Every finding on record at The Subacute at Autumn Lake Healthcare

Based on observations, interviews, record review, and review of facility policy, it was determined that the facility failed to ensure that 1 of 4 residents (Resident #122) observed during the medication administration observation were given their medication. Specifically, Resident #122 did not have their medication Sevelamer HCl (phosphate binding medication) available for administration in the medication cart and was given another unidentified resident's home medication of Sevelamer HCl.This deficient practice was identified by the following: On 3/18/2026 at 9:04 AM, during medication pass observation on the third floor nursing unit, the surveyor observed a Licensed Practical Nurse (LPN #2) administer medications for Resident #122. The LPN was unable to locate Resident #122's medication, Sevelamer HCl (phosphate binding medication) Oral Tablet 800 MG (Sevelamer HCl) give 2 tablets by mouth three times a day and take with meals. The LPN stated that the medication should have been available in the medication cart, however she could not locate it. She explained that she could not obtain the medication from the back up medication dispensing machine because that medication was not stocked there. The LPN referred the issue to the Licensed Practical Nurse Unit Manager (LPN/UM).A review of the admission Record (an admission summary) indicated that Resident #122 was admitted to the facility with the diagnoses which included but were not limited to; polyneuropathy (a general degeneration of the peripheral nerves) and end stage renal (kidney) failure.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool that facilitates a resident's care, dated 3/6/26, indicated that Resident #122 scored a 14 out of 15 on the Basic Interview for Mental Status (BIMS), which indicated that the resident was cognitively intact. Further review of the MDS also indicated that the resident required supervision with activities of daily living and was on hemodialysis (a life-saving treatment for kidney failure to filter wastes and excess fluid from the blood).A review of Resident #122's Medication Administration Record (MAR) indicated that the resident was admitted to the facility on [DATE]. The surveyor observed nursing signatures on the MAR which indicated that some nurses documented that they administered the medication, some were documenting that the resident refused the medication, and some nurses were documenting that the medication was not available. A Review of Resident #122's physician orders (PO) reflected the following orders:-PO dated 3/6/26 for the medication Sevelamer HCl Oral Tablet 800 MG (Sevelamer HCl) give two tablets by mouth three times a day for take with meals.-PO dated 3/6/26 for Sevelamer HCl Oral Tablet 800 MG (Sevelamer HCl) give 2 tablets by mouth three times a day for take with meals and discontinued 3/14/2026. -PO dated 3/14/26 for Sevelamer HCl Oral Tablet 800 MG (Sevelamer HCl) give 2 tablets by mouth three times a day every Monday, Wednesday, Friday. Take with meals. Discontinued on 3/18/2026.-PO dated 3/14/26 for Sevelamer HCl Oral Tablet 800 MG (Sevelamer HCl) Give 2 tablet by mouth three times a day every Tuesday, Thursday, Saturday, and Sunday. Take with meals. Discontinued on 3/18/2026. -PO dated 3/18/26 for Sevelamer HCl Oral Tablet 800 MG (Sevelamer HCl) give 2 tablets by mouth three times a day every Tuesday, Thursday, Saturday, Sunday for supplement take with meals. On 3/18/2026 at 9:37 AM, the surveyor interviewed the third floor LPN/UM who stated that Resident #122 was a dialysis patient who was admitted to the facility a couple of weeks ago. The LPN/UM explained the process the facility followed when medications were ordered. She explained that when medications were ordered on admission the physicians confirmed the medications orders, the medications were then entered into electronic medical records (EMR) and once confirmed, the medication orders were considered active and then the pharmacy delivered the medications. She stated that the medication Sevelamer was ordered for Resident #122 on the 3/6/26, and that the resident should still have a supply of the medication Sevelamer in the medication cart. The LPN/UM reviewed the MAR with the surveyor and she stated that she was not sure how some nurses were documenting that they administered the medication, some nurses documented that the medication was not available, and some nurses documented that the resident refused the medication. She stated that the medication Sevelamer was not available in the electronic back up medication machine and was not a stock medication. She revealed that the nurses who documented on the MAR that the medication was not available should have documented in the progress notes (PN) what they did about the unavailable medication or should have notified a supervisor. She added that if a resident was not receiving scheduled medication as ordered, they could have adverse effects. She stated that sometimes the dialysis center would supply the Sevelamer and sometimes the facility provided it. She then added that if the resident's medication was to be provided by the dialysis center, then someone should have called them to let them know that the medication was not there and then someone should have notified the supervisor so that they could have investigated where the medication was.The surveyor reviewed the PN with the LPN/UM who confirmed that there were no PN documented when the resident refused their scheduled dose of Sevelamer and that there was no documentation to indicate what the nurses did when they identified that the medication was not available.On 3/19/2026 at 9:39 AM, the surveyor interviewed Resident #122 who was alert and oriented. The resident stated that they only took the medication, Sevelamer, about three times since admission to the facility. The resident stated that they refused the medication the rest of the time because the nephrologist told him/her that they did not need to take the medication as their phosphorus levels were within normal range. The resident stated that the facility continued to offer him/her the medication because they told him/her they had not received any orders to stop the medication. The resident stated that the nurse was in this morning with the medication and offered it to him/her, however he/she refused it. The resident further added that during their stay, some nurses would sometimes bring in one pill and sometimes they would bring in three pills of the Sevelamer. The resident stated, When I questioned the nurse, they would tell me this is what was ordered. Considering I have all my faculties I knew it was not the right dosage, so I would refuse to take the medications.On 3/19/2026 at 11:14 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she investigated the reason Resident #122 did not have the medication Sevelamer in the medication cart to be administered on 3/18/26 during the medication pass observation. The DON stated that the delivery did not occur when the resident was first ordered the medication and based on her investigation staff were administering Resident #122's, another resident's home supply of medication that was discharged from the facility. She stated that the medication was from a bottle that the other resident had brought from home. She stated that she was not sure whose medication it was because the name was blacked out on the bottle with marker. The DON confirmed delivery of the Sevelamer on 3/18/26 from the pharmacy. She also confirmed that the medication was not delivered from the pharmacy or dialysis when ordered on admission. She stated that the facility performed laboratory work to ensure that there were no concerns with Resident #122s phosphorous levels. She stated that labs were done immediately and were within normal range. The surveyor reviewed those labs, and they were in fact within normal range. She stated that there was no harm to Resident #122. The DON provided the surveyor with the bottle of medication and stated that the facility pharmacy consultant (PC) identified the medication that was in the bottle to be Sevelamer 800 mg tablets.On 3/19/2026 at 12:04 PM, the surveyor telephoned the facility pharmacy consultant (PC) who confirmed that she came to the facility on 3/18/26 and inspected the medication cart of the third floor and found a bottle of Sevelamer 800mg with the resident's name blacked out on the bottle. The PC further explained to the surveyor that she talked to the nurse who was assigned to the medication cart who stated that she had not used the medication. The PC could not provide the surveyor with the nurse's name because she could not remember it. She stated that when she conducted medication review for the residents, she reviewed the orders and the MAR. The PC stated that she reviewed Resident #122's medications on 3/8/26, because the resident was a new admission and she had seen that there was a 3 coded on the MAR. She stated that the code indicated that the resident was out of the facility. The PC stated at that time, my recommendation included changing the time of the medications to accommodate for dialysis days and times. The PC further stated that if the nurses were administering another resident's medication to Resident #122, there was a federal law that indicated that you cannot share medications that were not prescribed to you. She stated that the law protected people from taking other people's medications that were not prescribed to them. She continued to add that even though the nurse should not have been giving Resident #122 another resident's medication, at least it was the right medication and the right dose.On 3/19/2026 at 1:24 PM, the surveyor interviewed LPN #15 who admitted resident #122 to the facility. The LPN stated that she put medication orders in the system (EMR) and then the medications would be delivered. She stated that she was not sure why the medication was not delivered from the pharmacy and was not sure if dialysis provided the medication or the pharmacy provided the medication.On 3/19/2026 at 1:46 PM, the surveyor telephone interviewed the Pharmacist from the facility pharmacy who stated that for residents who were on dialysis and had insurance, insurance would not pay for the medication through the facility pharmacy. She further explained that the dialysis center provided the medication and that insurance would cover the medications when it was obtained through the dialysis center. She stated that the only reason why the facility pharmacy sent the medication Sevelamer on 3/18/26 was because the facility agreed to pay for the medication. On 3/23/2026 at 8:53 AM, the surveyor interviewed a Registered Nurse (RN) from the resident's dialysis center, and she explained that the residents' medications were bundled in Medicare part B and then the medication would be mailed to the facility. She stated that the nephrologist and the dietician were responsible for ordering the Sevelamer for the resident. She stated that she was not sure why the medication was not delivered to the resident and stated that the surveyor would need to speak to the clinical director of the dialysis center. On 3/23/2026 at 9:07 AM, the surveyor telephone interviewed LPN #8 who documented on the MAR on 3/7/26 at 2000 hours (8:00 PM) that she had administered Sevelamer 800 mg two tablets to Resident #122. The LPN stated that if the medication was not available, she would have borrowed it from another resident. She stated that this medication usually came in from the family, however, she did not notify the family that the resident did not have the medication. She also confirmed that she did not notify the pharmacy or the nursing supervisor that the medication was not available. She stated that when she realized that the medication was not available in the medication cart, she went to another unit to borrow another resident's medication. She stated that she was not educated regarding borrowing medications from other residents. On 3/23/2026 at 10:24 AM, the DON provided the surveyor with the following nurse statements: A review of an untimed written statement from LPN # 4 dated 3/18/26, indicated that she administered Resident #122 the medication off the medication cart but she did not remember if it was given from a home supply or a bingo card (a card with medications sealed beneath blister packaging). A review of the untimed written statement from LPN #5 dated 3/18/26, indicated that she administered Resident #122 the medication off the medication cart but did not remember if it was given from a home supply or a bingo card. A review of the untimed written statement from LPN #6 dated 3/18/26, indicated that she administered