rather than entering the required codes, and in some instances were not entering codes in the appropriate column. On 3/25/26 at 10:39 AM, S #1 interviewed the Nurse who stated that monitoring for mood, behaviors, and medication (med) refusal was completed each shift and documented on the eTAR. 2. On 3/26/26 at 12:10 PM, Surveyor #2 (S #2) observed Resident #9 on the south nursing unit self-propelling in their w/c. The resident smiled at S #2 but did not respond verbally. On 3/27/26 at 12:00 PM, S #2 observed Resident #9 seated in a w/c in the day room in the south nursing unit. A review of the admission Record or face sheet (an admission summary) revealed Resident #9 had diagnoses which included but were not limited to; major depressive disorder, dementia, psychosis, and anxiety disorder. A review of the Order Summary Report included an active order dated 6/28/24 for Seroquel 100 mg (milligram) give 100 mg by mouth two times a day for psychosis; an active order dated 10/13/25 for sertraline HCL (hydrocholoride) 100 mg give 1 tablet (tab) by mouth one time a day for depression monitor behaviors. A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 12/26/25, reflected that Resident #9 had a brief interview for mental status (BIMS) score of 3 out of 15 which indicated a severe cognitive impairment and that the resident is taking High-Risk Drug Classes, including antipsychotic meds, antianxiety meds, and antidepressant meds. A review of Resident #9's CP included the following: A focus area for the use of anti-depressant med, initiated 5/2/24, with interventions that included but were not limited to; observe for effectiveness and s/e, monitor/document/report to physician ongoing s/sx (sign/symptoms) of depression unaltered by antidepressant med, or worsening signs or symptoms of depression. A focus area for use of anti-psychotic med r/t (related to) dementia with behaviors/psychosis, initiated 5/2/24, with interventions to observe for effectiveness and s/e, and report to the nurse possible med s/e. A focus area for use of anti-anxiety med r/t anxiety disorder, initiated 5/2/24, with interventions to observe for effectiveness and s/e, provide a quiet space and reduced stimuli, and report to the nurse possible med s/e. A review of Resident #9's March 2026 Behavior Monitoring Record (BMR) revealed: Behaviors/Intervention monitor for yelling and crying during care; Intervention Codes . 1. Redirection 2. (1:1) 3. Activity 4. Toilet 5. Food/fluid offered 6. Position change 7. Other Intervention codes (specify in progress notes) 8. Med every shift for psychosis use of Seroquel . The BMRs documented the following: Four shifts were left blank where monitoring was not completed. Throughout the BMR, X and 0 were marked where monitoring was not completed. The BMR custom prompt legend and codes did not include X or O for the number (#) of behaviors exhibited. Nurses documented NO or placed markings above initials rather than using required codes, and in some instances, failed to enter codes in the appropriate column. Two shifts were left blank on the BMR for monitoring the s/e of Anti-Psychotic med; throughout, there were X marks, check marks, and markings above initials rather than the required codes. On 3/27/26 at 12:37 PM, the DON confirmed that there should not be any X marked, as that indicated the monitoring was not done. On 3/30/26 at 11:12 AM, S #1 interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The DON confirmed that behavior monitoring was not fully completed for all required shifts and stated there should be no blanks in the documentation. The DON further acknowledged that staff were not following the facility's designated coding system for documenting s/e, confirming that the code chart required nurses to document code 15 in the s/e column for s/e not seen and code 13 for s/e noted, and that nurses were instead documenting 15 or NO above their initials and placing an X in the side effect column. On that same date and time, the LNHA acknowledged that behavior monitoring was not completed for all required shifts and that the facility's designated coding system for s/e documentation was not being followed consistently by nursing staff. A review of the facility's Behavioral Assessment, Intervention, and Monitoring Policy, revised February 2025, reflected. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment.If psychotropic medications are prescribed for behavior symptoms, documentation includes .specific target behaviors and expected outcomes.monitoring for efficacy and adverse consequences.Interventions are adjusted based on the impact on behavior and other symptoms.The IDT (Interdisciplinary Team) monitors for and documents any new, worsening or improved behavior, mood and function; If psychotropic meds are used to treat behavioral symptoms, the IDT monitors s/e and adverse consequences related to psychotropic meds. On 3/30/26 at 12:30 PM, no further information was provided by the LNHA. NJAC 8:39-27.1(a)
Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure availability of a medication (med) for 1 of 4 residents (Resident #21) observed during the facility's med pass observation. 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.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/26/25 at 8:51 AM, the surveyor, while observing the med pass, observed the Licensed Practical Nurse (medLPN) assigned to Resident #21 prepare and administer medications (meds) for Resident #21. As the medLPN prepared the meds, they stated that they could not locate the resident's enoxaparin (an injectable med used to treat and prevent blood clots). The surveyor observed the medLPN access Resident # 21s electronic medication administration record (eMAR). The medLPN stated that the eMAR showed that the med was on order from the pharmacy. The surveyor observed the eMAR which reflected that the med was on order. The surveyor then observed the medLPN documented in the eMAR that the med was on order from the pharmacy and was awaiting delivery. The surveyor asked the medLPN what the procedure was if a med was on order. The medLPN stated that if the med did not come within two days, they would call the pharmacy. The surveyor asked the medLPN if they would call anyone else such as the resident's doctor. The medLPN stated, yes, I guess I could call him too. The surveyor observed the medLPN administered the remaining due meds to the resident. The surveyor concluded the observation. The surveyor reviewed the electronic medical record (EMR) for Resident #21 which revealed the following: A review of the admission Record (AR) (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; displaced bicondylar fracture (break in both sides of the upper shin bone), essential hypertension (high blood pressure), and difficulty in walking. A review of the comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 3/4/26, under Section C, reflected a brief interview for mental status (BIMS) score of 14 out of 15, which indicated that the resident's cognitive status was intact. A review of an Order Summary Report (OSR) revealed that the resident had an order dated 2/26/26 that reflected Enoxaparin Sodium Injection Solution Prefilled Syringe 30 MG/0.3ML (milligram/milliliters) inject 0.3 ML subcutaneously one time a day for DVT (deep vein thrombosis) prophylaxis. A review of the resident's eMAR revealed the same order for enoxaparin and reflected that on 3/25/26 and 3/26/26 there were 22 documented for administration. Further review of the eMAR revealed that the documentation of 22 reflected that the drug or treatment was not administered. On 3/27/26 at 12:37 PM the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations (RDoO), and Regional Director of Clinical Services (RDoCS) for concerns. The surveyor asked the DON if the medLPN should have notified the physician of the missing med and if it was appropriate to just document awaiting delivery and not give the med. The DON stated that the medLPN should have notified the physician right away and obtained further instructions, see if the med was in the backup supply, or call the pharmacy for an immediate delivery. On 3/30/26 at 10:37 AM, the LNHA, RDoO, RDoCS, and the DON stated that education was provided to the staff and the medLPN regarding meds that were not delivered or not in the med cart. The LNHA did not provide any further pertinent information. A review of the facility's Administering Medications Policy, dated April 2019, reflected, under 4. Meds are administered in accordance with prescriber orders. The policy did not reflect anything about missing or meds that were not delivered. NJAC 8:39-29.6(a).
Based on observation, interview and record review, it was determined that the facility failed to act upon Consultant Pharmacist (CP) recommendations for 3 of 23 residents (Resident #1, Resident #6 and Resident #58), from 2 of 3 nursing units, whose medication regimen were reviewed. This deficient practice was evidenced by the following: 1.On 3/24/26 at 11:33 AM, Surveyor #1 (S #1) observed Resident #1 seated in their bed while on nebulizer treatment. A review of Resident #1's admission Record or face sheet (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic obstructive pulmonary disease (COPD), muscle weakness, difficulty walking, and need for assistance with personal care. A review of Resident #1's most recent comprehensive Minimum Data Set (cMDS), an assessment tool, with an Assessment Reference Date (ARD) of 3/5/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that Resident #1's cognition was intact. The cMDS reflected that the resident received antianxiety and pain meds. A review of the Consultant Pharmacist aMRR (Medication Regimen Review) Recommendation to Prescriber, with an MRR Date: 2/28/26, under Recommendation .2. clonazepam 0.5 mg (milligram) po q (every) 24 PRN (as needed) insomnia: identify stop date. Document rationale if use is to exceed 14 days. *note: resident also ordered trazodone 50 mg by mouth HS (bedtime) and melatonin 3 mg PRN for insomnia. 3. tramadol PRN: clarify pain severity/pain scale . The above MRR had a check mark in each number and handwritten information complete- by Licensed Practical Nurse/Unit Manager (LPN/UM). The physician/prescriber response were blank and there was no rationale. A review of Resident #1's March 2026 electronic Medication Administration Record (eMAR) included the following physician's orders (PO): -Melatonin tablet (tab) 3 mg, give 1 tab by mouth q 20 hours PRN for insomnia.-Start date 2/26/26. The med was administered on 3/1/26 at 8:30 PM by Licensed Practical Nurse (LPN). - Trazodone HCl (hydrocholoride) oral tab 50 mg, give 50 mg by mouth at HS for insomnia-Start Date 2/27/26. The med was administered at 9:00 PM from 3/1/26 to 3/23/26. -Clonazepam oral tab 0.5 mg, give 1 tab by mouth q 24 hours PRN for insomnia.-Start Date 2/27/26 and was discontinued (dc'd) on 3/3/26. The medication (med) was administered on 3/1, 3/2, and 3/3/26. -Clonazepam oral tab 0.5 mg, give 1 tab by mouth q 24 hours PRN for insomnia for 14 days.-Start Date 3/3/26 and was dc'd on 3/17/26. The med was administered on 3/4, 3/5, 3/6, 3/7, 3/9, 3/11, 3/12, 3/13, 3/15, 3/16, and 3/17/26. -Tramadol HCL oral tab 50 mg, give 50 mg by mouth q 6 hours PRN for pain-Start date 2/27/26 and was dc'd on 3/3/26. The med was administered on 3/2 and 3/5/26. -Tramadol HCL oral tab 50 mg, give 50 mg by mouth q 6 hours PRN for sever pain-level 5-10-Start date 3/3/26. The med was administered on ¾, 3/5, 3/6, 3/7, 3/9, 3/11, 3/12, 3/13, 3/14, 3/15, 3/16, 3/17, 3/18, 3/20, 3/21, 3/22, and 3/23/26. The above order of tramadol with start date of 3/3/26, was administered on 3/14/26 and 3/15/26 for a pain level of 0 by the LPN. The recommendation of the CP was not followed to clarify the pain scale according to the order. Furthermore, the 2/28/26 recommendation of the CP to identify stop date and document rationale if the PRN med was to exceed 14 days. The recommendation was also not acted upon for ordered trazodone 50 mg by mouth HS and melatonin 3 mg PRN both for insomnia. On 3/25/26 at 9:03 AM, S #1 interviewed LPN/UM who stated that the diagnosis and indication of meds should be based on the physician(s) documentations in their visit notes and H&P (History and Physical), and the list of meds. The LPN/UM further stated PRN meds should have a stop date and acknowledged that there should be a documented rationale from the physician as to why there should be no stop date for PRN meds. At that same time, S #1 notified the LPN/UM of the concern that there was no sequencing for PRN meds for insomnia and the dx of PRN clonazepam were insomnia/anxiety was not clarified according to the recommendations of the CP. The surveyor also notified the concern that the CP's recommendations were not acted upon or followed with regard to pain med and psychoactive meds. The LPN/UM stated that she had to check the eMAR and order first and would get back to S #1. On 3/25/26 at 9:25 AM, S #1 interviewed the LPN via a phone interview in the presence of the survey team, and S #1 notified the LPN of the above concern that on 3/14/26 and 3/15/26, he signed the eMAR and administered the PRN Tramadol for pain level of 0. The LPN responded that it was probably an error because the resident was always in pain, usually level of 7 and never a 0. He added that he did not know why it was coded a pain level of 0, it was probably an error. On 3/26/26 at 10:57 AM, S #1 notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations (RDoO), Regional Director of Clinical Services (RDoCS) of the above findings and concerns with regard to Resident #1's MRR with regard to psychoactive meds and pain med. On 3/26/26 at 12:38 PM, the survey team met with the LNHA, DON, RDoO, and the RDoCS stated that the LPN S #1 spoke to yesterday did put a progress notes (PN), a late entry for the two days that he documented pain level of 0. S #1 reviewed the provided PN and showed to the facility management that it was documented by LPN for pain level of 8 of 10, which was different from what the LPN had told S #1 yesterday which was 7 of 10. The LNHA did not provide any additional information. 2. On 3/24/26 at 12:01 PM, Surveyor #2 (S #2) observed Resident #6, in bed. The resident had a tracheostomy (an opening in the neck into the windpipe to provide a direct airway) and was using a mechanical ventilator (a machine that helps air move in and out of the lungs). On 3/25/2026, S #2 reviewed Resident #6's electronic medical record (EMR). A review of the AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; hemiplegia and hemiparesis (weakness and or partial paralysis in part or all the body caused by a brain injury), intracranial hemorrhage (a life-threatening type of stroke), and essential hypertension (high blood pressure). A review of Resident #6's most recent cMDS, with an ARD of 12/31/25, reflected that the resident had a BIMS score of 0 out of 15, which indicated that Resident #6's cognition was severely impaired. A review of the resident's care plan revealed a focus that reflected a potential for constipation due to decreased mobility, date initiated, 12/31/24. A review of the Order Summary Report (OSR) revealed the following PO: Acetaminophen (also known as Tylenol) Oral Suspension 650 mg/20.3 ml give 20.3 ml via PEG-Tube every 6 hours PRN for mild pain do not exceed 3 grams. Acetaminophen Oral Suspension 650 mg/20.3 ml give 20.3 ml via PEG-Tube every 6 hours PRN for Temp > 100.5. S #2 reviewed the CP's recommendation for Resident #6 dated 6/30/25. The recommendation reflected the following: .consider changing this patient's PRN Tylenol liquid doses from 650 mg, which is difficult to measure (20.3 ml) to 640 mg (20 ml) . The CP recommendation also reflected, under the response section, a signature and a date of 7/11/25. On 3/27/26 at 12:37 PM, S #2 met with the LNHA, DON, RDoO, and RDoCS, and S #2 notified them of the concern regarding the follow up on the June 2025 CP's Recommendations to Prescriber regarding the acetaminophen orders. S #2 asked the DON if it was possible to measure 20.3 ml in the commonly used dose cup. The DON stated no it could not be. On 3/30/26 at 10:51 AM, S #2 met with the facility administration for response to the MRR concern. The DON stated that the orders were clarified (after surveyor inquiry). A review of the facility's Medication Regimen Review Policy, with a revision date of July 2025, revealed, under Physician Response, 3. Irregularities.will be addressed within 30 days of receiving. 3. On 3/24/26 at 11:33 AM, Surveyor #3 (S#3) observed Resident #58 lying in bed and was pleasant. On 3/24/26 at 1:37 PM, S #3 reviewed the EMR of Resident #58, and revealed diagnoses which included but not limited to; type 2 diabetes mellitus with diabetic chronic kidney disease, malignant neoplasm of endometrium, and bilateral primary osteoarthritis (OA) of knee. A review of the Quarterly MDS with an ARD of 2/6/26, revealed a BIMS score of 15 out of 15 indicating intact cognition; Section J (pain management) of the MDS indicated resident with occasional pain frequency, a pain scale of 2 (mild); Section N-medications (meds) resident received PRN meds. A review of the resident's Care Plan revealed: back pain. hand and wrist pain probably due to OA, date initiated, 11/7/17; chronic pain and/or potential for pain related to arthritis, date initiated 12/5/25 (interventions did not specify pain scale). A review of the OSR revealed: -Monitor for pain q shift, document pain scale (0-10) q shift -Start Date 7/11/22. The order did not indicate pain scale of mild, moderate and severe. -Acetaminophen tablet (tab) 325 mg, give 2 tablets (tabs) by mouth q 4 hours PRN for mild pain (2 tabs = 650 mg.) not to exceed 3 grams of all sources -Start Date 7/28/22. The order did not indicate pain scale for mild pain. -Ibuprofen oral tab 600 mg, give 1 tab by mouth q 6 hours PRN for pain, administer for moderate pain of a scale of 3 or more. Take with food or milk -Start Date 12/4/25. The order did not indicate the pain scale for or more. -Naproxen oral tab 375 mg, give 1 tab by mouth PRN for moderate to severe pain twice daily - Take with food or milk -Start Date12/4/25. The order did not indicate pain scale for moderate or severe pain. On 3/25/26 at 10:21 AM, S #3 interviewed the Registered Nurse Supervisor (RNS), regarding the pain med orders. The RNS stated that the orders were confusing because there was no pain scale for the Tylenol and the Naproxen orders. On 3/26/26 at 10:03 AM, S #3 observed Resident #58 in their room, sitting on side of the bed, using an electronic device. S #3 interviewed the resident regarding pain. The resident stated they had arthritis on their fingers and knees and had knee replacements. The resident stated they took Motrin (Ibuprofen) for pain on their fingers PRN, resident also stated they were not aware of any other pain meds ordered. On 3/26/26 at 12:12 PM, S #3 reviewed the CP's MRR Recommendation to Prescriber. The CP recommended on 2/27/26 that the Resident has the following order for PRN pain Ibuprofen .If more than one med is being utilized for pain, please include continuity of pain scales across each order and be sure to address all choices 1-10. The recommendation was signed by the RN/UM (RN/Unit Manager). On 3/27/26 at 11:00 AM, S #3 interviewed the RN/UM, regarding the process for CP's Monthly Review and Recommendations. The RN/UM stated that she would confirm the recommendations with the physicians and if they agreed, she would proceed and make changes in the orders. S #3 asked the RN/UM if the February MRR were already completed and she confirmed, The February recommendations should be all done already. S #3 asked if she recalled if Resident #58's MRR regarding pain meds were addressed and she replied, I don't recall. S #3 asked the RN/UM how nurses administered PRN pain meds, and she replied, I will ask them for numerical numbers if they are verbal. I do between mild, moderate, and severe if they have more than one pain med ordered. Mild 1-3, moderate 4-6, severe 7-10, whatever number they give me back, then that's how to determine which med to give. On 3/27/26 at 12:37 PM, S #3 met with the LNHA, DON, RDoCS, and RDoO, and S #3 notified them of the concern regarding no follow up on the February 2026 CP's MRR Recommendations to Prescriber. On 3/30/26 at 10:51 AM, S #3 met with the facility administration for response to the MRR concern, and the DON provided copies of in-services dated 3/27/26 and 3/28/26 to follow up on MRR Recommendations (after surveyor inquiry). A review of the facility's Medication Regimen Review Policy that was provided by the DON, with a revision date of July 2025, revealed a policy statement, a licensed pharmacist reviews the med regimen of each resident at least monthly. Under policy interpretation and implementation.2. The purpose of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with med. 3. The MRR includes a review of the medical record to prevent, identify, report, and resolve med-related problems, med errors, or other irregularities, for example, the use of med: a. inconsistent with accepted pharmaceutical services standards of practice.d. ordered without clinical indication or in excessive dose.4. Irregularities may also include.f. incorrect meds, administration times, or dosage forms. NJAC 8:39-29.3(a)(1)
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store and label medication (med) per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 3 med carts and 1 of 2 med storage rooms observed in the facility. This 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On [DATE] at 10:30 AM, the surveyor began to inspect selected med storage areas in the facility. The surveyor observed the following: The surveyor in the presence of the Director of Nursing (DON) and Registered Nurse/Unit Manager (RN/UM) inspected the med storage room in the North Nursing Unit. The surveyor observed a container of Iodoform packing strips with an expiration date of 2/2026 and a container of acetaminophen ER (extended release) 650 mg (milligram) dated as opened [DATE] with no expiration date. The RN/UM confirmed that the expired medn and packing strips should have been discarded. On [DATE] at 11:00 AM, the surveyor inspected the med cart on the North nursing unit (med cart north 2) in the presence of the Licensed Practical Nurse (LPN #1). During the narcotic count, the surveyor and LPN#1 reconciled controlled medications (meds) and observed that a blister pack of clonazepam 1 mg tablets (tabs) was missing a med label and did not include a resident name. LPN #1 stated that the blister pack belonged to Resident #72. During the narcotic count, the surveyor observed that the back of the bingo card identified the med as clonazepam 1 mg tabs with a use-by-date of [DATE]. The blister pack contained 27 tabs, which was consistent with the declining inventory sheet for Resident #72. The surveyor reviewed the shift-to-shift narcotic count sheet, which confirmed that LPN #1 had counted the controlled substances with the 11:00 PM-7:00 AM nurse at the beginning of the 7:00 AM-3:00 PM shift. LPN #1 confirmed that he should have discarded the med and notified the pharmacy. On [DATE] at 11:10 AM, the surveyor discussed the above concerns with the RN/UM. On [DATE] at 11:20 AM, the surveyor inspected the med cart (med cart North 1) in the presence of LPN #2 and observed that a bottle of acetaminophen 325 mg OTC (over the counter) (100 tabs) had no expiration date. LPN #2 confirmed that she should have discarded the bottle. On [DATE] at 11:40 AM, the surveyor discussed the above observations with the DON. The DON confirmed that all meds should be labeled with the resident's name, and that if the label was missing the nurse should discard the med and contact the pharmacy. The DON further stated that all expired meds should be discarded. On [DATE] at 12:37 PM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator, DON, Regional Director of Clinical Services and Regional Director of Clinical Operations. A review of the facility's Medication Labeling and Storage Policy, dated 2001 reflected .The nursing staff is responsible for maintaining med storage.Labeling of meds and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.The med label includes, at a minimum:a. med name (generic and/or brand)b. prescribed dosec. strengthd. expiration date, when applicablee. resident's namef. route of administrationg. appropriate instructions and precautionsFor OTC meds in bulk containers (if permitted by state law) the label contains:a. the med nameb. strengthc. quantityd. accessory instructionse. lot numberf. expiration date (if applicable)Multi=-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date. If med containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.Only the dispensing pharmacy may label or alter the label on a med container or package. On [DATE] at 12:30 PM, no further information was provided by the LNHA. NJAC 8:39-29.4 (a)1-10, (g)(h)
Inspection of December 4, 2025
1 findingComplaint: 2613838 Based on interviews, record reviews, and review of facility documentation it was determined that the facility failed to a.) keep resident medical information confidential and b.) follow their Resident Rights policy. The deficient practice was identified for one of 3 residents reviewed for medical records (Resident #4). This deficient practice was evidenced by the following:According to the, admission Record, Resident #4 was admitted to the facility with diagnoses including but not limited to: muscle wasting and atrophy (loss of muscle mass and strength); type 2 diabetes (chronic condition where the body cannot keep blood sugar at a normal level); need for assistance with personal care; and chronic lymphocytic leukemia (cancer of the blood and bone marrow). Review of the Minimum Data Set (MDS), an assessment tool, revealed that Resident #4 had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. The progress notes (PN) for Resident #4 were reviewed. A PN written by the Social Worker (SW #1) on 02/03/2025 at 11:55 AM, revealed that an interdisciplinary team (IDT) meeting was conducted to update the resident's family member on Resident #4's progress. The PN further revealed that Resident #4 wanted the call to be cut short because Resident #4 no longer wanted their family member to participate. The PN revealed that the Unit Manager (UM #1) discussed medications and overall health, and SW #1 discussed the discharge plan. SW #1 was no longer employed at the facility and was not available for an interview. The surveyor attempted to reach UM #1 for a telephone interview but was not successful. A statement signed by SW #1 and dated 02/04/2025, was reviewed. The statement revealed that on 02/03/2025 SW #1 and UM #1 called Resident #4's family member in preparation for an IDT meeting. The statement revealed that UM #1 began reading Resident #4's medication information when Resident #4's family member stated that the resident who was present did not sound like their family member. It was at that time that UM #1 stopped reading Resident #4's medication information, checked the resident who was present's identification (ID) band, and determined that it was not Resident #4. The statement revealed that SW #1 then stopped the meeting and located Resident #4 in the rehabilitation department. SWW #1 later informed Resident #4 of what occurred during the earlier IDT meeting and apologized. A statement signed by UM #1 and dated 02/04/20025 was reviewed. The statement revealed that on 02/03/2025 a meeting was held to provide Resident #4's family with a progress update. The statement revealed that UM #1 began to read Resident #4's medication information at the beginning of the meeting. At the beginning of the meeting Resident #4's facility member, who attended by phone stated that the voice of the resident who was also attending the meeting did not sound like Resident #4. The statement further revealed that the meeting was stopped and the ID band of the resident in attendance was checked, and it was identified that the resident at the meeting was Resident #3, not Resident #4. A letter written by the Licensed Nursing Home Administrator (LNHA) to Resident #4 was reviewed. The letter revealed, .it is important to us that you are made fully aware of a potential privacy issue. We have learned that your personal information may have been compromised. [.] it was discovered that our Social Worker was holding a care conference on 2/3/2025 along with the Unit Manager with the incorrect resident in the room. The Social worker along with the Unit manager contacted your [family member] to review your medications when your [family member] stated that the resident in attendance didn't sound like [their family member] . An interview was conducted with the LNHA on 09/26/2025 at 2:20 PM. The LNHA stated that the expectation was for staff to verify the identity of a resident before medical information was discussed. The LNHA stated that this was important to ensure that accurate information was given and for the Health Insurance Portability and Accountability Act (federal standards protecting sensitive health information from disclosure without patient's consent). The LNHA stated that resident identification could have been done by verifying the name with the resident and by checking the resident's ID band. The LNHA confirmed that on 02/03/2025, Resident #4's family member was called to participate in a care conference, but it was Resident #4's roommate (Resident #3) who was present when the conference started. The LNHA stated that UM #1 began reading Resident #4's medications when Resident #4's family member recognized that the resident present did not sound like their family member. During ta follow up interview on 09/26/2025 at 5:00 PM, the LNHA stated that maintaining resident privacy and confidentiality was important to maintain resident rights. The LNHA further stated that reading Resident #4's medications with Resident #3 present did not maintain Resident #4's privacy and confidentiality. The facility policy, Resident Rights, with a revised date of February 2021, was reviewed. Under, Policy Interpretation and Implementation, the policy revealed, 1. Federal and state laws guarantee certain rights to all residents of this facility. Thes rights include the resident's right to: [.] t. privacy and confidentiality. NJAC 8:39-4.1(a)12