Resident #122 Sevelamer 800mg out of a bottle that was in the medication cart. She indicated that the PC was in and removed all expired medications, discharged medications and a bottle of Sevelamer out of the cart because the name on the medication was blacked out. She stated that she was assigned to that medication cart on 3/17/26 on the 7:00 AM to 3:00 PM shift. A review of the untimed written statement from LPN #8 dated 3/18/26, indicated that she administered Resident #122 Sevelamer from a home supply that was in the medication cart.A review of the untimed written statement from LPN #9 dated 3/18/26, indicated that Resident #122 refused the medication and the refusal was documented. A review of the untimed written statement from LPN #10 dated 3/18/26, indicated that she administered Resident #122 Sevelamer from a home supply that was in the medication cart. A review of the untimed written statement from LPN #11 dated 3/18/26, indicated that she administered Resident #122 Sevelamer from a home supply that was in the medication cart. A review of the untimed written statement from LPN #12 dated 3/18/26, indicated that on 3/10/26 and 3/12/26 she administered Resident #122 Sevelamer 800mg the morning and noon doses out of a home supply of Sevelamer 800 mg.A review of the untimed written statement from LPN #13 dated 3/18/26, indicated that she administered Resident #122 Sevelamer from a home supply that was in the medication cart.On 3/23/2026 at 10:57 AM, the surveyor conducted a telephone interview with the dialysis Clinical Coordinator (CC) who stated that the resident's medication was ordered by the dialysis center from a pharmacy in Florida. The CC stated that it took a couple weeks for the medication to be mailed. The CC could not provide any additional information as to who was responsible for ensuring that the resident had the medication while a resident in the facility.On 3/23/2026 at 11:01 AM, the surveyor conducted a telephone interview with the dialysis center's Dietician who could not provide information regarding who was responsible to ensure that the resident received a medication that was ordered though the dialysis center.On 3/23/2026 at 11:10 AM, the surveyor conducted a telephone interview with the facility's Medical Director who stated he would have to call the dialysis center to find out where the medication was or how to get the medication. He stated that there should have been better communication between the facility and the dialysis center to assure that the medication was available for the resident.On 3/23/2026 at 11:25 AM, the surveyor interviewed the resident's primary care physician who stated that the Medical Director and the DON should have policies regarding medications that came from the dialysis center. She stated that she could not recall being notified by the facility staff that the resident did not have the medication Sevelamer in the facility. She stated that it should have been communicated to the DON and administration by the nurses so that the issue could have been resolved. On 3/24/2026 at 9:50 AM, the surveyor interviewed the DON who explained that during her investigation into why Resident #122's medication was not available, the dialysis center did not order the resident's medication, however the nursing staff upon recognizing that the medication was not available, should have followed the medication procurement policy and notified the physician, contacted the pharmacy, supervisor, DON and/or Medical Director. A review of the facility undated policy titled, Abuse, Neglect and Exploitation indicated that misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings, money without the resident's consent.NJAC 8:39-4.1(a)5

Complaint # 2699716, #398990 Based on observation, interview, and review of medical records it was determined that the facility failed to establish a system to ensure that residents on dialysis received their medications according to physician orders. This deficient practice was identified during the medication pass administration observation for 1 or 4 residents (Resident #122), observed and was evidenced by the following:On 3/18/2026 at 9:04 AM, during medication pass observation on the third floor, the surveyor observed a Licensed Practical Nurse (LPN) administer medications for Resident #122. The LPN was unable to locate Resident #122's medication, Sevelamer HCl (phosphate binding medication) Oral Tablet 800 MG (Sevelamer HCl) give 2 tablets by mouth three times a day for take with meal. The LPN stated that the medication should be available in the medication cart, however she could not locate it. She explained that she could not obtain the medication in the back up medication dispensing machine because that medication was not stocked there. The LPN referred the issue to the Licensed Practical Nurse Unit Manager (LPN/UM).A review of the admission Record (admission summary) indicated that Resident #122 was admitted to the facility with the diagnoses which included but were not limited to polyneuropathy (a disease that affects the peripheral nerves) and end stage renal (kidney) failure.A review of the comprehensive Minimum Data Set (MDS), (an assessment that facilitates a resident's care) dated 3/6/26, indicated that Resident #122 scored 14 out of 15 on the Basic Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Further review of the MDS indicated that the resident required supervision with activities of daily living and was on hemodialysis (life-sustaining treatment for kidney failure). A review of Resident #122's Medication Administration Record (MAR) indicated that the resident was admitted to the facility on [DATE]. The surveyor observed nursing signatures on the MAR that indicated some nurses documented that they administered the medication, some were documenting that the resident refused the medication, and some nurses were documenting that the medication was not available. A review of Resident #122's physician orders (PO) reflected the following orders:-PO dated 3/6/26 for the medication Sevelamer HCl Oral Tablet 800 MG (Sevelamer HCl) give two tablets by mouth three times a day for take with meals.-PO dated 3/6/26 for Sevelamer HCl Oral Tablet 800 MG (Sevelamer HCl) give 2 tablets by mouth three times a day for take with meals and discontinued 3/14/2026. -PO dated 3/14/26 for Sevelamer HCl Oral Tablet 800 MG (Sevelamer HCl) give 2 tablets by mouth three times a day every Monday, Wednesday, Friday. Take with meals. Discontinued on 3/18/2026.-PO dated 3/14/26 for Sevelamer HCl Oral Tablet 800 MG (Sevelamer HCl) Give 2 tablet by mouth three times a day every Tuesday, Thursday, Saturday, and Sunday. Take with meals. Discontinued on 3/18/2026. -PO dated 3/18/26 for Sevelamer HCl Oral Tablet 800 MG (Sevelamer HCl) give 2 tablets by mouth three times a day every Tuesday, Thursday, Saturday, Sunday for supplement take with meals.On 3/18/2026 at 9:37 AM, the surveyor interviewed the LPN/UM for the third floor who stated that Resident #122 was a dialysis patient who was admitted to the facility a couple of weeks ago. The LPN/UM explained the process the facility followed when medications were ordered. She explained that when medications were ordered on admission the physicians confirmed the medications orders, medications were then entered into electronic medical records (EMR) and once confirmed, the medications were considered active and then the pharmacy delivered the medications. She stated that the medication Sevelamer was ordered for Resident #122 on the 3/6/26, and the resident should still have a supply of the medication Sevelamer in the medication cart. The LPN/UM reviewed the MAR with the surveyor the LPN/UM stated that she was not sure how some nurses were documenting that they administered the medication, some nurses documented that the medication was not available, and some nurses documented that the resident refused the medication. She stated that the medication Sevelamer was not available in the electronic back up medication machine and was not a stock medication. She revealed that the nurses who documented on the MAR that the medication was not available should have documented in the progress notes what they did about the unavailable medication or should have notified a supervisor. She added that if a resident was not receiving the scheduled medication as ordered, they could have an adverse effect. She stated that sometimes the dialysis center would supply the Sevelamer and sometimes the facility provided it. She then added that if the resident's medication was to be provided by the dialysis center, then someone should have called them to let them know that the medication was not there and then someone should have notified the supervisor so that they could have investigated where the medication was.The surveyor reviewed the progress notes (PN) with the LPN/UM who confirmed that there were no PN documented when the resident refused and that there was no documentation to indicate what the nurses did when they identified that the medication was not available.On 3/19/2026 at 9:39 AM, the surveyor interviewed Resident #122 who was alert and oriented. The resident stated that they only took the medication Sevelamer about three times since admission to the facility. Resident #122 stated that they refused the medication the rest of the time. He explained that the nephrologist (kidney doctor) told him/her that he/she did not need to take the medication as their phosphorus levels were within normal range. The resident stated that the facility continued to offer him/her the medication because they told him/her they had not received any orders to stop the medication. The resident stated that the nurse was in this morning with the medication and offered it to him/her, however they refused it. The resident further added that during the resident's stay, some nurses would sometimes bring in one pill and sometimes they would bring in three pills of the Sevelamer. The resident further stated, When I questioned the nurse, they would tell me this is what was ordered. Considering I have all my faculties, I knew it was not the right dosage so I would refuse to take the medications. On 3/19/2026 at 11:14 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she investigated the reason Resident #122 did not have the medication Sevelamer in the medication cart to be administered on 3/18/26 during the medication pass observation. The DON stated that the delivery did not occur when the resident was first ordered the medication. She confirmed delivery of the Sevelamer on 3/18/26 from the pharmacy after surveyor inquiry. The DON also confirmed that the medication was not delivered from the pharmacy or dialysis when ordered on admission. She stated that the facility performed laboratory work to ensure that there were no concerns with Resident #122s phosphorous laboratory levels. She stated that labs were done immediately and were within normal range. The surveyor reviewed those labs, and they were in fact within normal range. She stated that there was no harm to Resident #122. On 3/19/2026 at 12:04 PM, the surveyor telephoned the facility pharmacy consultant (PC) who confirmed that she came to the facility on 3/18/26 and inspected the medication cart on the third floor and found a bottle of Sevelamer 800mg with the name blacked out on the bottle. The PC interviewed explained to the surveyor that she talked to the nurse on the cart who stated that she hadn't used the medication. The PC could not provide the surveyor with the nurse's name because she could not remember it. She stated that when she conducted medication reviews for the residents, she reviewed the orders and the MAR. The PC stated that she reviewed Resident #122's medications on 3/8/26 because the resident was a new admission and she had seen that there was a 3 coded on the MAR. She stated that the code indicated that the resident was out of the facility. The PC stated at that time, my recommendation included changing the time of the medications to accommodate for dialysis days and times. The PC further stated that if the nurses were administering another resident's medication to Resident #122, it was a federal law that indicated that you cannot share medications that were not prescribed to you. She stated that the law protected people from taking other people's medications that were not prescribed to them. She continued to add that even though the nurse should not have been giving Resident #122 another resident's medication, at least it was the right medication and the right dose.On 3/19/2026 at 1:24 PM, the surveyor interviewed the LPN that admitted resident #122 to the facility. The LPN stated that she put medication orders in the system (EMR) and then the