Inspection of October 29, 2024
5 findingsComplaint# NJ 174618 Based on interview, review of closed medical records, and review of pertinent facility documents, it was determined that the facility failed to ensure appropriate care was provided with no delay in treatment for a resident who sustained an injury during rehabilitation therapy on 2/23/24, complained of pain and was not assessed by a Registered Nurse until 2/25/24 (two days later), and the physician ordered an x-ray which indicated a non-displaced fracture of the medial malleolus (ankle fracture). This deficient practice was identified for 1 of 3 closed medical records reviewed (Resident #101), and 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 or 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 regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 10/24/24 at 10:00 AM, the surveyor reviewed the closed medical record for Resident #101. According to the Admission Record face sheet, an admission summary, reflected that Resident #101 was admitted to the facility with diagnoses that included; acute embolism (obstruction of an artery), thrombosis (blood clot in an artery or vein) of unspecified deep veins of unspecified lower extremity, and displaced bimalleolar fracture (a break in the ankle), acquired during the resident's stay in the facility. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 3/6/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of the resident's functional range in motion reflected the resident had a lower extremity impairment (hip, knee, ankle, foot) to one side. Further review of the MDS revealed Resident #101 experienced frequent pain that caused difficulty to sleep and limited the resident's participation in rehabilitation (rehab) therapy sessions. The pain level measurement intensity was 6 out of 10, with 10 being the highest pain intensity and the resident received an as needed (PRN) pain medication or was offered and declined. A review of the individual comprehensive care plan included a focus area for pain, initiated on 1/24/24. The interventions included to administer analgesia (pain relief medication) per orders, observation of effectiveness, initiated on 1/24/24. A review of the Physical Therapy Treatment and Encounter Note (PT/TEN) dated and signed by the Physical Therapist (PT) and the Physical Therapy Assistant (PTA) on 2/23/24 at 5:07 PM, included that Resident #101 was moving about with contact guard assist (physical therapist uses one or two hands to help the patient perform a functional action, with no additional support required), then rolled on their ankle. At that time, the resident did not verbalize pain and did not convey nonverbal communication of pain. A treatment of cryotherapy (ice) and [brand name redacted] bandage wrapping was applied to the left ankle. The PT/TEN did not include documentation that the nursing staff and the physician were informed of the sustained injury. A review PT/TEN signed by the PT and the PTA dated 2/24/24 at 2:36 PM, included that Resident #101 was seen for physical therapy and was noticed to have a swelling on the left ankle. The resident complained of pain upon movement with an intensity of 9 out of 10 (severe), and pain at rest with an intensity of 4 out of 10 (moderate). The bandage was removed due to increased swelling and the left lower extremity was elevated with pillows in bed. The PT/TEN reflected that the nurse was notified of the left ankle swelling and of the resident's verbalized pain. A review of the Nursing Progress Notes (NPN) did not include any documentation/data entry made by the nursing staff on 2/24/24, regarding the resident's pain or injury. A review of the February 2024 electronic Medication Administration Record (MAR) included a physician's order dated 1/23/24, for Tylenol 325 milligram (mg; a pain relief medication); give 2 (two) tablets by mouth every 6 (six) hours PRN for mild pain (1-3). Tylenol was administered on 2/25/24 at 4:00 PM. There was no documented administration of pain medication from 2/23/24, until the Tylenol received on 2/25/24 at 4:00 PM. Further review of the MAR revealed that the nurses documented every shift on 2/23/24 through 2/25/24, that the resident was assessed with no pain, which contradicted the PT/TEN from 2/24/24 at 2:36 PM. A review of the Nursing Daily Skilled Pathway (a daily head to toe assessment/evaluation of the resident) that included skin/wound and pain assessments did not include a daily assessment on 2/24/24. A review of the NPN dated 2/25/24 at 4:00 PM, reflected a documentation made by the Registered Nurse (RN #2) that included, Resident #101 was in bed awake, alert, oriented to person, place, and time. Resident #101 was quoted I twisted my ankle whilst at therapy on Friday, therapy and nursing staff were aware. The nurse assessed Resident #101's ankle, and observed it was red, warm, and edematous (swollen with fluid). The NPN further revealed that the physician was notified, who ordered an x-ray, (radiology imaging to diagnose and treat) and Tylenol 325 mg, two (2) tablets were administered (on 2/25/24 at 4:00 PM) and documented that the Tylenol was effective on 2/25/24 at 5:43 PM. At 8:30 PM, the x-ray was taken, and the resident denied pain at that time. At 11:45 PM, the physician was made aware of the x-ray result of non-displaced fracture of the medial malleolus (ankle fracture without bone displacement), and the physician ordered a transfer of Resident #101 to the emergency room for evaluation. A review of the Radiology Result Report dated 2/25/24 at 9:32 PM, reflected the resident had a non-displaced fracture of the medial malleolus. A review of the Accident/Incident Report signed 2/27/24, for an incident that occurred on 2/23/24, included the following: A review of the PTA statement included that the resident twisted their ankle during rehab. The PTA documented that while Resident #101 was moving with the rollator (mobility aid that helps people with limited mobility walk longer distances) the resident informed the PTA that they had twisted their ankle. The PTA seated the resident, observed no swelling, and applied a precautionary therapy of ice and bandage. The PTA explained to the resident that they will be placed in bed, with their foot elevated, and that the PTA and Resident #101 were going to inform nursing on the way back to the resident's room. As they approached the resident's room, Resident #101 stated to the nurse I'm [going to] need some help, I twisted my ankle in therapy but first I am [going to] have a cigarette. The PTA went back to check on the resident who was seated in the sitting room and was informed by the resident that they did not think it would hurt that bad. The report further revealed that the PTA was under the impression that the resident had discussed it with the nurse and that everything was okay. The investigative statement of the nurse reflected that she was not aware of the incident. The investigative statement made by Resident #101 reflected that at that time, they were not in much pain. The conclusion was the resident was participating in physical therapy session, and while walking with the rollator, resident twisted their left ankle. The resident was seated, ice pack applied and [brand name redacted] bandage wrap was applied. An x-ray was performed on 2/25/24, and indicated a left ankle fracture. The resident was sent to the emergency room for further evaluation. Inservice training report was completed. A review of the included inservicing dated 2/26/24 at 12:00 PM, indicated that the Physical Therapy Assistant/Director of Rehabilitation (PTA/DOR) inserved the rehab staff to communicate with nursing about [resident] care. On 10/24/24 at 2:23 PM, during an interview with the surveyor, the PTA/DOR stated that if an accident occurred during rehab, the rehab staff notified nursing, who assessed the resident, and notified the physician, and rehab evaluated the injury. On 10/28/24 at 9:52 AM, the surveyor interviewed RN #1 regarding the facility's policy and procedure for a resident injury/accident, who stated that she remained with the resident, requested for assistance, asked the resident what had occurred, and began an assessment of the resident with another nurse which included pain evaluation. If a resident was in pain, she asked the resident what had occurred to cause the pain, and administered the PRN pain relief medication, such as Tylenol. After the assessment the physician, supervisors, and family were notified of the injury/accident sustained and results of the assessment conducted by the nurses. RN #1 continued that an incident report was initiated and the care plan interventions were adjusted. The nursing department documented under progress notes of the injury/accident and all the activities that were pending and conducted. The resident was reoriented to call us (the nursing staff) for any needs to prevent future accidents, and the staff increased their surveillance of the resident. On 10/28/24 at 10:10 AM, during an interview with the surveyor, the Licensed Practical Nurse/Supervisor (LPN/S) stated that the expectation for a situation that involved a resident who had an injury/accident in rehab was that the rehab department informed the nursing department immediately after an injury/accident had occurred. The nurse then assessed the resident and determined what had happened and documented in the progress notes. The LPN/S stated rehab documented in their own notes and rehab may apply treatment of ice and bandage to the injured site if there was an order, but the nurse assessed the resident first. After the assessment of vitals, skin, and pain level, the physician, the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), and family were notified. The LPN/S continued that when a resident experienced pain, he asked where the pain was, assessed the resident, and based on the orders, he administered the standard PRN Tylenol for pain relief. The LPN/S stated that in the event a resident had no orders for pain relief or had a pain intensity greater than five (5), he notified the physician. The LPN/S did not recall Resident #101. On 10/28/24 at 10:42 AM, in the presence of the survey team, the DON, LNHA, the Regional Director of Clinical Operations (RDCO), and the Regional Director of Clinical Services (RDCS), the surveyor discussed the concerns regarding the failure to notify the nursing department immediately on 2/23/24, when Resident #101 had an injury/accident in rehab, which caused a delay in treatment, and the resident was not assessed until 2/25/24, and an x-ray was ordered which resulted in an ankle fracture. On 10/28/24 at 12:43 PM, the PTA/DOR, in the presence of the survey team and the LNHA, stated that she was made aware after the incident of Resident #101's injury/accident but could not recall exactly when. The PTA/DOR stated that the expectation was that after a witnessed injury that occurred during rehab, rehab notified nursing immediately, and the nursing staff notified the physician. The PTA/DOR acknowledged that the rehab staff did not inform nursing immediately after the injury on 2/23/24, but documented informing the nursing staff of the injury and pain observed on 2/24/24. On 10/28/24 at 1:20 PM, the DON, in the presence of the survey team, stated that nursing should have been informed at the time of the injury, and that the previous DON and the previous LNHA investigated on 2/26/24 (three days after the injury/accident), obtained witness statements, and the PTA/DOR and the rehab staff was provided education on communication with nursing and resident care. On 10/29/24 at 10:58 AM, the DON confirmed and acknowledged that the rehab department should have notified the nursing department to conduct an assessment, that the resident should not be expected to report their own injury/accident to the nurse. The DON confirmed and acknowledged that the resident should have been medicated for the pain, the physician should have been notified, and the delay in notification resulted in the delay of the diagnosis. The DON stated that after the result of Resident #101's ankle fracture, it should have been reported to the Ombudsman. A review of the undated facility's Change in Resident's Condition or Status policy included that the nurse would notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident. Prior to notifying the physician or health care provider the nurse would make detailed observations and gather relevant and pertinent information for the provider . A review of the undated facility's Charting and Documentation policy included that all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . A review of the facility provided Accidents, and Incidents - Investigating and Reporting policy dated revised July 2017, included under Policy Interpretation and Implementation that the nurse supervisor/charge nurse/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . A review of the facility provided Accident and Incident policy dated August 2021, included that all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator and that the administrator and/or director of nursing shall promptly initiate and document investigation of the accident or incident . No additional information was provided. NJAC 8:39-11.2(b); 27.1(a)
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 6 of 37 residents reviewed for accommodation of needs (Resident #70, #15, #1, #48, #13, and #86), and was evidenced by the following: a. On 10/22/24 at 10:43 AM, the surveyor observed Resident #70 in bed, with his/her eyes closed. Resident #70 did not respond to the surveyor's greeting. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was not within the Resident's reach. On 10/23/24 at 12:59 PM, the surveyor observed Resident #70 in bed with his/her eyes closed. Resident #70 did not respond to the surveyor. The surveyor observed the resident's call bell was not within the Resident's reach. The surveyor reviewed the medical record for Resident #70. A review of Resident #70's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia, diabetes mellitus and chronic obstructive pulmonary disease (a lung disease which causes permanent lung damage and breathing difficulties). A review of Resident #70's annual Minimum Data Set (MDS) an assessment tool dated 4/8/24 revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated Resident #70 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance and or supervision for activities of daily living (ADLs). A review of Resident 70's individualized care plan (ICP) initiated on 4/2/23 included a focus area: resident is at risk for falls with interventions which included but were not limited to: be sure call light is within reach and provide reminders to use call bell for assistance as needed. On 10/24/24 at 1:30 PM, the surveyor observed Resident #70 in bed with his/her eyes closed. The surveyor observed Resident #70's call bell on the floor behind the resident's bed. On 10/24/24 at 1:35 PM, the surveyor accompanied by the Certified Nursing Assistant (CNA #1) assigned to care for Resident #70, entered the resident room. The surveyor and the CNA observed Resident #70's call bell on the floor under the resident's bed. The CNA confirmed that she should have checked to ensure that the call bell was within the resident's reach. b. On 10/23/24 at 1:15 PM, the surveyor observed Resident #15 in bed. The surveyor observed the call bell was under the resident's bed not within the resident's reach. On 10/24/24 at 8:00 AM, the surveyor in the presence of the Registered Nurse (RN #1), observed Resident #15's call bell under the resident's bed not within the resident's reach. The RN stated, it's stuck and further stated that it should have been clipped to the bed and kept within the resident's reach. The surveyor reviewed the medical record for Resident #15. A review of Resident #15's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia, diabetes mellitus and repeated falls. A review of Resident #15's admission MDS dated [DATE] revealed Resident #15 had a BIMS score of 3 out of 15 which indicated Resident #15 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance and or supervision for activities of daily living. A review of Resident 15's ICP initiated on 5/10/24 included a focus area: resident is at risk for falls with interventions which included but were not limited to: be sure call light is within reach and provide reminders to use call bell for assistance as needed. c. On 10/23/24 at 1:20 PM, the surveyor observed Resident #1 was out of bed seated in a geriatric chair in his/her room. The surveyor observed the call bell was positioned in the middle of the resident's bed, not within the resident's reach. On that same day, at that same time, the surveyor observed RN #2 entered Resident #1's room. The surveyor showed RN #2 the call bell and asked RN #2 if the call bell should have been positioned so that the resident could reach it. RN #2 did not respond verbally to the surveyor's inquiry and positioned the call bell within Resident #1's reach. The surveyor reviewed the medical record for Resident #1. A review of Resident #1's Admission Record revealed Resident #1 was admitted to the facility with diagnoses which included but were not limited to acute respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease and dementia. A review of Resident #1's most recent Minimum Data Set (MDS), an assessment tool, dated 9/20/24 revealed Resident #1 had short-term and long-term memory problems and had a severe cognitive impairment. A review of the resident's ICP initiated on 5/25/24 included a focus area: Resident is at risk for falls with interventions which included but were not limited to: Be sure call light is within reach and provide reminders to use call bell for assistance as needed. d. On 10/24/24 at 7:50 AM, the surveyor and RN #1 entered Resident #48's room and observed Resident #48 in bed with their call bell on the floor under the bed, not within the resident's reach. RN #1 confirmed that the call bell should be kept within the resident's reach. A review of Resident #48's Admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited dementia, depression and an overactive bladder. A review of Resident #48's quarterly MDS dated [DATE] revealed Resident #48 had a BIMS score of 7 out of 15 which indicated Resident #48 had a severe cognitive impairment. The MDS further revealed that the resident required staff supervision and or assistance for ADLs. A review of Resident 48's ICP initiated on 11/13/23, included a focus area: Resident has an ADL Self Care Performance Deficit with interventions which included but were not limited to: Encourage me to use call bell for assistance. e. On 10/24/24 at 7:53 AM, the surveyor accompanied by RN #1 observed Resident #13 in bed. The surveyor and RN #1 observed Resident #13's call bell was behind the headboard, hanging down towards the floor. RN #1 stated that the call bell was stuck behind the bed and should have been within the resident's reach. A review of Resident #13's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to hypertension and chronic obstructive pulmonary disease. A review of Resident #13's most recent MDS revealed Resident #13 had a BIMS score of 2 out of 15 which indicated Resident #13 had a severe cognitive impairment. The MDS further revealed that the resident required staff supervision/ assistance for ADLs. A review of Resident 13's ICP initiated on 11/8/23, included a focus area: Resident has an ADL Self Performance Deficit with interventions which included but were not limited to: Encourage me to use call bell for assistance. f. On 10/24/24 at 8:00 AM, the surveyor accompanied by RN #1 observed Resident #86 in bed. The surveyor and RN #1 observed Resident #86's call bell was behind the headboard not within the resident's reach. A review of Resident #86's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia and cognitive communication deficit. A review of Resident #86's admission MDS revealed Resident #86 had a BIMS score of 4 out of 15 which indicated the resident had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance for ADLs. A review of Resident 86's ICP initiated on 7/3/24, included a focus area: I have an ADL Self Care Performance Deficit with interventions which included but were not limited to: Encourage me to use the call bell for assistance. On 10/24/24 at 8:10 AM, the surveyor interviewed RN #1 who stated that the nurses and CNAs should ensure that the call bells are always kept within the resident's reach. The surveyor attempted phone interviews with the assigned 11 PM-7 AM, CNAs for Residents #15, #48, #13, and #86. The surveyor left messages for both CNAs with no return calls. On 10/24/24 at 1:54 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The DON confirmed that call bells should be kept within the resident's reach. A review of the facility policy entitled, Answering the Call Light undated, reflected .The purpose of this procedure is to ensure timely responses to the resident's requests and needs . NJAC 8:39-31.8 (c)(9)
Based on observation, interview and record review, it was determined that the facility failed to issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and/or the Notice of Medicare Non-coverage (NOMNC) for 3 of 3 residents (#82, #349, #348) reviewed for facility change notifications regarding insurance termination. The evidence is as follows. On 10/28/24 at 11:28 a.m., the facility presented the surveyor with a list of residents who were discharged from the facility within 6 months and were required to have received Beneficiary Notices. The surveyor reviewed 3 of the residents listed (Resident #82, #349, #348) who were discharged from a Medicare Part A stay at the facility and were documented as having a discontinuation of their Medicare Part A insurance payment to the facility. Resident #82's last documented day of coverage for Medicare Part A service was 4/28/24. The resident elected to stay in the facility. The facility was required to provide both a SNF ABN form and a NOMNC form to the resident/responsible party. The facility provided a NOMNC, however, they did not present the resident with the required SNF ABN form to notify them of the termination of insurance. Resident #349's last documented day of coverage for Medicare Part A service was 6/27/24. The resident elected to stay in the facility. The facility was required to provide both a SNF ABN form and a NOMNC form to the resident/responsible party. The facility provided a NOMNC, however, they did not present the resident with the required SNF ABN form to notify them of the termination of insurance. Resident #348's last documented day of coverage for Medicare Part A service was 5/22/24. The resident was discharged either to home or to a lesser level of care. The facility was required to provide a NOMNC form to the resident/responsible party. A NOMNC was not presented to the resident. On 10/29/24 at 11:00 a.m., the surveyor informed the Administrator and the Director of Nursing of the above-noted concerns regarding insurance termination notification omissions. The Administrator stated there was a change in social service staff who were responsible for providing notification to residents which may have caused the errors. No additional information was provided. NJAC 8:39-5.4 (b)(c)
Complaint # NJ 172317, NJ 172237; NJ 174618; NJ 175890 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 7 of 8 residents (Resident #82, #199, #48, #13, #86, #24, and #14) observed for incontinence care on 2 of 4 units (North Unit and [NAME] Unit). This deficient practice was evidenced by the following: On 10/24/24 at 7:35 AM, the surveyor completed an incontinence tour on the North Unit and observed the following: a. On 10/24/24 at 7:40 AM, the surveyor accompanied by Registered Nurse (RN #1) observed Resident #82 in bed. RN #1 exposed Resident #82's incontinence brief. At that time when RN #1 exposed the incontinence brief another incontinence brief was observed which was saturated with urine. RN #1 stated that no resident should be wearing two incontinence briefs. A review of Resident #82's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia, diabetes mellitus, and anxiety disorder. A review of Resident #82's admission Minimum Data Set (MDS) an assessment tool dated 3/14/24 revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated Resident #82 had a severe cognitive impairment. The MDS further revealed that the resident required assistance from staff for personal hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident 82's Individualized Care Plan (ICP) initiated on 3/12/24 included a focus area: Activities of Daily Living (ADL) self care deficit with interventions that included but were not limited to: resident is dependent on staff for toileting. b. On 10/24/24 at 7:45 AM, the surveyor accompanied by RN #1 observed Resident #199 in bed. RN #1 exposed Resident #199's incontinence brief. At that time when RN #1 exposed the incontinence brief another incontinence brief was observed which was saturated with urine. RN #1 stated that it did not appear as if the night aide had changed the resident recently. A review of Resident #199's admission record reflected Resident #199 was admitted to the facility with diagnoses which included but were not limited to Parkinson's Disease, dementia and anxiety disorder. A review of Resident #199's admission MDS dated [DATE] revealed Resident #199 had short-term and long-term memory problems and was assessed as having a moderate cognitive impairment. The MDS further reflected that Resident #199 required supervision from staff for personal hygiene, and was frequently incontinent of urine and bowel movements. A review of Resident 199's ICP initiated on 10/15/24 included a focus area: Resident has bowel and bladder incontinence with interventions which included but were not limited to: check resident approximately every 2 hours and provide incontinence care as needed. c. On 10/24/24 at 7:50 AM, the surveyor accompanied by RN #1 observed Resident #48 in bed. The surveyor observed that Resident #48's adult pull- up was saturated with urine. The surveyor and RN #1 observed that Resident #48's sheets were also saturated with urine. A review of Resident #48's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited dementia, depression and an overactive bladder. A review of Resident #48's quarterly MDS dated [DATE] revealed Resident #48 had a BIMS score of 7 out of 15 which indicated Resident #48 had a severe cognitive impairment. The MDS further revealed that the resident required staff supervision for personal hygiene, and he/she was occasionally incontinent of bowel and bladder. A review of Resident 48's ICP initiated on 11/21/23, included a focus area: Resident is on diuretic therapy with interventions which included but were not limited to: Resident may need to