medications would be delivered. She stated that she was not sure why the medication was not delivered from the pharmacy and was not sure that dialysis provided the medication or the pharmacy provided the medication. On 3/19/2026 at 1:46 PM, the surveyor conducted a telephone interview with the Pharmacist from the facility pharmacy who stated that residents who were on dialysis and had insurance, insurance would not pay for the medication through the facility pharmacy. She further explained that the dialysis center provided the medication and that insurance would cover the medications when they were obtained through the dialysis center. She stated that the only reason why the facility pharmacy sent the medication Sevelamer on 3/18/26 was because the facility agreed to pay for the medication. On 3/23/2026 at 8:53 AM, the surveyor interviewed a Registered Nurse (RN) from the resident's dialysis center, and she explained that the residents' medications were bundled in Medicare part B and then the medication would be mailed to the facility. She stated that the nephrologist and the dietician would be responsible for ordering the Sevelamer for the resident. She stated that she was not sure why the medication was not delivered to the resident and further stated that the surveyor would need to speak to the clinical director of the dialysis center.On 3/23/2026 at 10:57 AM, the surveyor conducted a telephone interview with the dialysis Clinical Coordinator (CC) who stated that the resident's medication was ordered by the dialysis center from a pharmacy in Florida. The CC stated that it took a couple weeks for the medication to be mailed. The CC could not provide any additional information as to who was responsible for ensuring that the resident had the medication while a resident in the facility.On 3/23/2026 at 11:01 AM, the surveyor conducted a telephone interview with the dialysis center's Dietician who could not provide information regarding who was responsible to ensure that the resident received a medication that was ordered though the dialysis center.On 3/23/2026 at 11:10 AM, the surveyor conducted a telephone interview with the facility Medical Director (MD) who stated he would have to call the dialysis center to find out where the medication was or how to get the medication. He stated that there should have been better communication between the facility and the dialysis center to assure that the medication was available for the resident. On 3/23/2026 at 11:25 AM, the surveyor interviewed the resident's primary care physician who stated that the Medical Director and the DON should have policies regarding medications coming from the dialysis center. She stated that she could not recall being notified by the facility staff that the resident did not have the medication Sevelamer in the facility. She stated that it should have been communicated to the DON and administration by the nurses so that the issue could have been resolved. On 3/24/2026 at 9:50 AM, the surveyor interviewed the DON who explained that during her investigation into why Resident #122's medication was not available, the dialysis center did not order the resident's medication, however, the nursing staff upon recognizing that the medication was not available, should have followed the medication procurement policy and notified the physician, contacted the pharmacy, supervisor, DON and/or Medical Director. A review of the facility policy dated 1/2025 and titled, Medication Procurement Policy indicated that the facility was committed to ensuring that all residents receive their prescribed medications as ordered by their physician. Medications must be available in the facility when needed and alternate physician-approved medications must be provided if the medication ordered was unavailable. To ensure that all physician-ordered medications are received, available, and administered to residents in a timely, safe and accurate manner and to prevent delays that could result in unmanaged pain or other adverse outcomes. This policy applies to all licensed nursing staff, nursing supervisors, pharmacy personnel, and any other staff involved in ordering, receipt, and administration of medications.NJAC 8:39-29.2

Based on observation, interviews, record review and review of facility provided documents, it was determined that the facility failed to obtain a physician's order (PO) for a left leg immobilization device for 1 of 1 resident (Resident #9) reviewed for supportive devices. 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 3/17/26 at 11:21 AM, during the initial tour of the facility, the surveyor observed Resident #9 sitting in a wheelchair with a hinged brace (a supportive medical device using rigid bars on the sides of the leg connected by a mechanical hinge mechanism to control the knee's range of motion and prevent side-to-side instability) on their left leg, that was visible over top of their pants. On 3/18/26 at 10:02 AM, the surveyor observed Resident #9 sitting in their room with a hinged brace on their left leg, over top of their pants. Resident #9 stated they fell a few months ago and fractured their bone just below the knee, but did not have surgery to repair the broken bone. The resident stated a black knee immobilizer (a padded wrap made of foam or cloth with vertical supports extending from the mid-thigh to mid-calf) was put on their left leg which they wore all day and night. Resident #9 stated they had to pull their pants up over top of the immobilizer because the immobilizer could not be removed. The resident stated in mid-January (2026) they went to a follow up doctor's appointment where the immobilizer was removed and a hinged brace was placed, with the hinges locked straight for almost 60 days. Resident #9 stated the hinged brace was taken off when they went to bed and put back on every morning, to be worn when they stood or walked. Resident #9 added the hinged brace was put on overtop of their pants, which was much easier than pulling their pants up over the old immobilizer. Resident #9 stated in early March (2026) they went to another follow up doctor's appointment. At that appointment, the hinges were opened. The resident stated they were allowed to gradually bend their knee, and now I can bend it all I want, straightening and bending their left leg to demonstrate to the surveyor. At this point, the surveyor observed Resident #9 pull on the hinged brace by the 2nd strap from the top, on their thigh. Resident #9 stated they were lifting the strap off of their leg for comfort and added they were adjusting the position because it's important the hinges align with the top of my knee. Depending on what I'm wearing it slides down sometimes. On 3/18/26 at 11:09 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who was assigned to Resident #9. LPN #1 stated Resident #9 wore a left knee immobilizer with settings on it. LPN #1 stated there should be a PO for when to put it on, and where to put it. LPN #1, together with the surveyor, reviewed Resident #9's PO's in the electronic medical record (EMR). LPN #1 acknowledged she was not able to locate a PO for the resident to wear the knee immobilization device.On 3/18/25 at 11:25 AM, the surveyor interviewed LPN/UM #1 who stated Resident #9 was at the facility after a fall with fracture and wore a knee immobilizer. LPN/UM #1 stated her expectation was that the nurses followed the residents' care plans and orders. She stated Resident #9 should have an order for their device to make sure it was placed in the right location, and at the right settings. LPN/UM #1, together with the surveyor, reviewed the EMR for Resident #9. LPN/UM #1 acknowledged there was not a PO for the placement of the knee immobilization device. On 3/18/26 at 12:03 PM, the surveyor interviewed the Registered Nurse/Assistant Director of Nursing (RN/ADON) who stated residents with immobilization devices should have physician orders including proper placement and fit. The RN/ADON stated it's the default that a brace stays on at all times unless the PO says otherwise. The RN/ADON, together with the surveyor, reviewed the EMR for Resident #9. The RN/ADON acknowledged there was not a PO for the resident to wear the knee immobilization device. The surveyor reviewed the EMR for Resident #9. A review of the admission Record (an admission summary) reflected diagnoses which included but were not limited to; unspecified fracture of upper end of left tibia, initial encounter for closed fracture.A review of the most recent comprehensive Minimum Data Set (MDS, a standardized assessment tool) dated 1/4/26, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of the individualized comprehensive care plan (ICCP) with last reviewed date of 1/14/26 reflected focus areas including but not limited to; a risk for falls related to limited mobility, NWB (non-weigh bearing) LLE (left lower extremity), history of falls; and a self-care performance deficit in activities of daily living related to limited mobility, deconditioning, and ambulatory dysfunction. A review of the downloaded documents in the resident's EMR included a letter from [doctor's office name redacted] dated 3/4/26 which reflected Resident #9 was seen in their office on 3/4/26.WBAT (weight bearing as tolerated) LLE with hinged brace unlocked, only needs brace for walking.A review of the progress notes included a general nurses note dated 3/4/26 which reflected the resident had returned from [doctor's office name redacted].orders received WBAT LLE with brace unlocked, only needs brace when walking.A review of the Order Summary Report (OSR) which included order status: active, completed, and discontinued reflected a PO for WBAT LLE dated 3/9/26, but did not reflect a PO for the placement or use of the knee immobilization device. A review of the facility provided policy Physician Orders updated April 2024, reflected. Medications, diets, therapy, or any other treatment may not be administered to the residents without the written approval from the attending physician. A review of the undated facility provided policy Consulting Physician/Practitioner Orders reflected, policy explanation and compliance guidelines including but not limited to:Consulting physician/practitioner orders are those provided to the facility by a physician/practitioner other than their resident's attending physician.For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will:Call the attending physician to verify the order.Document the verification order by entering the order and the time, date, and signature on the physician order sheet. NJAC 8:39-11.2(b)

Based on observation, interview, review of the medical record (MR) and review of other pertinent facility documents, it was determined that the facility failed to consistently ensure communication with a contracted dialysis facility according to facility policy and procedure. This deficient practice was evidenced for 1 of 1 resident (Resident #13) reviewed for dialysis. This deficient practice was evidenced by the following: On 03/18/2026 at 9:04 AM, the surveyor observed Resident #13 seated in the wheelchair eating breakfast. Resident #13 offered no complaints and told the surveyor that they attended dialysis for approximately two and a half years on Monday, Wednesday and Friday. On 3/18/2026 at 11:03 AM, the surveyor reviewed the medical record (MR) for Resident #13 which revealed the following:A review of the admission Record, an admission summary, revealed that Resident #13 had the following but not limited to diagnoses; Morbid obesity, end stage renal disease, malignant neoplasm (cancerous tumor) of liver and intrahepatic bile duct.A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/1/2026, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident received dialysis services.A review of Resident #13's Individual Comprehensive Care Plan (ICP) included a focus area, dated 3/9/2026, that the resident required hemodialysis. Interventions included: Monitor for dry skin and apply lotion as needed, monitor/report to MD (medical doctor) s/sx (signs/symptoms) of infection to access site: redness, swelling, warmth or drainage and monitor/report to MD s/sx of the following: bleeding, hemorrhage.A review of the Order Summary Report (OSR), dated as of 2/24/2026, included the following physician order dated 2/2/3/2026 for Send communication book with resident on dialysis days and check book upon return every day shift every Mon, Wed, Fri for dialysis protocol.A review of Resident #13's hemodialysis communication binder on 03/19/2026 at 11:36 AM revealed the following:On 2/25/2026 the facility failed to document post-dialysis information for Resident #13.On 3/3/2026 the facility failed to document Pre-Dialysis Information for Resident #13, which included vital signs, physician name, medications administered prior to dialysis, meal/snack sent, any additional information (changes in condition, physician order changes, new labs since last visit) and the nurse signature. In addition, no post-dialysis information was documented. (shunt/catheter location/status, catheter dressing intact, Bleeding, general condition of the resident, date/time and vital signs.On 3/4/2026, the facility failed to document post-dialysis information upon return to facility. On 3/6/2026, the facility failed to receive documentation from the dialysis center and failed to document post-dialysis information. On 3/9/2026, the facility failed to document post-dialysis information and failed to document pre-dialysis information for Resident #13.On 3/11/2026, the facility failed to receive documentation from the dialysis facility post-treatment and failed to document post-dialysis information.On 3/13/2026, the facility failed to document post-dialysis information. On 3/16/2026 the facility failed to document post-dialysis information.On 3/18/2026, the facility failed to document post-dialysis information for Resident #13.On 03/19/2026 at 11:54 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) for the 2nd Floor. The surveyor asked LPN/UM #1 to explain the purpose of the Dialysis Communication Form. LPN/UM #1 explained the communication sheet was to be filled out by the nurse assigned to the resident prior to leaving facility. The facility sends the communication book with the resident to dialysis. Dialysis staff was responsible for documenting pre and post weights and anything pertinent during treatment. LPN/UM #1 further explained that the communication form/book comes back with the resident, and the receiving nurse looks at the sheet and notes any new orders. Then, they assessed the catheter site upon return and write a progress note. The surveyor then asked LPN/UM #1 if the receiving nurse was to fill out the Post-Dialysis Information on the Dialysis Communication Form upon return to the facility. LPN/UM #1 could not confirm that the facility receiving nurse was responsible for documenting the post-dialysis information. She stated, I guess it could go either way (Dialysis staff to fill out or facility staff.) She then stated that it was the facilities' responsibility to fill out the post-dialysis information. The surveyor then asked LPN/UM #1 what the process was if the dialysis facility failed to document on the Dialysis Communication Form. LPN/UM #1 responded that If dialysis failed to document any information under dialysis center information the nurse was to call the dialysis facility and get any pertinent information. LPN/UM #1 further stated that on 3/11/2026, the receiving nurse should have called the dialysis facility to get the dialysis center information that was left blank.On 03/23/2026 at 2:11 PM, the survey team conducted an interview with facility administration which included the Licensed Nursing Home Administrator (LNHA), the facility Director of Nursing (DON) and the Regional Nurse (RN). The surveyor asked the staff to explain the dialysis communication form process. The DON told the surveyor that the facility filled out the communication form and took vitals prior to dialysis. The binder goes with the resident to dialysis and pre and post weights, vital signs, any medications delivered, or medications ordered were to be documented by the dialysis staff. The surveyor then asked what the facility should do if the dialysis staff failed to document on the dialysis communication form. The DON stated that the staff should contact the dialysis center if the form comes back blank and gets the necessary information from dialysis. The surveyor then asked the DON if facility staff were required to document post-dialysis information upon return to the facility. The DON responded, the receiving nurse should check the MAR (Medication Administration Record) and TAR (Treatment Administration Record) upon return to the facility. They could also write a skilled documentation note. These items were located on the MAR and TAR and are documented upon return (referring to the items to be assessed under post-dialysis information on the Dialysis Communication Form.)On 03/24/2026 at 9:56 AM, during a meeting with facility administration the DON told the surveyor the following: The sending staff would be responsible for filling out the top portion of the communication (dialysis) sheet. The dialysis facility will be responsible for filling out the middle section of the dialysis sheet (post-dialysis/part 2). She then told the surveyor that the receiving facility nurse would be responsible for documenting part 3 (post-dialysis information) upon return to the facility as well as, documenting in the electronic medical record status post return to facility. The surveyor then asked if all three (3) sections of the Dialysis Communication Form were required to be completed and the DON replied, Yes, all 3 sections are to be completed on the communication sheet.A review of the facility provided and undated policy titled Dialysis Care. revealed under Policy Statement: It is the policy of this facility to provide care to the resident with end stage renal disease who is receiving hemodialysis offsite. The purpose of this care is to provide comfort and quality of life for these residents. In addition, the following was observed under Policy Interpretation and Implementation: Initiate communication sheets which will be sent and received from the dialysis unit. The communication sheets will contain routine communication between the facility and dialysis unit. The dialysis unit will notify the facility by phone if there is any further information. This will be documented on the communication sheet. The communication sheets will be maintained on the unit.The surveyor reviewed the facility provided policy titled, End Stage Renal Disease, Care of a Resident with, updated and reviewed June 2024. The following was revealed under Policy Interpretation and Implementation: Staff caring for residents with ESRD (end stage renal disease), including residents receiving dialysis care outside of the facility, shall be trained in the care and special needs of these residents. The policy also revealed the following: Initiate communication sheets which will be sent and received from the dialysis unit to have routine communication. The communication sheet will be kept on the unit and/or in resident medical record.NJAC 8:39-27.1(a)

Based on observation, interview, and review of the Electronic Medical Record (EMR) and other facility documentation, the facility failed to follow through on recommendations made by the Consultant Pharmacist (CP) during their medication review regimen (MRR) in a timely manner. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #8) and was evidenced by the following: During the initial tour of the facility on 3/17/26 at 12:10 PM, Resident #8 was receiving care and was unavailable for an interview.A review of the electronic medical record (EMR) on 3/18/26 at 1:50 PM revealed the following:According to the admission Record, Resident #8 was admitted to the facility with diagnoses that included but was not limited to type II diabetes mellitus (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar) and severe sepsis (a life-threatening, emergency condition where an infection triggers a severe, systemic immune response, causing organ dysfunction, such as kidney damage or low blood pressure).A review of the comprehensive Minimum Data Set (MDS), an assessment tool that facilitates a resident's care dated 2/23/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, reflecting intact cognition.A review of the Order Summary Report revealed the following physician orders (PO):A PO for Lispro insulin 100 units/mL (milliliter) subcutaneously. Inject as per sliding scale: if 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units for diabetes mellitus.A PO for ropinirole 5 mg (milligram) tablet two times per day for restless leg syndrome.A PO for Flomax capsule 0.4 mg one time a day for urinary incontinence.A PO for Protonix 40 mg by mouth one time a day for gastrointestinal reflux disease.A review of the consultant pharmacist's report dated 2/14/26 noted the following: Insulin Lispro.is a rapid-acting insulin and should be administered within fifteen minutes before a meal or immediately after a meal.A further review revealed, ropinirole is recommended 2-3 hours before bedtime when given for restless leg syndrome. Please review current time of administration. Flomax should be administered 30 minutes after a meal. Do not crush, chew, or open Flomax capsules. If the resident is unable to swallow the capsules whole, consider changing to Rapaflo, which can be opened if needed for administration. Alternatively, the physician can update the order to include 'may open for administration.' Do not crush Protonix. If the resident is unable to swallow whole, contact the physician to change to Protonix Granules or to another medication.There was no evidence in the medical record that the facility followed up with the CP's recommendations.On 3/23/26 at 10:51 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the desk nurse and unit managers have access to the CP reports daily. She added that the CP completed a medication regimen review upon admission and monthly. She continued to explain that the nurses were expected to address pharmacist concerns with the provider/physician to assure that corrections or updated were completed. She stated that the unit manager was responsible for ensuring recommendations were addressed, including making necessary updates and maintaining documentation to reflect that concerns were resolved. The unit managers should attach a copy of updated report with corrections which would indicate that the concerns were addressed. A review of the facility's Addressing Medication Regimen Review Irregularities policy, updated April 2023, included: It is the policy of this facility to provide a Medication Regimen Review (MRR) for each resident in order to identify irregularities and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event . 4. The pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing, and the reports must be acted upon . d. The nurses will forward the information to the attending physician, who must document in the resident's medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.NJAC 8:39-29.3(a)1

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to properly store and secure medication left at resident's bedside (Resident #15 and #43). This deficient practice was identified for 2 of 2 residents (Resident #15, and #43). This deficient practice was evidenced by the following: 1. On 3/17/2026 at 12:25 PM, the surveyor observed Resident #15 in their room, sitting on the side of their bed. At that time, the surveyor observed a Trelegy Ellipta inhaler (a prescription inhaler designed for adults to help manage breathing difficulties over the long term.) on top of their bedside table. The surveyor reviewed the medical record for Resident #15. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; Chronic obstructive pulmonary disease (A progressive lung disease that makes it hard to breathe due to long-term damage and airway inflammation, usually caused by smoking or irritants.), and acute respiratory failure with hypoxia (A sudden, life-threatening emergency where the lungs cannot bring enough oxygen into the blood). A review of Resident #15's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/20/2026, included that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated that the resident's cognition was moderately impaired. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 3/3/2026, that the resident had an altered respiratory status related to chronic obstructive pulmonary disease (COPD) exacerbation related to respiratory syncytial virus (RSV) (is a common respiratory virus that usually causes mild, cold-like symptoms), with acute respiratory failure (when your lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning). Interventions included: Monitor changes in orientation, increased restlessness, anxiety, and air hunger. Monitor for signs and symptoms of respiratory distress and report to the medical doctor as needed. Monitor and report abnormal breathing patterns to medical doctor. Review of the Order Summary report (OSR), dated 2/16/2026, included the following physician order (PO): A PO dated 2/16/2026, for Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (Fluticasone-Umeclidinium-Vilantero) prescription inhaler used by adults to improve breathing and reduce flare-ups for COPD. One Puff inhale orally one time a day for COPD. A review of the Medication Administration Record (MAR) revealed that Resident #15 was administered the Trelegy inhaler on 3/17/2026 at 9 AM. On 3/17/2026 at 1:36 PM, the surveyor interviewed the Registered Nurse (RN) #1, who stated that she administered Resident #15's 9 AM medications. She further stated that all medications should be stored in the medication cart and should never be left at the bedside. She added that it should not be left because the resident can take their own medication and can overdose. She added that if the nurse saw the medication at the bedside, the nurse should remove the medication, then put it in a bag and notify the provider and care manager. She further stated that the family would then be notified to pick up the medication. She further stated that the care manager would be notified if the resident wanted to self-administer any medications. On 3/17/2026 at 1:40 PM, the surveyor, accompanied by the Licensed Practical Nurse / Unit Manager (LPN/UM) #2, went to Resident #15's room, and she confirmed the findings. LPN/UM #2 removed the Trelegy inhaler from the bedside table and removed the packaging for the inhaler that was next to the sink. LPN/UM #2 exited Resident #15's room and stated that medication should not have been at the bedside unless the resident had an order to self-administer medication. She further explained that if the resident wanted to self-administer their own medication, they would have to be assessed by the nurse, then the physician must be notified, and an order for self-administration was obtained. On 3/18/2026 at 10:01 AM, the surveyor conducted a follow-up visit with Resident #15, when asked about the trelegy inhaler that was left on top of their bedside table the day before, Resident #15 stated that the nurse gave them the inhaler. 2. On 3/17/2026 at 12:43 PM, the surveyor observed Resident #43 lying awake in their bed. At that time, the surveyor observed multiple medications on top of bedside table as follows: Breztri Aerosphere Inhalation Aerosol 160-9-4.8 MCG/ACT (Budesonide-Glycopyrrolate-Formoterol fumarate) used for COPD; Mylanta (used for fast relief of heartburn, acid indigestion, sour stomach, and gas.); TUMS (used to treat heartburn, indigestion and upset stomach caused by too much stomach acid.); and Asper Creme (a topical medication used for temporary relief of minor pain in muscles and joints). On 3/17/2026 at 1:41 PM, the surveyor, accompanied by LPN/UM #2, and another surveyor, went to Resident #43's room. LPN/UM #2 confirmed the findings. LPN/UM # 2 removed the following medications: Breztri inhaler, tums, mylanta and asper creme. LPN/UM#2 asked the resident where they got the medications from, and the resident stated that they brought the medications in from home. LPN/UM #2 explained to Resident #43 that they cannot have medication at their bedside unless they have an order to self-administer the medication. The resident allowed the nurse to remove the medications from their bedside. LPN/UM #2 verified that Resident #43 did not have an order to self-administer their medication. LPN/UM #2 stated that Resident #43 should not have had the medications at their bedside because they did not have an order to self-administer medications. On 3/17/2026 at 2:30 PM, the surveyor reviewed the medical record for Resident #43. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypoxia (A sudden, life-threatening emergency where the lungs cannot bring enough oxygen into the blood.), Displaced fracture of greater trochanter of right femur, (Broken right hip bone where the bone fragments have moved out of place (displaced) Subsequent encounter for closed fracture with routine healing. (the skin was not broken, and the bone is healing normally.) Essential (Primary) Hypertension (A chronic long-term condition where blood pressure is consistently too high.) A review of resident #43's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/22/2026, included the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 3/6/2026, that Resident #43 had an altered respiratory status/difficulty breathing related to COPD and chronic respiratory failure. Interventions included: administer medication/ nebulizer/ puffers as ordered. Monitor for effectiveness and side effects. Elevate the head of the bed to help facilitate effective breathing. Maintain a clear airway by encouraging the resident to clear their own secretions with effective coughing. If secretions cannot be cleared, suction as ordered/required to clear secretions. Monitor /document changes in orientation, increased restlessness, anxiety, and air hunger. Provide oxygen as ordered. A review of the Order Summary Report (OSR), dated as of 3/13/2026, included a PO dated 03/13/2026, for Breztri Aerosphere 160-9-4.8 MCG/ACT Aerosol 1 Puff inhale orally two times a day for COPD, and the resident should rinse their mouth with water without swallowing after each use to decrease the risk of an oral fungus infections. On 3/19/2026 at 10:33 AM, the surveyor interviewed the Director of Nursing (DON), who stated medications should be stored on the medication cart, unless they have an order to self-administer medication, then the medication would be stored in a lock cabinet in the resident's room. She further stated that if medication was left at the bedside, it could result in adverse effects. The DON added that she would have to look up the policy for self-administering medications because she did not know it off top of her head. On 3/19/2026 at 10:42 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that medications should be stored in the medication cart unless the resident had an order for self-administration. A review of the facility's policy undated, titled, Storage of Medications, revealed Policy Statement: the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage. A review of the facility's policy titled, Self-Administration of medication, revealed residents in our facility who wish to self-administer medications may do so, if it is determined that they can do so. Self-administration medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for bedside storage, for return to the family or responsible party. NJAC 8:39-29.4(h)

Based on record review, interviews, and review of pertinent facility documents, it was determined that the facility failed to honor the food preference for one (1) of two (2) residents (Resident #141) reviewed for nutrition. This deficient practice was evidenced by the following: On 3/19/26 at 12:59 PM, the surveyor reviewed the medical record for Resident #141 which revealed the following:A review of the admission Record, an admission summary, revealed that Resident #141 had diagnoses which included but were not limited to dysphagia (difficulty swallowing), mild protein-calorie malnutrition (a nutritional deficiency characterized by inadequate intake of protein and calories), hyperlipidemia (elevated cholesterol), and type II diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar) .A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/9/26, included the resident a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cognition was severely impaired. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 10/25/25, which indicated that the resident had diabetes mellitus. Interventions included a dietary consult for nutritional regimen and ongoing monitoring.A subsequent focus area that was on Resident #141's ICCP indicated that the resident had an increased nutrient need for wound healing and that the resident followed a Halal diet (food allowed under Islamic law). The interventions included: Honor food preferences-Lacto-ovo vegetarian (a person who eats vegetables, eggs, and dairy products but who does not eat meat) preference, seafood allowed. No other meat unless Halal.A review of the physician Order Summary Report (OSR) included a physician's orders (PO) dated 10/3/25 for regular diet, regular consistency.A review of the Nutrition Evaluation Note dated 9/24/25 at 3:46 PM, indicated that Resident #141 ate Halal at home. The nutrition intervention included honor food pref [preference] as able -No meat.A review of the Nutrition Evaluation Note dated 10/4/25 included continue current diet food preference on meal tracker, will honor as able.A review of Resident #141's dietary slip, dated 10/6/25, included no chicken, beef, pork, or turkey.A review of the progress notes included a nurse's note (NN), dated 10/6/25 at 9:10 AM, which included that the resident rec'd (received) the wrong dinner meal from the kitchen, not respecting dietary restrictions (no meat). The resident care nurse went to the kitchen three different times to accommodate residents' food wishes and the resident was given a salad and ate dinner without complications. Resident [relation redacted] unhappy with dietary mistakes. The 3-11 supervisor made aware that a kitchen error was corrected and made family aware that he would escalate issues with his superiors.On 3/19/26 at 11:28 AM, the surveyor interviewed the Certified Nurse Aide (CNA), who stated that the meal trays should be accurate for the most part. She added that she would check the meal ticket to ensure that the tray was correct. On 3/23/26 at 12:08 PM, the surveyor interviewed the Food Service Director (FSD) who stated that the dietary aide would check to verify the diet was correct before placing the tray on the cart for transport to the unit. She further stated that the Certified Nursing Aide (CNA) would then distribute the meal tray to each resident when it arrived on the unit.On 3/19/26 at 1:39 PM, the surveyor interviewed the Registered Dietician (RD), who stated that she would meet with every resident upon admission to the facility to get their food preferences, allergies, and likes/dislikes. She stated she would educate them if they were on an altered diet, and she would offer the resident written education about their diet, if they wanted it. The RD stated that she would then go into the food service portal and update the preference or send it to the FSD so she could update it. She added that each resident was provided with a food preference questionnaire to complete. She further stated that if the resident did not complete the food preference form, the FSD would go to the resident and obtain the resident's food preference, so their likes and dislikes, and food preference would be documented on the dietary slip.The RD further stated that Resident #141 required a kosher diet (a term used to describe food that complies with the strict dietary standards of traditional Jewish law). Upon admission to the facility the resident and the family were notified that this was not a kosher facility, and they did not have Halal meat. She further stated that Resident #141 did not want to be served any meat from the facility. She noted that when Resident #141 first arrived at the facility, the resident's diet was modified to a puree diet. She stated that considering the facility would not have been able to give them a pureed kosher meal or Halal diet, they accommodated the resident with a vegan diet. The RD explained that she had received complaints regarding meal accuracy, and based upon an internal investigation, the person who made the meal trays did not look at the ticket. She added that they had new team members and there has been a 100% turnover.On 3/23/26 at 11:22 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that resident meals should be accurate and added that the dietician would obtain the resident's food preference upon admission to the facility. The LNHA further stated that the facility could not accommodate a resident with a Halal diet and different textured meats so they would offer a vegan diet. He added that the meals trays should be accurate. On 3/24/2026 at 11:22 AM, the surveyor conducted a follow-up interview with the RD who stated that upon admission to the facility Resident #141 had a preference for a halal diet and always maintained a halal diet throughout their admission to the facility. She added that a halal diet did not require a physician's order since it was a preference and the resident's preferences would be printed on the meal ticket. She further stated that the kitchen must verify the diet that was on the meal ticket. The RD added that once the meal was delivered to the unit, the CNAs would again verify the meal ticket when distributing the trays. The RD stated that half the staff probably doesn't know what a halal diet is. She further stated that she was aware of the incident when the grievance was filed. She noted that Resident #141 received meat that was not Halal /Kosher, and the family informed the facility, and it was taken care of. The 10/4/25 dietary evaluation that was completed by the dietician should have reflected that the resident preferred a halal diet. She then stated, That is why she doesn't work here anymore.A review of the facility's Resident Food Preferences, policy, updated January 2026, included Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications for diet will only be ordered with the resident's or representative's consent.A review of the facility's Resident Rights updated January 2026, included Residents are entitled to exercise their rights and privileges to the fullest extent possible.NJAC 8:39-17.4(a)1, e