void frequently and quickly. Routinely check and offer/provide toileting assistance. d. On 10/24/24 at 7:53 AM, the surveyor accompanied by RN #1 observed Resident #13 in bed. RN #1 exposed Resident #13's pull up. At that time when RN #1 exposed the pull up an incontinence brief was observed under the pull up. The surveyor and RN #1 observed both the pull up and incontinence brief were saturated with urine. The surveyor and RN #1 observed Resident #13's perineal area was very red. RN #1 stated that no resident should be wearing a diaper and pull up as it could cause skin breakdown. A review of Resident #13's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to hypertension and chronic obstructive pulmonary disease (a lung disease that causes permanent damage to the lungs.) A review of Resident #13's most recent MDS revealed Resident #13 had a BIMS score of 2 out of 15 which indicated Resident #13 had a severe cognitive impairment. The MDS further revealed that the resident required staff supervision for personal hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident 13's ICP initiated on 11/16/23, included a focus area: Resident is on diuretic therapy with interventions which included but were not limited to: Resident may need to void frequently and quickly. Routinely check and offer/provide toileting assistance. e. On 10/24/24 at 8:00 AM, the surveyor accompanied by RN #1 observed Resident #86 in bed. RN #1 exposed Resident #86's incontinence brief. At that time when RN #1 exposed the incontinence brief another incontinence brief was observed. The surveyor and RN #1 observed both incontinence briefs were saturated with urine. The surveyor and RN #1 observed Resident #86's blanket was also saturated with urine. A review of Resident #86's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia and cognitive communication deficit. A review of Resident #86's admission MDS revealed Resident #86 had a BIMS score of 4 out of 15 which indicated Resident #86 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance for personal hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident 86's ICP initiated on 7/3/24, included a focus area: Resident has bowel and bladder incontinence with interventions which included but were not limited to: check resident approximately every two hours and provide incontinence care as needed. On 10/24/24 at 8:10 AM, the surveyor interviewed RN #1 who stated that the facility policy was to use only one incontinence brief as two briefs could cause the resident's skin to breakdown. RN #1 further stated that incontinence care should be provided every two hours. f. On 10/24/24 at 8:15 AM, the surveyor observed RN #2 during medication administration observation on the North unit. The surveyor observed RN #2 prepared to administer an injection in Resident #24's abdomen. RN #2 exposed Resident #24's incontinence brief. At that time the surveyor and RN #2 observed another incontinence brief. The surveyor and RN #2 observed both incontinence briefs were saturated with urine. RN #2 stated that residents should not be wearing two incontinence briefs as it could cause skin breakdown. A review of Resident #24's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to dementia, muscle weakness and hypertension. A review of Resident #24's quarterly MDS revealed Resident #24 had a BIMS score of 3 out of 15 which indicated Resident #24 had a severe cognitive impairment. The MDS further assesses that the resident required moderate staff assistance for personal hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident 24's ICP initiated on 10/29/21, included a focus area: Resident has episodes of incontinence of bowel and bladder with interventions which included but were not limited to: Check and change resident as needed. On 10/24/24 at 8:30 AM, the surveyor interviewed RN #2 who stated the facility policy was for the residents not to be double diapered and that they should be provided incontinence every 2 hours. g. On 10/24/24 at 10:30 AM, during the resident council meeting, Resident #14 stated that staff used a mechanical lift to transfer her/him from the bed to the wheelchair and that once he/she was lifted out of the bed into the chair she/he has to stay there and doesn't receive incontinence care until she/he was transferred back to bed in the evening. The resident stated that if she/he requested to go back to bed to be changed the staff would refuse to transfer her/him back into the chair and therefore stay in bed for the remainder of the day. On 10/24/24 at 12:20 PM, the surveyor interviewed Resident #14 who stated that she/he was transferred out of bed with the mechanical lift at approximately 8:30 AM. The Resident confirmed that she/he had not received any incontinence care since that time. A review of Resident #14's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to chronic kidney disease, depression and overactive bladder. A review of Resident #14's annual MDS dated [DATE] revealed Resident #14 had a BIMS score of 15 out of 15 which indicated Resident #14's cognition was intact. The MDS further revealed that the resident was dependent on staff for toileting hygiene, and he/she was always incontinent of bowel and bladder. A review of Resident 14's ICP initiated on 10/30/2023, included a focus area: resident has bowel and urinary incontinence with interventions which included but were not limited to: check resident approximately every 2 hours and provide incontinence care as needed. On 10/24/24 at 12:30 PM, the surveyor interviewed the Certified Nursing Assistant on [NAME] Unit (CNA-W) assigned to provide care for Resident #14, who stated that she provided incontinence care for all residents every 2 hours which included residents who required mechanical lifts for transfers. The surveyor asked CNA-W if Resident #14 was incontinent of bowel and bladder. The CNA-W confirmed that she/he was. The surveyor asked the CNA why she had not provided incontinence care for Resident #14. The CNA replied it was because the resident had not asked to be changed. On 10/24/24 at 12:50 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the care of Resident #14 who stated that the facility policy was to provide incontinence care every 2-2 1/2 hours to all residents who were incontinent of bowel and or bladder. The surveyor stated that the CNA had not provided incontinence care for Resident #14 since that morning. The LPN replied that Resident #14 was alert and oriented and did not ask to be changed. On 10/24/24 at 12:55 PM, the LPN and CNA transferred Resident #14 back to bed with the use of a mechanical lift. The CNA exposed the incontinence brief and at that time, the LPN, CNA and surveyor observed a second incontinence brief in place. The surveyor, LPN and CNA all observed that both incontinence briefs were saturated with urine. At that same time, the resident stated that she/he requested 2 incontinence briefs because by the evening when she/he gets transferred back to bed she is saturated with urine. She/he further stated that even her/his clothing and mechanical lift pad were saturated with urine. Resident #14 stated that she/he bought a new spray to use on the mechanical lift pad so that he/she did not smell like urine. On 10/24/24 at 1:00 PM, the LPN stated that it was unacceptable that Resident #14 was saturated with urine and further stated that even though the resident was alert and oriented she/he should be offered incontinence care and be permitted to get back out of bed if that was her/his preference. On 10/24/24 at 1:54 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The DON confirmed that incontinence care should be provided every 2 hours on all shifts and that if residents requested 2 incontinence briefs it should be care planned. The surveyor attempted phone interviews with the assigned 11 PM-7 AM, CNAs for Resident #82, #199, #48, #13, #86, and #24. The surveyor left messages for both CNAs with no return calls. A review of the facility's Urinary and Fecal Incontinence policy, undated reflected .the purpose of this procedure is to provide guidelines that will aid in preventing the resident's exposure to urine and feces . NJAC 8:39-27.1 (a), 27.2 (h)
Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to a.) discontinue a treatment order for a healed wound and b.) follow a physician's treatment order. The deficient practice was identified for 1 of 18 residents (Resident # 50) reviewed for physician orders and is 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 or 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. On 10/22/24 at 1:30 PM, the surveyor observed Resident # 50 lying in bed alert and awake and able to make their needs known. On 10/23/24 at 1:30 PM, the surveyor reviewed the following medical records. The Admission Record revealed the following diagnoses, which included but were not limited to, atherosclerotic heart disease, acute and chronic systolic congestive heart failure and essential hypertension. The Minimum Data Set assessment tool (MDS) dated [DATE] revealed the brief interview for mental status (BIMS) score was 15 of a possible 15 indicating no cognitive deficits. The October 2024 Order Summary Report included two physician's orders as follows. Clean toe web spaces well with soap and water and place gauze in each web space to wick moisture daily every day shift for moisture. Cleanse right buttock deep tissue injury (DTI) with normal saline solution (NSS) and apply foam cover daily every day shift for DTI. The October 2024 Treatment Administration Record (TAR) indicated the nurse continued to sign the treatment order daily for the right buttock up to and including on 10/23/24. The 9/21/24 Wound Assessment Report noted that the right buttock wound had resolved. On 10/23/24 at 12:10 PM, the surveyor interviewed the Registered Nurse (RN) Supervisor. The surveyor and the RN Supervisor reviewed the resident's treatment orders which included the order for the right buttock DTI and the order for gauze placement in between toes. The RN Supervisor confirmed that nursing continued to sign the TAR daily up to and including on 10/23/24 even though the buttock wound was documented to have healed on 9/21/24. Additionally the treatment for gauze placement was signed as performed on 10/23/24. At that same time, the surveyor and the RN Supervisor went to the resident's room. The resident was interviewed and stated they were not receiving any wound treatments. The RN Supervisor inspected the resident's right buttock area and the resident's feet. The RN Supervisor confirmed there was no dressing on the right buttock or gauze placed in between the toes. On 10/23/24 at 1:20 PM, the surveyor discussed with the Director of Nursing the concerns regarding physician treatment orders. NJAC 8:39-27.1 (a)
Inspection of July 30, 2019
2 findingsPart [NAME] Based on observation, interview, review of medical records and review of other facility documentation, it was determined that the facility failed to follow professional standards of clinical practice by a.) administering blood pressure (BP) medications consistently outside of the physician ordered BP parameters and heart rate (HR) parameters when 12 nurses on 1 unit for 1 of 19 residents (Resident #41), disregarded ordered BP parameters and HR parameters for administration of medications from (MONTH) 22, 2019 to (MONTH) 24, 2019; The facility's failure to administer medications according to physician ordered BP parameters, HR parameters and clinical standards of nursing practice had the likelihood to affect all residents receiving medications with physician ordered parameters. On 7/26/19 at 1:45 PM, the facility Administrator was notified that an Immediate Jeopardy situation (IJ) had been identified. The IJ removal plan was put into place and accepted on 7/26/19 at 4:10 PM for Resident's #41. The Administrator ensured that current residents on medications with hold parameters were reviewed and cross-referenced with the respective Medication Administration Record (MAR) to identify additional occurrences. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a licensed practical nurse is defined as performing task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) According to the Admission Record (AR), Resident # 41 was admitted to the facility with the medical [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) an assessment tool dated 6/6/2019, reflected that the resident was cognitively intact, independently ambulated (walked), and required extensive assistance of one staff member for activities of daily living (ADL's). The physician's orders [REDACTED]. Resident #41's POS dated 3/22/19, revealed physician's orders [REDACTED]. The MAR reviewed from (MONTH) 22, 2019 to (MONTH) 24, 2019 revealed the following: - 3/22/19 to 3/31/19, the medication [MEDICATION NAME] 10 mg was administered outside of the physician ordered parameters 1 time out of 27 opportunities by one nurse - 4/31/19, the medication [MEDICATION NAME] 25 mg was administered outside of the physician ordered parameters 1 time out of 1 opportunity by one nurse. - 5/1/19 to 5/31/19, the medication [MEDICATION NAME] 25 mg was administered outside of the physician ordered parameters 13 times out of 93 opportunities by 5 nurses; and, [MEDICATION NAME] 10 mg was administered outside of the physician ordered parameters 41 times out of 93 opportunities by 10 nurses. - 6/1/19 to 6/30/19, the medication [MEDICATION NAME] 25 mg was administered outside of the physician ordered parameters 18 times out of 90 opportunities by 5 nurses; and, [MEDICATION NAME] 10 mg was administered outside of the physician ordered parameters 24 times out of 90 opportunities by 3 nurses. - 7/1/19 to 7/24/19, the medication [MEDICATION NAME] 25 mg was administered outside of the physician ordered parameters 15 times out of 75 opportunities by 6 nurses; and, [MEDICATION NAME] 10 mg was administered outside of the physician ordered parameters 45 times out of 75 opportunities by 7 nurses. The Care Plan dated 2/28/2019, reflected that the resident had a [DIAGNOSES REDACTED]. On 07/25/19 at 11:17 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1 who stated that when a medication was administered to a resident it was identified on the MAR as a check mark. The LPN added, that she did not work consistently on the North Unit but was aware that Resident # 41 was on blood pressure medication with physician ordered blood pressure and heart rate (HR) parameters. The LPN showed the surveyor on the MAR where she documented the resident's blood pressure and that she administered the medication because it was in the physician ordered parameters. The LPN also stated that when a medication is not administered it was because the BP or HR were out of the physician ordered parameters, It would be coded according to the code key located on the bottom of the MAR. The LPN revealed that according to Resident #41's MAR, the aforementioned blood pressure medications were given to Resident #41 by some of the nurses on the North Unit out of the physician ordered B/P and HR parameters. On 07/25/19 at 11:46 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who reviewed Resident # 41's MAR in the presence of the surveyor, confirmed that the medications [MEDICATION NAME] 25 mg and [MEDICATION NAME] 10 mg were administered to Resident # 41 out of the physician's orders [REDACTED]. On 07/25/19 at 12:55 PM, the surveyor interviewed the Director of Nursing (DON) who reviewed Resident # 41's (MONTH) 2019 MAR in the presence of the surveyor. The DON confirmed that the medications [MEDICATION NAME] 25 mg and [MEDICATION NAME] 10 mg were administered to Resident # 41 out of the physician's orders [REDACTED]. She stated The nurses should not have administered the blood pressure medications out of the physician ordered parameters and, the nurses did not follow the physician orders. On 07/25/19 at 01:49 PM, the surveyor interviewed the facility Pharmacy Consultant (PC) who stated, I do drug regimen reviews monthly and look at all the resident's medications. If I have concerns or recommendations, I would e-mail the facility with my findings. The PC informed the surveyor that any immediate concerns are brought to the attention of the facility's Administrator, DON and Unit Managers by the end of the day or emailed for follow-up. The pharmacy review recommendation sheets are presented to the physician for signature and then the recommendation sheets would go back into the resident's medical record. The PC further stated, that the MARs are reviewed monthly and any concerns identified are documented on the drug regimen review form. The PC stated, I don't know how I did not find the error with the resident's blood pressure medications being given out of the physician ordered parameters. On 07/26/19 12:21 PM, the surveyor interviewed the DON and Administrator who both confirmed, that it was not common practice at the facility to administer blood pressure medications out of the physician ordered parameters, and that this was considered a medication error. The DON and Administrator both added that the nurses involved should have been more diligent and read the physicians order more closely. On 07/26/19 at 12:51 PM, the surveyor interviewed LPN #2 who stated that she did not know why she administered the medication [MEDICATION NAME] out of physician ordered B/P parameters because she knew the resident's parameters, By heart. LPN #2 further stated, I would have definitely held the medication if it was out of the physician ordered parameters and, I might have mistakenly hit the button on the computer that indicated I administered it when I didn't. On 07/26/19 at 12:55 PM, the surveyor interviewed Registered Nurse (RN) #1 who stated, I'm not sure why the MAR says that I gave the blood pressure medications. I will have to be more careful and read the MAR when I give the medications. On 07/26/19 at 01:13 PM, the surveyor attempted to telephone interviewed LPN #3 however, there was no answer. On 07/26/19 at 01:17 PM, the surveyor interviewed LPN #4 who worked at the facility for a couple months. LPN #4 informed the surveyor that when she administers a blood pressure medication, the resident's blood pressure is taken. Furthermore, she checks the entire order in the computer system. The LPN stated, that under the word more the B/P and HR parameters are revealed. The LPN added, If I gave the resident the B/P medications it must have been a mistake. On 07/26/19 at 02:27 PM, the surveyor interviewed the RN Supervisor (RN/S) #1 who worked in the facility for [AGE] years. The RN/S stated, I usually administer medications to the residents in the facility. I don't remember, maybe I charted in the wrong spot. The RN/S further stated, I would never knowingly give the resident a B/P medication outside of the physician ordered parameters. I honestly don't remember. On 07/29/19 10:47 AM, the surveyor interviewed Resident # 41 who stated that he felt ok and did not have any health issues or concerns at this time. On 07/29/19 at 11:28 AM, the surveyor attempted to telephone interview RN #3, however there was no answer. On 07/29/19 at 11:29 AM, the surveyor attempted to telephone interview RN #4, however there was no answer. On 07/29/19 at 11:30 AM, the surveyor interviewed LPN #4 who stated that she was not sure how the medication error occurred. LPN #4 stated that the facility was re-educating the nurses, and is also performing medication pass competencies for all licensed nurses in the facility. On 7/29/19 at 11:06 AM, the surveyor interviewed the DON who stated, I dropped the ball in regard to the nurses administering B/P medications out of physician ordered parameters. The facility policy titled, Administration Medications with revised date of (MONTH) 2012, indicated that 1.) the DON would supervise and direct all nursing personnel who administer medications and/or have related functions 2.) Medications must be administered in accordance with orders, including any required time frame 3.) the individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. This deficiency is continued at a scope and severity of a Level D see (Part B): Part B. Based on observation, interview, review of medical records and review of other facility documentation, it was determined that the facility failed to follow professional standards of clinical practice by failure to delineate a specific time to administer insulin on the Medication Administration Record (MAR), and failed to delineate specific times to don (apply) and remove splinting devices for 1 of 19 residents (Resident #62). 2.) According to the AR, Resident # 62 was admitted to the facility with the medical [DIAGNOSES REDACTED]. The annual MDS dated [DATE], reflected that the resident had severe cognitive deficits and required total assistance with ADL's. The MDS also indicated that the resident received daily insulin injections and had impairment in the range of motion on one side of the upper and lower extremity. The surveyor reviewed the POS which revealed an order dated 11/21/18, for the medication [MEDICATION NAME] (insulin long acting) 6 units to be injected subcutaneously daily for the [DIAGNOSES REDACTED].#62. The MAR dated (MONTH) 2019, revealed that the medication [MEDICATION NAME] (insulin) was administered at times ranging from the earliest time documented at 9:19 AM to the latest time of administration documented at 12:16 PM. On 07/25/19 at 10:27 AM, the surveyor interviewed the LPN who stated that Resident # 62 was a diabetic and had an order for [REDACTED]. The LPN reviewed the MAR in the presence of the surveyor. There was an order dated 4/16/19 for the medication [MEDICATION NAME] 6 units, to be administered subcutaneously once a day. The hour slotted for the insulin to be administered was day on the MAR. There was no specific time slotted. The LPN admitted that she should have called the physician to get an exact time when the insulin was to be administered and should have clarified the order with the physician. On 07/25/19 at 10:35 AM, the surveyor interviewed the RN/UM who stated that the medication [MEDICATION NAME] (insulin) should have a time slotted on the MAR as to when it should be administered. The RN/UM stated, There should be a specific time delineated on the MAR as to when the nurses were to administer the medication [MEDICATION NAME]. I'm not sure what time the insulin was being administered. I will call the physician to get the time clarified with the physician. On 07/26/19 at 10:17 AM, the surveyor interviewed the Regional Director of Operations and the Administrator. Both parties addressed that there should have been specific times documented on the MAR as to when Resident # 62 was to be administered insulin and that this was not the facilities normal practice. In addition, they stated that the nurses should have been more diligent and called the physician and got the administration time for the insulin clarified. On 07/25/19 at 01:49 PM, the surveyor interviewed the facility Pharmacy Consultant (PC) who stated, I do drug regimen reviews monthly and look at all the resident's medications. If I have concerns or recommendations, I would email the facility my findings. The PC informed the surveyor that any immediate concerns are brought to the attention of the facility's Administrator, DON and Unit Managers by the end of the day and/or, emailed for follow-up. The pharmacy review recommendation sheets are presented to the physician for signature and then the recommendation sheets would go back into the resident's medical record. The PC further stated, that the MARs are reviewed monthly and any concerns identified are documented on the drug regimen review form. The PC stated she was unsure how she missed that there was no specific time for insulin plotted on the MAR for insulin administration. On 7/29/19 at 11:30 AM, the surveyor attempted to interview the attending physician for Resident #62, but the physician was unavailable. On 7/29/19 at 12:20 PM, the surveyor interviewed the Medical Director (MD) who stated, that the medication [MEDICATION NAME] was a long acting insulin and should have had a specific time delineated because the resident also received an additional dose of insulin at 9:00 PM. Additionally the MD stated, that if the medication was given too late in the morning, the morning dose could run into the evening dose and the resident could have experienced a hypoglycemic (low blood sugar) episode. The surveyor reviewed the medical record which identified that there was no documentation that the resident experienced a hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) episode. On 07/23/19 at 10:23 AM, the resident was observed lying in bed and could not be interviewed due to severe cognitive deficits. On 07/24/19 at 11:00 AM, the surveyor reviewed the POS which revealed an order dated 10/9/2018, for Resident # 62, to have a right elbow brace and right knee brace for 4 hours a day to promote extension and prevent flexion contracture (tightening and hardening of the tendons). The surveyor reviewed the Treatment Administration Record (TAR) and observed that there was no time delineation documented on the TAR to determine when the brace was to be donned (applied) and when it was to be removed. According to the resident's Care Plan (CP), Resident #62 had a right knee and right elbow brace for 4 hours a day. No specific time of application or removal was documented on the CP. On 07/25/19 at 10:10 AM, the surveyor interviewed the CNA who stated, that Resident # 62 had severe cognitive deficits and required total care with activities of daily living. The CNA added, that the resident wore a right knee brace and right elbow brace and that the nurse applied it around 2:00 PM. The CNA told the surveyor that the devices were utilized to help with the contractures. On 07/25/19 at 10:10 AM, the surveyor interviewed the LPN. The LPN revealed that Resident # 62 was ordered to wear a brace to prevent contractures on the right elbow and right knee. The brace was ordered to be applied for 4 hours and then removed. The LPN stated that she applied the brace around 2 PM. The LPN stated that the nurse that worked the 3-11 shift would only know when the braces should be removed if the nurse that applied the braces gave that information in report. She admitted that there was no time slot documented on the TAR as to when to apply the braces or when to remove them. The LPN stated, I have to get the times clarified with the physician. On 07/25/19 at 10:35 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that there was no time delineated on the TAR as to when to apply the right elbow brace and right knee brace, and that she would call the physician for clarification. On 07/25/19 at 11:00 AM, the Director of Rehabilitation (DOR) stated that when the therapist (either the physical therapist or occupational therapist) evaluated and assessed a resident for the use of brace or splint, the therapist determines how long the resident was to wear the brace according to how the resident tolerated the device. For Resident # 62, the therapist determined that he/she could only tolerate the right elbow splint and the right knee splint for 4 hours and that is why it was important to assure that specific times were documented as to when to apply the device and when to remove it. On 07/26/19 at 10:17 AM, the surveyor interviewed the Regional Director of Operations, who was a registered nurse, and the DON. Both stated that there should have been an exact time delineated on the TAR as to what time the resident's braces should have been applied and should have been removed. They added, that the nurses should have notified the MD and should have clarified the order as to when the resident's right arm and right leg braces were to be applied and removed. The facility policy titled, Administration Medications with revised date of (MONTH) 2012, indicated that 1.) the DON would supervise and direct all nursing personnel who administer medications and/or have related functions 2.) Medications must be administered in accordance with orders, including any required time frame 3.) the individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. The facility policy titled, Insulin Administration with revised date of (MONTH) 2014 indicated that the type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician order. The facility policy titled Resident Mobility and Range of Motion with revised date of (MONTH) (YEAR) indicated that the care plan will include type, frequency, and duration of intervention, as well as measurable goals and objectives. NJAC 8:39-27.1 (a); 29.2 (d)