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) prepare food in a manner to prevent food-borne illness, b.) maintain the kitchen equipment in a sanitary manner, and c.)maintain food-contact equipment in a sanitary condition for 2 of 2 bistros (second and third floor bistros). This deficient practice was evidenced by the following:On 3/17/26 at 10:17 AM, the surveyor began the initial tour of the kitchen and observed the following:Immediately at the start of the tour, the surveyor observed the Food Service Director (FSD) with hair extending near her shoulder blades, uncovered and not within the hairnet that she was wearing. At that time, the surveyor interviewed the FSD, who stated that hairnets must be worn while in the kitchen. She added that if the hair cannot be tucked under the hairnet, the hair would be tucked behind them, in their shirts. She further stated that for food safety, hair should never be exposed.At 10:41 AM, the Regional Director of Operations (RDO) was observed making peanut butter and jelly sandwiches. At that time, he was wearing a baseball cap with hair exposed along both sides and the back of his head. The RDO removed his hat. The hairnet was noted to be flat on top of his head and was not expanded to cover the hair on the sides and nape of his neck.At 10:45 AM, the surveyor requested that the FSD open the ice machine door. The white hard plastic area inside was noted with black and brown residue, and some buildup in various areas. At that time, the surveyor interviewed the FSD, who stated that she did not know when the ice machine was last cleaned. She further stated that the ice machine should be deep-cleaned weekly and as needed, and it should be maintained in a clean and sanitary manner.On 3/18/26 at 12:31 PM, the surveyor toured the third-floor bistro, and the following was observed:The ice machine was noted with slime-like residue in the drip tray.The ice machine contained white corrosion on the interior and exterior parts of the spout.The ice scooper was resting in a metal container and was unable to drain freely.On 3/18/26 at 1:25 PM, the surveyor toured the second-floor bistro, and the following was observed:The ice machine contained a buildup of residue and corrosion around the interior and exterior parts of the spout.An ice scooper and a tong were noted resting on a yellow-tinged paper towel inside a metal pan.At that time, the Licensed Practical Nurse/Unit Manager (LPN/UM #2) stated that should not be like that, referring to the ice scooper, tong, and the yellow-tinged paper towel.On 3/23/26 at 8:32 AM, the surveyor returned to the kitchen for a follow-up visit.The surveyor requested the dishwasher temperature log. There was no entry on the log for 3/23/26.At that time, the surveyor interviewed the FSD, who stated that two wash cycles were completed that morning. She stated that the dishwasher temperature and chemical levels should have been checked and documented before running a cycle to ensure that the dishes were properly cleaned. On 3/23/26 at 8:36 AM, the surveyor interviewed the dietary aide, who stated that he was responsible for washing the dishes. He stated that he did not check the temperatures and chemical levels because he had to scrape four big racks of plates from last night's dinner.On 3/23/26 at 9:55 AM, the surveyor interviewed the Director of Maintenance, who stated that housekeepers were responsible for cleaning the ice machines. He further stated that the ice machines were deep-cleaned every three months or as needed. He also stated he agreed that the drip trays on the ice machines needed to be cleaned and or replaced. He added that he would attempt to clean them, and if they were uncleanable, he would replace them. The DM also stated that he would try to clean the ice machine spouts, and if they are uncleanable, he would replace them.On 3/23/26 at 10:16 AM, the surveyor interviewed the Infection Preventionist (IP), who stated that the ice machines should be maintained in a clean and sanitary manner at all times. She added that the ice scoopers should be washed daily and drain freely, and not where water could be collected and lead to bacteria buildup.On 3/23/26 at 10:37 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the ice machine was cleaned quarterly and as needed. He added that the ice machines should be maintained in a clean and sanitary manner. He also stated that the ice scoopers should drain freely for infection control purposes.The LNHA further stated that dishwasher temperatures should be checked every morning and documented. He added that it was important to check the temperature so they knew it was running properly. A review of the facility's Infection Prevention and Control Program policy, undated, included, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines.A review of the facility's Hair Restraint (Net) Policy updated January 2025, included, It is the policy of this facility that hair restraints prevent hair from contacting food, food service equipment, and utensils, thus avoiding cross-contamination. This policy applies to all food service staff within the facility, including those preparing, cooking, or serving food and/or any visitor or staff entering the kitchen area.Hair restraints must cover all head hair completely. This includes securing bangs and other loose strands that might escape from primary restraints.A review of the facility's Ice Machines and Ice Storage Chests Updated January 2025, included, Ice Machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Our facility has established procedures for cleaning and disinfecting ice machines and storage chests, which adhere to the manufacturer's instructions. The Infection Preventionist maintains a copy of these procedures.A review of the facility's Ice policy, revised 10/2022, included Ice will be prepared and distributed in a safe and sanitary manner.Ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention.NJAC 8:39-17.2(g)

C #: NJ00183386/398980, 2670006 Based on observation, interview, medical record review, and review of other pertinent facility documentation on 12/9/25 and 12/10/25, it was determined that the facility failed to consistently document and maintain a complete medical record regarding toileting, bowel & bladder continence/incontinent care for residents in accordance with the facility's policy and standard of care. This deficient practice was identified for 2 of 2 residents (Resident #4 and Resident #5) reviewed.The facility also failed to document when a resident was sent out of the facility for further evaluation after an allegation of a fall. This deficient practice was identified for 1 of 2 residents (Resident #5) reviewed and was evidenced by the following:1. According to the admission Record (AR) Resident #4 was admitted with diagnoses that included but were not limited to: type II diabetes, osteoarthritis, right artificial hip joint, and hypertension.The comprehensive Minimum Data Set (MDS), an assessment tool, dated 11/3/25, revealed a Brief Interview of Mental Status (BIMS) of 15 out of 15, which indicated that the resident was cognitively intact. Further review of the MDS indicated that the resident required substantial assistance with toileting. Review of Resident #4's Baseline Care Plan, revealed that the resident required a one person assist with toileting. Review of Resident #2's DSR and progress notes (PN) for February 2025 lacked any documentation about the care that was provided to the resident on the following dates:Bladder Continence-Day Shift (7 AM - 3 PM): 2/10/25, 2/11/25-Evening Shift (3 PM - 11 PM): 2/9/25, 2/10/25-Night Shift (11 PM - 7 AM): 2/10/25, 2/11/25 Bowel Continence-Day Shift (7 AM - 3 PM): 2/10/25, 2/11/25-Evening Shift (3 PM - 11 PM): 2/9/25, 2/10/25-Night Shift (11 PM - 7 AM): 2/10/25, 2/11/25 Bowel Movements-Day Shift (7 AM - 3 PM): 2/10/25, 2/11/25-Evening Shift (3 PM - 11 PM): 2/9/25, 2/10/25-Night Shift (11 PM - 7 AM): 2/10/25, 2/11/25 2. According to the admission Record (AR) Resident #5 was admitted with diagnoses that included but were not limited to: cerebral infarction, heart failure, abnormalities of gait and mobility, and cognitive communication deficit.The comprehensive Minimum Data Set (MDS), an assessment tool dated 10/17/25, revealed a Brief Interview of Mental Status (BIMS) of 13 out of 15, which indicated that Resident #5 was cognitively intact. Further review of the MDS indicated that the resident required partial assistance with toileting transfer and was fully dependent in toileting hygiene. Review of Resident #5's Baseline Care Plan, revealed that the resident required a one person assist with toileting.Review of Resident #5's DSR and progress notes for October 2025 lacked any documentation to show that care was provided to the resident on the following dates:Bladder Continence-Evening Shift (3 PM - 11 PM): 10/19/25Bowel Continence-Evening Shift (3 PM - 11 PM): 10/19/25Bowel Movements-Evening Shift (3 PM - 11 PM): 10/19/25Further review of the Resident #5's medical record revealed an incident report (IR) dated 10/24/25 at 12PM, which stated that the resident was transported out of the facility for further evaluation. The record stated, At the time of the event, the resident had already been transported. A corresponding post transfer summary from the outside facility provider confirmed that the resident was evaluated at their facility on 10/24/25.A review of Resident #5's Universal Transfer Form (UTF) dated 10/24/25, did not include the time of transfer.A review of Resident #5's PN revealed a note dated 10/24/25 at 12:49 PM, which indicated that the resident returned to the facility. Further review of the PN did not indicate when the resident left the facility.During interview on 12/9/25 at 6:59 AM, with Licensed Practical Nurse (LPN #1), the LPN stated that Certified Nursing Assistants (CNA) were responsible for documenting incontinent care in the electronic medical record. LPN #1 stated that documenting this was important because it captured the efforts being made to ensure that residents were free from sores and rashes. LPN #1 further stated that there should be no blanks, and that nurses and supervisors were responsible for ensuring that the CNAs are documenting.During interview on 12/9/25 at 11:04 AM with the Unit Manager (UM #1), she stated that CNAs were primarily responsible for monitoring residents for incontinent bowel and bladder and that they were to document in the electronic system. UM #1 stated that documentation was important to show that efforts were being made to prevent skin breakdown. UM #1 stated that it was the responsibility of the UM to ensure that documentation was completed.During an interview on 12/9/25 at 1:14 PM with the Director of Nursing (DON), the DON stated that CNAs were primarily responsible for monitoring residents for incontinent care and that they were to document in the electronic system. The DON further stated that the purpose of this documentation was to reflect that care was being provided. In the presence of the surveyor the DON reviewed the corresponding DSR sheets for Resident #4 and Resident #5 and confirmed that there were blanks as indicated above.During a telephone interview on 12/10/25 at 2:58 PM CNA #1, the CNA stated that CNAs were responsible for monitoring residents for incontinence and that they were to document in the electronic system. CNA #1 further stated occasionally forgetting to document.During a follow-up interview with DON on 12/10/25 at 3:58 PM, the DON stated that a resident's medical record should include documentation of all details relevant to a resident's care, including the time when a resident was sent out of the facility.A review of the facility's undated Charting and Documentation policy revealed that all services provided to a resident were to be documented in the medical record. Under the Policy Interpretation and Implementation section, the policy noted that documentation was to be complete and accurate. A review of the facility's undated Universal Transfer Form policy revealed that all information provided on the UTF would be complete and accurate. NJAC 8:39-27.1(a); 35.2(d)3