Based on observation, interview and review of medical records and other facility documentation, it was determined that the facility Pharmacy Consultant (PC) failed to a.) identify that blood pressure (B/P) medications were administered to a resident out of the physician ordered B/P and heart rate (HR) parameters from (MONTH) 2019 to (MONTH) 2019 for Resident # 41, 1 of 19 residents reviewed; and, b.) identify that there were no specific time delineations for the administration of insulin for Resident #62, 1 of 19 residents reviewed as was evidenced by the following: The facility's failure to administer medications according to physician ordered BP parameters, HR parameters and clinical standards of nursing practice had the likelihood to affect all residents receiving medications with physician ordered parameters. On 7/26/19 at 1:45 PM, the facility Administrator was notified that an Immediate Jeopardy situation (IJ) had been identified. The IJ removal plan was put into place and accepted on 7/26/19 at 4:10 PM for Resident's #41. The Administrator ensured that current residents on medications with hold parameters were reviewed and cross-referenced with the respective Medication Administration Record (MAR) to identify additional occurrences. 1.) According to the Admission Record (AR), Resident # 41 was admitted to the facility on [DATE] with the medical [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) an assessment tool dated 6/6/2019, reflected that the resident was cognitively intact, independently ambulated and required extensive assistance of one staff member for activities of daily living (ADL's). The physician's orders [REDACTED]. The POS dated 3/22/19, revealed physician's orders [REDACTED]. The Medication Administration Record (MAR) reviewed from (MONTH) 22, 2019 to (MONTH) 24, 2019 revealed the following: - 3/22/19 to 3/31/19, the medication [MEDICATION NAME] 10 mg was administered outside of the physician ordered parameters, 1 time out of 17 opportunities by one nurse. - 4/31/19, the medication [MEDICATION NAME] 25 mg was administered outside of the physician ordered parameters, 1 time out of 1 opportunity by one nurse. - 5/1/19 to 5/31/19, the medication [MEDICATION NAME] 25 mg was administered outside of the physician ordered parameters 13 times out of 93 opportunities by 5 nurses. [MEDICATION NAME] 10 mg was administered outside of the physician ordered parameters 41 times out of 93 opportunities by 10 nurses. - 6/1/19 to 6/30/19, the medication [MEDICATION NAME] 25 mg was administered outside of the physician ordered parameters 18 times out of 90 opportunities by 5 nurses. [MEDICATION NAME] 10 mg was administered outside of the physician ordered parameters 24 times out of 90 opportunities by 3 nurses. - 7/1/19 to 7/24/19, the medication [MEDICATION NAME] 25 mg was administered outside of the physician ordered parameters 15 times out of 75 opportunities by 6 nurses. [MEDICATION NAME] 10 mg was administered outside of the physician ordered parameters 45 times out of 75 opportunities by 7 nurses. On 07/25/19 at 01:49 PM, the surveyor interviewed the facility Pharmacy consultant (PC) who stated, I do drug regimen reviews and look at all the resident's medications. If I have concerns or recommendations, I would e-mail the facility with my findings. The PC informed the surveyor that any immediate concerns are brought to the attention of the facility's Administrator, DON, and Unit managers by the end of the day or emailed for follow-up. The pharmacy review recommendation sheets are presented to the physician for signature and then the recommendation sheets would go back into the resident's medical record. The PC further stated, that the MARs are reviewed monthly and any concerns identified are documented on the drug regimen review form. The PC when questioned about the aforementioned concerns stated, I don't know how I did not find the error with the resident's blood pressure medications being given out of the physician ordered parameters. According to the Drug Regimen Review dated 3/30/19, 4/30/19, 5/28/19, 6/28/19 and 7/22/19 there was no documentation from the Pharmacy Consultant that the resident was being administered blood pressure medications out of physician ordered B/P and HR parameters. On 7/29/19 at 11:06 AM, the surveyor interviewed the Administrator who stated that the facility takes this situation very seriously and that the PC took responsibility for not reviewing all the residents MAR's during the monthly medication review to assure that there were no issues. The Administerator stated that the facility notified the physician immediately of the medication error and the physician came in on 7/28/19, and examined Resident #41 and determined no harm was caused to resident. The administrator added, that the medical director was notified and will be part of the quality assurance plan regarding this medication error and that all licensed nurses received medication administration education and a medication pass competency. This deficiency is continued at a scope and severity of a Level D: Resident #62 2.) According to the AR, Resident # 62 was admitted to the facility with the medical [DIAGNOSES REDACTED]. The annual MDS dated [DATE], reflected that the resident had severe cognitive deficits and required total assistance with ADL's. The MDS also indicated that the resident received daily insulin injections. The surveyor reviewed the POS which revealed an order dated 11/21/18 for the medication [MEDICATION NAME] (insulin long acting) 6 units to be injected subcutaneously daily in the AM for the [DIAGNOSES REDACTED].#62. The MAR dated (MONTH) 2019 revealed that the medication [MEDICATION NAME] (insulin) was administered at times ranging from 9:19 to 12:16 PM. On 07/25/19 at 10:27 AM, the surveyor interviewed the LPN who stated that Resident #62 was a diabetic and had an order for [REDACTED]. In the presence of the surveyor, the LPN reviewed the MAR. There was an order dated 4/16/19 for the medication [MEDICATION NAME] 6 units to be administered subcutaneously one time a day. The hour slotted for the insulin to be administered was day on the MAR. There was no specific time slotted. The LPN admitted that she should have called the physician to get an exact time when the insulin was to be administered and should have clarified the order with the physician. The LPN added that she usually gave the [MEDICATION NAME] around 9 AM or 10:00 AM, but was observed giving the insulin today around 10:20 AM. On 07/25/19 at 10:35 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that the medication [MEDICATION NAME] (insulin) should have a time slotted on the MAR as to when it should be administered. The RN/UM stated she was not sure what time the insulin was being administered and would have to call the physician to get the time clarified. On 07/26/19 at 10:17 AM, the surveyor interviewed the Regional Director of Operations (RDO) and Administrator. Both stated, that there should have been specific times documented on the MAR as to when Resident #62 was to be administered insulin and that this was not the facility's normal practice. In addition the RDO and Administrator stated that the nurses should have been more diligent and should have called the physician to clarify the administration times for the insulin. On 07/25/19 at 01:49 PM, the surveyor interviewed the facility PC who stated, I do drug regimen reviews on all resident's medications monthly. If I have concerns or recommendations, I would email the facility my findings. The PC informed the surveyor that any immediate concerns are brought to the attention of the facility's Administrator, DON and Unit Managers by the end of the day and/or, emailed for follow-up. The pharmacy review recommendation forms are presented to the physician to sign, and after the physician signs them, the recommendation forms are returned to the resident's Medical Record. The PC when questioned about the aforementioned concerns stated, that she was unsure how she missed that there was no specific time for insulin plotted on the MAR for insulin administration. On 7/29/19 at 11:30 AM, the surveyor attempted to interview the attending physician for Resident #62, but the physician was unavailable. On 7/29/19 at 12:20 PM, the surveyor interviewed the Medical Director (MD) who stated, that the medication [MEDICATION NAME] was a long acting insulin and should have had a specific time delineated because the resident also received an additional dose of insulin at 9:00 PM. Additionally the MD stated, that if the medication was given too late in the morning, the morning dose could run into the evening dose and the resident could have experienced a hypoglycemic (low blood sugar) episode. The surveyor could not find documentation in the medical record that Resident #62 had issues with high or low blood sugar and/or that there was a negative outcome from insulin administration. The Drug Regimen Review dated 9/30/18, 10/30/18, 11/27/18, 12/30/18, 1/28/19, 2/24/19, 3/30/19, 4/30/19, 5/28/19, 6/28/19, and 7/22/19, identified that there was no documentation from the Pharmacy Consultant that noted there was not a specific time delineated to administer Resident #62's morning insulin. The facility policy titled, Pharmacy Services-Role of the Consultant Pharmacist with a revised date of (MONTH) 2007, indicated that the Consultant Pharmacist shall provide consultation on all aspects of pharmacy services in the facility, including (but not limited to): - Evaluating processes and receiving and interpreting prescribers' orders, acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responses to, and using and or disposing of all medications, biologicals, and chemicals. - Identifying pertinent resources and references about medications and their proper use and monitoring. -Helping the facility establish and implement effective quality assurance activities to identify, resolve, and prevent medication related problems. - Monthly reviews of the drug regimen of each skilled care resident, report and irregularities will be made to the nurse in charge and or the attending physician, and reports of significant irregularities or failure to correct irregularities will be made to the advisory physician and the facility administrator. N.[NAME][NAME]C 8:39-29.3
Inspection of March 19, 2014
2 findingsBased on observation, interview and record review, it was determined that the facility failed to thoroughly investigate a bruise of unknown origin to rule out abuse for 2 of 2 residents reviewed for injuries of unknown origin and potential abuse, Resident #3 and Resident #13. This resulted in an immediate jeopardy situation for Resident #3 and #13, as well as other confused, staff-dependent residents who remained in danger of being victims of abusive behavior from a staff member who might still be providing care, and/or resident to resident abusive behavior. This deficient practice was evidenced by the following: A. 1. On 03/12/14 at 12:30 p.m. the surveyor reviewed the medical record for Resident #3. The resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set (MDS), an assessment tool, of 10/08/13, the Interdisciplinary (IDC) team assessed Resident #3's cognitive level as being severely impaired. The resident displayed no behavioral symptoms. The IDC team further assessed the resident as requiring extensive assistance with activities of daily living. The surveyor reviewed nursing Progress Notes that revealed that on 10/30/13 the resident was found with a large black and blue discoloration on the mandible area (chin) measuring 7.5 cm by 4.5 cm. On 03/12/14 at 1 p.m. and 03/13/14 at 9 a.m., the surveyor requested the facility Investigative Report for the bruise noted on 10/30/13 from the Administrator and Director of Nursing (DON). On 03/13/14 at 9:30 a.m. in the presence of 3 surveyors, the Administrator stated that there was no Investigative Report for the bruise noted on 10/30/13. On 03/13/14 at 10 a.m., 2 surveyors spoke with the Administrator and DON. The surveyors discussed concerns regarding the incomplete investigation and the fact that the facility had no evidence to show that abuse had not occurred. The surveyors requested a written facility protocol outlining the process for the nurses to follow when they identified a bruise or injury of unknown origin. The Administrator said they did not have one. On 3/13/14 at 10 a.m., the Administrator provided the surveyor with the 24 hour report (Daily Eagle Room Report) dated 10/30/13. The nurse documented that Resident #3 was noted with a bruise on (his / her) right mandibular area and that information was documented in an Incident Report. The surveyor reviewed The Eagle Room Meeting Minutes dated 10/30/13 and noted that although seven staff members, including the Administrator and DON, attended the meeting and discussed the 24 hour report that documented the resident's bruise, no one initiated an investigation. The Administrator acknowledged that the information regarding this bruise of unknown origin was not complete and would be investigated further at this time. 2. On 3/11/14 at 9:20 a.m. during the initial tour of the facility in the presence of the Assistant Director of Nursing (ADON), the surveyor observed Resident #13 in his/her room in a Broda chair. The Certified Nursing Assistant (CNA) was with the resident. The ADON stated that the resident was confused, got out of bed daily to his/her Broda chair, and had a history of [REDACTED]. On 3/17/14 at 11:40 a.m. the surveyor observed the resident in the day room in a Broda chair with approximately 10 other residents. The resident was sitting forward on the front of the chair with his/her sneakers untied and at times appeared to be reaching for and grabbing the air. The surveyor did not observe a staff member in the area. The surveyor stayed in the area until she saw a nurse. The nurse stated that the residents should be supervised. On 3/17/14 at 10:10 a.m. the surveyor reviewed the resident ' s medical record. An Annual Minimum Data Set (MDS), an assessment tool, dated 2/26/14, included that Resident #13 had long and short term memory deficits; that his/her cognitive skills for daily decision making were severely impaired; that s/he had no behaviors; that s/he required extensive assistance of 2 persons for transfers and toilet use; and did not ambulate. At 10:15 a.m. the surveyor reviewed the progress notes which included the following: Progress Note - On 10/25/13 at 4:01 p.m. - "Noted Pt (patient) with swollen right shoulder. PMD (Primary Medical Doctor) notified, no new orders. MD will see Pt next week. Will continue to monitor." The surveyor did not find continued nursing assessments of the right shoulder in the Progress Notes that verified that the professional nurses "continued to monitor" the shoulder. On 3/18/14 at 1:30 p.m. the surveyor interviewed the DON and the Administrator to determine if the resident's right shoulder swelling as described in the progress note dated 10/25/13 was investigated. The DON stated he was not aware that the resident had been found with a swollen shoulder. The Administrator (ADM) stated that she was also unaware of the occurrence and would investigate further. The surveyor reviewed the Physician's Progress Notes. Although the physician documented on 11/5/13 at 3:45 p.m. that the resident's extremities were negative for [MEDICAL CONDITION], there was no documentation that the physician examined the resident's right shoulder to determine if the resident had difficulty with the shoulder. At 1:50 p.m. the surveyor reviewed the resident's care plan. The surveyor could not locate a care plan for the resident's right swollen shoulder. On 3/18/14 at 3:10 p.m. the survey team spoke with the ADM and DON about the resident's swollen shoulder. The team asked the Administrator and Director of Nursing how they ruled out potential abuse as the cause of the swelling. The facility had no investigative report for Resident #13's swollen shoulder. On 03/13/14 at 2:25 p.m. the surveyor spoke with the DON regarding the look back period when investigating injuries of unknown origin. The DON stated it should go back at least 3 days but could not explain why this was not done. The surveyor requested a written facility protocol indicating the look back period and the DON stated there was none. On 3/13/14 at 12 Noon the facility was notified of the Immediate Jeopardy. An acceptable Plan of Correction (POC) was submitted on 3/13/14 at 3:40 p.m. that removed the immediacy, as follows: " Investigation will be initiated immediately. Statements will be obtained and investigation summary will be completed. Any resident can be affected. Audit will be conducted to identify any resident who may have a bruise of unknown origin. Any residents identified will have investigation initiated immediately. The Administrative Director/ Designee will in-service staff on Abuse Prevention Guide. In-service will include the following: (A) Reporting requirements for all incidents (B) Immediate notification of alleged abuse and reporting (C) Eight steps to conduct an effective investigation: (1) Determine purpose (2) Choose investigator (3) Plan investigation (4) Review documents (5) Conduct interviews (6) Analyze findings (7) Complete investigation paperwork. (8) The staff will be educated now and annually for abuse prevention and reporting. The Administrative Director of Nursing Services/Designee will conduct daily audit of incident reports for completion of investigation for 3 months then if appropriate monthly for 3 months. Results of the audits conducted by the Director of Nurses/Designee will be forwarded monthly to the Quality Assessment and Assurance Committee for review and action as appropriate. The Quality Assessment and Assurance Committee will determine the need for further action. " On 3/17/14 at 3:30p.m., the facility added the following to the POC: " Addendum to Prevent Guide/Abuse Prevention for alleged abuse or incidents of unknown origin: The facility will expand and evaluate frequency to determine look back period depending on the situation identified. The look back period will be 3 days prior to the situation and may go back further up to 2 weeks or longer as the situation requires. During the look back period all staff who cared for the resident in the past 3 days or longer, if applicable, will be interviewed. " The facility amended the Plan of Correction on 03/17/14 at 3:30 p.m. which included actions implemented by the facility. The surveyors conducted random interviews across all departments, including a Director of Care Delivery, 2 Nurse Supervisors from the night shift and 2 nurses from the day shift, 4 Certified Nursing Assistants (CNAs) from the night shift, 3 CNAs from the day shift , a dietary aide, a housekeeper, and an activity assistant in order to verify that inservices were given, attended and understood. This deficiency continues at a scope and severity of D based on the evidence as follows: B. Based on observation, interview and record review, it was determined that the facility failed to determine the cause of bruising for 1 of 8 residents, Resident #13, reviewed for investigations of injuries of unknown origin and was evidenced by the following: On 3/17/14 at 10:10 a.m. the surveyor reviewed Resident #13' s medical record. An Annual Minimum Data Set (MDS), an assessment tool, dated 2/26/14, included that Resident #13 had long and short term memory deficits; that his/her cognitive skills for daily decision making were severely impaired; that s/he had no behaviors; that s/he required extensive assistance of 2 persons for transfers and toilet use; and did not ambulate. Progress Note - 12/6/13 - CNA found resident with a bruise on the upper left eyelid. At 12:45 p.m. on 3/18/14, the surveyor reviewed an Investigation Report for the bruise on the resident's left upper eyelid reported by the CNA on 12/6/13. Information documented by the Licensed Practical Nurse (LPN) in the Incident Report was that a CNA noticed that the resident had a bruise on the upper left eye lid when administering morning care. The LPN also documented that the bruise looked a little darker. There was no measurement of the bruised area documented. The only statement provided was from the CNA who reported the bruise. There were no other staff interviews conducted by the facility to determine how the bruise may have occurred and/or to rule out potential abuse . The LPN who completed the investigation concluded that the resident had a habit of rubbing his/her eyes. The Director of Nursing/ Registered Nurse (DON/RN) completed the investigation and concluded that the bruise on the resident's inner canthus of the left eye lid was localized and that the bruise would be much bigger if s/he was hit or if s/he bumped into something. There was no measurement of the bruise documented. There was no signature on the Investigation Report. The surveyor reviewed the progress notes and could not find any entries that a professional nurse assessed the bruise, measured the bruise or attempted to determine the cause of the bruise at the time it occurred. On 3/18/14 at 3:10 p.m. the survey team spoke with the Administrator and Director of Nursing and requested any additional documentation available. On 3/19/14 at 11:15 a.m. the DON and Administrator said that they did not have any further information. NJAC 8:39-4.1(a)5;27.1(a)(b)
Based on observation, interview and record review, it was determined that the facility failed to put a plan in place when a resident, Resident #18, verbally expressed a wish to kill themself. The facility failed to address the mental and psychosocial needs of 1 of 1 resident reviewed for provision of care and services related to psychosocial needs. This resulted in an immediate jeopardy situation for Resident #18 who expressed thoughts of suicidal ideation by stating he / she wanted to harm self. In addition, the facility failed to ensure that all staff were aware and that a policy was in place, about a resident who expressed suicidal thoughts or behaviors. This deficient practice was evidenced by the following: On 03/17/14 at 1:45 p.m. the surveyor reviewed the medical record for Resident #18. The resident was originally admitted to the facility on [DATE], discharged , and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/07/13 the Interdisciplinary (IDC) team assessed Resident #18's cognitive level as moderately impaired utilizing a Quarterly Minimum Data Set (MDS), an assessment tool. The Progress Note dated 10/07/13 at 5 p.m. revealed that the resident had an altercation with his roommate. Resident #18 was moved to another room. A psychiatric consultation was ordered on [DATE] and done on 10/10/13. The Psychiatric Evaluation form indicated a plan to start the resident on [MEDICATION NAME] 15 mg at bedtime for mood and anxiety. The Primary Medical Doctor (PMD) was notified and ordered the medication. The Progress Note dated 10/11/13 at 9 p.m. written by the nurse revealed that the resident was found on the floor in front of the bathroom door in her/his room. The nurse noted that the resident's right upper eyebrow was swollen and ice was applied. The PMD was made aware and neurological checks were ordered. The family was also made aware. The surveyor reviewed a Progress Note dated 10/13/13 at 6:41 a.m. written by the nurse that indicated "resident stated he wants to kill (him / her) self by throwing (him / her) self on the floor. That's why (he / she) fell recently. " The nurse also wrote "close monitoring " and "will endorse to next shift." The nurse failed to document the frequency of observation. The next entry in the Progress Note made by the nurse was at 11:34 a.m. The Progress Notes contained no entries regarding the resident's statement about wanting to harm self. The surveyor was not able to find any documentation that the PMD, Administrator, Social Worker (SW), Director of Nursing (DON) or family member was notified of the resident's suicidal ideation. On 03/17/14 at 2:15 p.m. the surveyor spoke with the SW regarding the facility protocol to follow when a resident expressed thoughts of taking her/his life. The SW stated that the psychiatrist would be called immediately, the resident would be kept under constant watch and the family would be notified. The SW stated he had no knowledge of the statement made by Resident #18. The surveyor requested a copy of the facility protocol for Suicidal Thoughts or Attempts. The SW was unable to provide one. On 03/17/14 at 3:10 p.m. the surveyor spoke with the Administrator and a corporate Quality Assurance Manager (QAM) regarding the facility protocol to follow when a resident expressed thoughts of taking her/his life. The Administrator and QAM stated that all dangerous items in the resident's room would be removed, the PMD and the family would be notified, and the staff would continue to monitor the resident frequently. On 03/18/14 at 8:30 a.m. the surveyor spoke with the facility Medical Director (MD) regarding the facility protocol to follow when a resident expressed thoughts of taking her/his life. The MD stated that the psychiatrist should be notified immediately. On 03/18/14 at 9:30 a.m. the surveyor requested a copy of the facility protocol for suicidal thoughts or attempts from the Administrator and DON. The Administrator and DON were unable to provide one. On 03/18/14 at 10 a.m. the surveyor requested a copy of the facility 24 hour report (Daily Interdisciplinary Eagle Room Report) and sign in sheet for the daily clinical meeting for 10/13/13 from the Administrator. The 24 hour report indicated that Resident #18's statement to harm self was included on the report. The surveyor reviewed The Eagle Room Meeting Minutes dated 10/14/13 and noted that although seven staff members, including the DON, attended the meeting that discussed the 24 hour report documenting the residents suicidal statement. No one initiated notification of the physician and family and the schedule for monitoring Resident #18 was not established. The immediate jeopardy was identified on 03/18/14 at 12:45 p.m. An acceptable Plan of Correction (POC) was submitted on 3/18/14 at 3:30 p.m. that removed the immediacy, as follows: "Resident #18 is no longer in the facility. Any resident can be affected. Audit will be conducted to identify any resident as of today 3/18/14 who may have verbalized [MEDICAL CONDITION]. Any residents identified will have investigation initiated immediately. The Administrator, Attending Physician and family will be notified immediately and plan put in place. The Administrative Director/Designee will re-inservice Licensed Nursing staff on notification of the Administrator, Physician, and family immediately, when any trigger event occurs, to include [MEDICAL CONDITION]. Education initiated on 3/18/14 with Licensed Nursing staff for 100% compliance, for those on duty and prior to beginning their assignment today. Education will continue on 3/18/14 with remainder of Licensed Staff, CNAs, and Ancillary staff for 100% compliance. The Administrative Director of Nursing Services/Designee will conduct a daily audit of Progress Note Documentation Summary Report, with IDCP team discussion and follow up actions as required. This will be done daily for 3 months. Results of the daily audit conducted by the Administrative Director of Nurses/Designee will be forwarded monthly to the Quality Assessment and Assurance Committee for review and actions, as appropriate. This will be done monthly for 3 months. The Quality Assessment and Assurance Committee will determine the need for further action. " On 3/19/14 at 11:30 a.m., the facility added the following to the POC: " Addendum to Trigger Event Notification Process: 1. Staff, who identified any triggered event, will notify the Administrator immediately. 2. The Administrative Director of Nurses will be notified immediately, if applicable. 3. Licensed Nurse will notify the Attending Physician, and family immediately when any trigger events occurs. 4. The Investigation process will be initiated immediately with any triggered event. " On 3/18/14 at 11:30 a.m. the facility amended the plan of correction that incorporated all facility action. The surveyors conducted random interviews across all departments, including a Director of Care Delivery, 2 Nurse Supervisors from the night shift and 2 nurses from the day shift, 4 Certified Nursing Assistants (CNAs) from the night shift, 3 CNAs from the day shift, a dietary aide, a housekeeper, and an activity assistant in order to verify that inservices were given, attended and understood. NJAC8:39-27.1(a)
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