Complaint #: 398977Based on record review, interview, and document review, the facility failed to notify the physician of a resident's refusal to have an immediate (STAT) laboratory test on [DATE] and [DATE]; failed to obtain a Urine with Culture and Sensitivity (C&S) test when ordered on [DATE]; failed to monitor the resident after reports of nausea without emesis for three days, decreased appetite secondary to the nausea, and continued diarrhea; and failed to act upon a critically high white blood cell (WBC) count for one of 16 sampled residents (Resident (R) 7). These failures caused serious harm or death to R7.The facility's Director of Nursing (DON) and the Regional Nurse Consultant (RNC) were informed on [DATE] at 8:00 PM an Immediate Jeopardy (IJ) existed at F684: Quality of Care related to the failure of notifying the physician of the resident's refusal of laboratory tests, failing to monitor the resident after reports of nausea without emesis for three days, decreased appetite secondary to the nausea, and continued diarrhea; and failing to act upon a critically high WBC count. The Immediate Jeopardy began on [DATE], the date of the R7's first refusal of the laboratory test.The facility provided an acceptable Removal Plan on [DATE] at 4:32 PM. The Removal Plan consisted of the facility educating the licensed nurses on the documentation and provider notification requirements when residents refuse diagnostic testing or exhibit changes in condition, acute changes in condition protocol and documentation requirements, and honoring resident's /family rights to transfer to hospital when requested, including the obligation to inform the providers and document the decision in the electronic medical record (EMR). Through interviews and review of staff education documentation, the survey team removed the IJ, effective [DATE] at 5:00 PM.Review of R7's New Jersey Department of Health Certificate of Death, revealed the resident's causes of death were, . Immediate Cause a. Suspected Sepsis .Due to (or as a consequence of) b. diarrhea . Due to (or as a consequence of) c. hypokalemia . It was recorded the interval between the onset of the suspected sepsis and diarrhea and death was two days.Review of R7's undated Face Sheet, located under the Profile tab in the EMR, indicated R7 was admitted to the facility with diagnoses that included myelodysplastic syndrome, anemia, and acute congestive heart failure.Review of R7's AUTM Admit/Readmit Screener 1.0 -V 8, dated [DATE] and located under the Evaluation tab of the EMR, indicated R7 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R7 was cognitively intact.Review of R7's Provider Progress Note, located under the Progress Note tab in the EMR and dated [DATE], revealed R7 was seen by Physician's Assistant (PA) 1. PA1 documented R7's [NAME] Blood Count (WBC) was 2.5. PA1 documented, . healthy-appearing, well-nourished . no acute distress . monitor CBC .Review of R7's Physician's Order, located under the Orders tab in the EMR and dated [DATE], indicated an order for a STAT Complete Blood Count (CBC) and Basic Metabolic Panel (BMP).The review of laboratory logs, dated [DATE] at 7:29 PM and [DATE] at 6:01 AM, provided by the facility, revealed that R7 refused the laboratory draw on both dates.Review of R7's entire EMR revealed no documented evidence that the physician was notified of the refusals.Review of R7's Provider Progress Note, dated [DATE] and located under the Progress Notes tab of the EMR, revealed R7 reported abdominal pain to PA2. The PA recorded the patient reported lower abdominal pain, nausea, and mild dysuria. A urinalysis (UA) with culture and sensitivity was ordered.Review of R7's entire EMR revealed no documented evidence that a specimen was collected for the UA or that the physician was notified that the specimen was not collected.Review of R7's Nursing Progress Note, dated [DATE] at 11:08 AM and located under the Progress Note tab in the EMR, indicated R7 had . decreased appetite for 2 days, and diarrhea for 3 days . It was recorded that the on-call provider was called, and Imodium was ordered for use after every diarrhea episode.Review of R7's Nursing Progress Note, dated [DATE] at 11:16 AM and located under the Progress Notes tab of the EMR, revealed, . on call physician ordered STAT labs cbc, bmp .Review of R7's Lab Results Report, dated [DATE], with a collection time of 11:31 AM and provided by the facility, revealed R7 had a WBC count of 26.4 thousand per cubic millimeter (K/CU.MM). The normal reference range was documented as 3.5 to 11.0 K/CU.MM. The lab result report indicated the results were called to Licensed Practical Nurse (LPN) 10, who then read the results back to the laboratory staff member.Review of R7's Nursing Progress Note, dated [DATE] at 6:58 PM and located under the Progress Notes tab of the EMR, revealed, . stat labs completed . WBC Count . 26.4 .Review of R7's Nursing Progress Note, input by LPN9 on [DATE] at 12:16 AM as a late entry for [DATE] at 7:03 PM, revealed, . patient endorses loose watery stool w/ [with] loss of appetite, [positive] nausea [without] emesis x 3 days . patient further endorsed decreased appetite 2/2 [secondary to] nausea .Review of a Nurse Practitioner (NP) Note, dated [DATE], revealed, . Pt's [family member] states patient has had nausea and vomiting but nursing staff taking care of patient state . has not vomited once . Elevated WBC expected with PMH [past medical history], Recommend repeat labs, Imodium 2mg x 1 dose and PRN [as needed] for diarrhea. If no further symptoms, provider to follow-up in AM . There was no documented evidence that the NP completed a physical assessment of the resident. Review of R7's Orders and Progress Notes tabs of the EMR revealed no documented evidence follow-up laboratory tests were ordered as recommended by the NP.Review of R7's entire clinical record revealed no documented evidence that R7 was assessed or monitored for changes in condition after the late entry dated [DATE] at 7:03 PM through [DATE] at 8:06 AM.Review of R7's General Nurses Note, dated [DATE] at 1:29 PM, revealed, . At approximately 08:06 [AM] [sic] it was reported by primary nurse that the above noted patient was unresponsive. This nurse immediately checked patient chart to confirm code status, called code blue and began CPR [cardiopulmonary resuscitation] at 08:09 [AM] [sic] 911 notified. Compressions performed, Breaths administered AED [Automated External Defibrillator], and no shock advised, no signs of life noted, CPR continued and unsuccessful. Provider made aware, Patient was pronounced at 8:22am by ER provider via phone, Family made aware .During an interview on [DATE] at 11:57 AM, PA1 stated, I saw R7 as a follow up visit on [DATE]. When I saw R7 . had no complaints and was feeling well. It was a very benign assessment. PA1 was asked if she would have sent the resident to the hospital when the results of the resident's WBC came back as 26.4 if she had been working. PA1 stated, In reviewing R7 labs from the hospital, white count had been 1.1 and then there was an increase to 26, then yes, I would have sent R7 to the ER for further evaluation because I would not have known where R7 real problem was coming from. I would come in and have a conversation with the resident and family explaining the plan of keeping a resident and doing everything here or sending R7 out for further evaluation. But I was not the one that was working on [DATE] so I really can't answer to as why this was not done.During an interview on [DATE] at 9:48 AM, the Director of Nursing (DON) was asked about the process nurses used to order laboratory tests. The DON stated during the day there was a desk nurse. The DON stated the MD (Medical Doctor), PA, or NP (Nurse Practitioner) would enter the orders into PCC (Point Click Care, the EMR system), and then the nurse could look into the pending confirmation report to see what orders were still pending. The DON stated that if the lab came out and the resident had been a hard stick or the lab technician (tech) did not come out, then the desk nurse would write and hand off in the shift report that the lab was not drawn, and the staff would need to add the resident to the next day lab draws.During an interview on [DATE] at 12:40 PM, the DON stated that she had called the lab company and obtained the log that showed on [DATE] at 7:27 PM, the lab tech documented Refused, and then on [DATE] at 6:01 AM, the lab tech again documented Refused. The DON was asked if this was documented in the EMR, and she stated, No, it wasn't. The DON was asked if this should have been documented by the staff, and the DON stated, Yes, it should have been documented. The DON was asked how the staff would know if a resident refused a lab stick, and the DON stated, The lab tech would have to tell the nurse.During an interview on [DATE] at 2:35 PM, the DON stated, I have looked into the Urine with C&S test that was ordered on [DATE]. I don't know if it was not obtained due to the patient having a lot of diarrhea that day. The DON confirmed there was no documented evidence in the nursing notes to reflect this.During an interview on [DATE] at 4:08 PM, the Medical Director stated, If a resident refuses to have blood drawn for a STAT lab, then I expect the lab staff to tell the nurses and then come back and try again. If after the second time the resident refuses, I expect the lab staff to tell the nurses and get the nurses to talk to the resident to see what their reasoning is behind this. Then if the resident continues to refuse after the nurse talks to them, then the nurses should notify the provider that ordered the lab.During an interview on [DATE] at 6:08 PM, the Regional Customer Support (RCS)1 for the laboratory company confirmed on [DATE] and [DATE], it was documented by the lab tech the resident refused, and nurse was made aware of the resident's refusal to have a CBC with Differential and BMP drawn. The RCS1 was asked if there was documentation to show which nurse was made aware of the resident's refusals. The RCS1 stated, No, there is not. RCS1 confirmed the Urine test with C&S ordered on [DATE] was documented by the lab staff as No specimen.During an interview on [DATE] at 9:03 AM, Family Member (FM) 2 stated when she visited R7 on [DATE], there was a horrible odor in the resident's room. FM2 stated R7 was afraid to have visitors because she did not want anyone to get the stomach bug that she had. FM2 stated the staff was giving R7 Imodium for diarrhea, and she informed the staff R7 should not have Imodium because of her previous history of diverticulitis. FM2 stated she and another family member requested 911 to be called for R7 to go to the hospital but were told by staff that the physician had said that it was just a virus and she (R7) didn't need to go to the hospital for a stomach virus and he would not approve it. FM2 stated if she had known that she could have called 911 herself and had R7 transferred, she would have done just that. FM2 stated, [R7] was perfectly fine when .left the hospital and then got there and died. I just feel no one was paying attention to [R7] decline.During an interview on [DATE] at 9:42 AM, FM3 stated, [FM2] and I called the facility on 01/01/ [25]. We had to call several times because the phone kept ringing, and no one would pick up. Finally, a nice nurse on the second floor answered [,] and we explained the situation to her about [R7]. She said she would walk upstairs and tell the nurse on the third floor to call us back. We called the third floor back ourselves, and a nurse . answered the phone . I explained that [R7] had developed diarrhea and now was confused and not doing very well. We explained that we wanted 911 called and [R7] taken to the hospital. The nurse said, 'Oh, I can't do that, I don't have the authority to do that.' She [nurse] said she would call the doctor on call and give us a call back. She [nurse] called me back and wouldn't give me any information, so I called [FM2] and got her on the line with us. The nurse said she called the doctor on call, and he said there was no reason for [R7] to be taken to the hospital. I [FM3] said, 'Oh, so did you tell him that [R7] has diarrhea and is being given Imodium which [R7] shouldn't have because they had diverticulitis?' The nurse said I told him that [R7] was nauseous and vomited . I [FM3] said so you didn't tell him that [R7] has been declining and now is confused with this also. The nurse didn't answer me back. I [FM3] told her [nurse] that it wasn't good practice for a doctor to take the nurse's word on what is wrong with the patient and not even come into see [R7] to see if he/she needs to go to the hospital before refusing to have him/her transferred there. Had I had known [,] I could have called 911 and had taken R7 to the hospital, I would have done that . I feel that no one was watching R7 and paying attention to his/her needs.During a phone interview on [DATE] at 4:24 PM, LPN10, who was identified on the lab results as receiving the results, stated, I don't remember [R7].During a phone interview on [DATE] at 10:25 AM, LPN12 stated, I admitted [R7] when she came in. [R7] wasn't having diarrhea on admission that I can remember, but did complain of minor pain all over. I was off and then I came back to work on 01/02, and the nurse told me [R7] had passed away that morning.Review of the undated facility's policy titled, Laboratory Services and Reporting indicated, . The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the timeliness of the services .::NJAC 8:39-27.1

Complaint #: 398975Based on record review, interview, and document review, the facility failed to consistently provide pain management for one of 16 sampled residents (Resident (R)16). R16 was admitted to the facility with diagnoses including pancreatic adenocarcinoma and had admitting orders for pain medications, in particular Dilaudid (an opioid pain medication used to treat moderate to severe pain), and staff failed to administer the medication as ordered. R16 had pain levels up to a 10 (on a zero to 10 scale, with 10 being the most intense pain possible). This failure of R16 not receiving the ordered medication for pain caused harm and increased the likelihood for a painful death.The facility's Administrator, Director of Nursing (DON) and Regional Nurse Consultant (RNC) were informed on 09/25/25 at 7:40 PM an Immediate Jeopardy (IJ) existed at F697 Pain Management related to the failing to manage R16's pain when they did not consistently provide physician ordered pain medications as ordered to R16. The Immediate Jeopardy began on 12/31/24, when R16 was admitted to the facility with physician orders for Dilaudid.The facility provided an acceptable Removal Plan on 09/26/25 at 11:45 AM. The removal plan consisted of education to the licensed nurses on the facility's policy for Pain Management, what to do when physician ordered medications are unavailable for administration, the use of Pyxis for the immediate availability of narcotics on admission, documenting pain scores before and after the pain medication administration and documenting the effectiveness within the required timeframes for PRN medications used for pain, and education on any resident experiencing unmanaged pain, the nurse will call the physician for alternate orders, and the resident will be provided alternate physician ordered medications to ensure relief until the prescribed narcotic is available. An acceptable removal plan was verified onsite on 09/26/25 at 2:40 PM. Findings Include: Review of R16's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), and review of the Hospital Discharge Summary, located under the MISC (Miscellaneous) tab in the EMR, indicated R16 was admitted to the facility in 12/2024 at 10:30 PM with diagnoses that included pancreatic adenocarcinoma, an upper gastrointestinal bleed, portal vein thrombosis, esophagitis, unspecified without bleeding, and esophageal varices without bleeding. The resident had a [NAME] Roth I Gastroduodenostomy (surgical procedure where the lower portion of the stomach is removed and then connected to the duodenum (first part of small intestine), which was complicated by a biliary leak.Review of R16's admitting Physician Orders, located under the Orders tab in the EMR, revealed orders for medications including Dilaudid 2 milligrams (mg), give 0.5 tab (tablet) every four hours as needed for pain, and acetaminophen 325 mg three tabs every four hours as needed for mild pain.Review of R16's Medication Administration Record MAR, dated 01/2025 and located under the Orders tab of the EMR, revealed R16's Dilaudid 2mg every four hours was to be administered at 1:00 AM, 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM.Review of R16's Nursing Progress Note, located under the Progress Note tab in the EMR and dated 01/01/25 at 1:35 PM, revealed, . patient stating in high level of pain. Called pharmacy at 1300 [1:00 PM] to confirm they received the patient's medication Rx [prescription]. medication should be delivered no later than 1800 [6:00 PM]. On call physician . prescribed a PRN [as needed] for Tramadol [an opioid pain medication used to treat moderate to severe pain] 50 mg PO [by mouth] q 6hr [every six hours] .Review of R16's MAR, dated 01/01/25 at 1:35 PM, revealed R16 received three 325mg acetaminophen tablets for a pain level of 8. The MAR indicated the medication was ineffective. However, further review of R16's entire clinical record revealed no documented evidence that the resident received the Tramadol at this time.Review of R16's eMAR Medication Administration Note, dated 01/01/25 at 2:48 PM, revealed, . Follow-up Pain Scale was: 3 minimal relief noted . Review of R16's MAR, dated 01/02/25 at 1:20 AM and located under the Orders tab of the EMR, revealed the resident's pain level was noted to be a 7. It was recorded that R16 was administered Tramadol 50 mg one tab. This was documented as being effective at 1:42 AM, but no pain level was documented. This was the first documented evidence that R16 received Tramadol, approximately 12 hours after receiving the order. Further review of R16's MAR, dated 01/02/25 at 11:51 AM and located under the Orders tab of the EMR, revealed the resident's pain level was noted to be 10. It was recorded that the resident was administered Dilaudid, 2mg, give 0.5 tab. This was the first documentation that R16 had been administered Dilaudid, and it was approximately 35 hours after arriving at the facility. Review of R16's Practitioner Note, with a date of service of 01/02/25 at 9:56 PM and located under the Progress Notes tab of the EMR, revealed, . Presented to [hospital name] ED with coffee ground emesis. Was found in work up to have esophagitis but no bleeding, and had an open G [gastrostomy] tube done. During the procedure was found to have changes suggestive of recurrence of cancer and [an] Interventional Radiology biopsy was positive for recurrent pancreatic CA [cancer] . Patient c/o [complained of] abdominal pain . Nsg [Nursing] concerned about coffee ground emesis, uncontrolled pain . Dilaudid 1 mg not managing pain. Increased dilaudid to 2mg q4 [every four hours around the clock] . Chronic pain due to malignant neoplastic disease - increased dilaudid to 2mg q [every] 4 . Script written . Awaiting . evaluation for pain management recommendations . Review of a Provider Note, dated 01/03/25 at 8:10 PM and located under the Progress Notes tab of the EMR, indicated, . feels much better today than . did yesterday. is very appreciative that .pain medications have been adjusted along with . Zofran which are really controlling .symptoms .Review of R16's MAR, dated 01/04/25 at 1:00 AM and located under the Orders tab of the EMR revealed the following:1:00 AM - A 5 was documented where R16's Dilaudid was supposed to be documented as administered. The MAR indicated 5 meant Hold/See Nurse Notes. No pain level was documented. The MAR indicated 5 meant Hold/See Nurse Notes. Review of R16's Progress Notes for 01/04/25, located under the Progress Notes tab of the EMR, revealed no documented evidence of why the Dilaudid was held.3:42 AM - Tramadol 50 mg was administered to R16. It was recorded that the resident's pain level was 9 and the medication was ineffective.5:00 AM - A 5 showed that R16 had a pain level of 9.Review of R16's eMAR-Medication Administration Note, dated 01/04/25 at 5:01 AM and located under the Progress Notes tab of the EMR, revealed, . Dilaudid . 2 mg . medication unavailable, Tramadol given, proven effective . The eMAR revealed at 6:27 AM, . tramadol 50 mg . PRN Administration was: Ineffective Follow-up pain scale was: 7 . This was recorded as a follow-up to the 3:42 AM note. Further review of the eMAR at 9:07 AM, revealed, . awaiting pharmacy delivery of medication . SEE NOTES . There was no documented evidence why Dilaudid was held or why Tramadol was not given.Review of R16's Progress Note, dated 01/04/25 at 5:02 AM and located under the Progress Notes tab of the EMR, revealed, . Dilaudid 2 mg . pharmacy needs script from physician, PRN Tramadol given . Review of R16's MAR, dated 01/04/25 at 1:00 PM and located under the Orders tab of the EMR, revealed documentation Dilaudid 2mg was administered. There was no pain scale documented.Review of R16's Progress Note, dated 01/04/25 at 2:29 PM and located under the Progress Notes tab of the EMR, revealed, . Wound Management was unable to perform due to the resident staying [sic] to the resident of experiencing extreme pain . There was no documented evidence that pain medications were given.Review of R16's MAR, dated 01/04/25 at 5:00 PM and located under the Orders tab of the EMR, revealed the resident's Dilaudid was not administered as ordered. There was no documented evidence the resident's pain level was evaluated.Review of R16's eMAR - Medication Administration Note, dated 01/04/25 at 5:07 PM and located under the Progress Notes tab of the EMR, revealed, . Dilaudid . 2 mg Awaiting Pharmacy delivery of medications, Shift Supervisor made aware of the situation. SEE NOTES . There were no notes documented in the EMR, and no documented evidence that R16 was provided any pain medication.Review of R16's General Nurses Note, dated 01/04/25 at 5:15 PM and located under the Progress Notes tab of the EMR, revealed, . resident currently prescribed Dilaudid 2 mg and Marinol 5 mg. Medications are currently on order. Resident did not mention pain to the writer earlier on the shift whilst awaiting pharmacy delivery of medication. However, at this time, the resident is requesting pain meds . Doctor was called for an intervention around 1645 [4:45 PM], voicemail was left to return call .Review of the Pyxis report, dated 01/04/25 at 6:24 PM and provided by the facility, revealed Tramadol 50 mg was removed for R16; however, there was no documented evidence that the medication was administered to R16.Review of R16's General Nurses Note, dated 01/04/25 at 7:19 PM and located under the Orders tab of the EMR, revealed, . Writer called the pharmacy to get info regarding the resident's Controlled Substances . resident did not receive Dilaudid or Marinol on 0700-1900 shift. [Name of pharmacy] notified the writer that these medications were not listed with them. NP from . stated to the writer that shed [sic] be contacting [name of pharmacy] to rectify this matter .Review of the Pyxis system report, provided by the facility, revealed on 01/04/25 at 7:31 PM, one Dilaudid 4 mg tab was removed from the Pyxis system for R16.Review of R16's General Nurses Note, dated 01/04/25 at 8:02 PM and located under the Orders tab of the EMR, revealed, . resident was given Tramadol 50 mg tablet as a breakthrough for pain without relief. At 1900 [7:00 PM] [the] oncoming shift nurse located Dilaudid [sic] 4 mg tab and provided 1/2 tab to the resident. Supervisor also aware of each stage of this situation . This was the first Dilaudid administered since 01/04/25 at 1:00 PM, seven hours earlier.Review of R16's MAR, dated 01/05/25 at 1:00 AM through 01/06/25 at 9:00 AM and located under the Orders tab of the EMR, revealed R16 received Dilaudid 2 mg every four hours as ordered. Review of R16's Progress Note, dated 01/06/25 at 1:31 PM, revealed, . approx. 1054 [10:54 AM] writer was called to patient room by CNA. Writer found patient unresponsive . Physician made aware and assessed and pronounced patient .During an interview on 09/24/25 at 3:51 PM, the Director of Nursing stated, Everyone has access to the Pyxis except for the new employees in their first 90 days. I feel it is hard enough to learn the medication cart and the procedures for giving medications. There is always someone working with them that has access, along with a nursing supervisor who is here that can get medications that they may need out of the Pyxis.Attempts to call Licensed Practical Nurse (LPN) 9 were made on 09/24/25 at 4:22 PM and on 09/26/25 at 9:29 AM. Voice messages were left with a callback number. There was no return call received from LPN9 prior to the exit conference on 09/26/25.During a phone interview on 09/24/25 at 4:24 PM, LPN10 stated, I don't remember [R16].During an interview on 09/24/25 at 4:30 PM, the Pharmacist stated, The facility can call us and ask for a STAT order to be delivered, and we will do that even if it is a holiday. The Pharmacist stated the pharmacy did not receive a written prescription for Dilaudid when R16 was admitted to the facility, and did not receive a written prescription on 01/02/25. The Pharmacist confirmed the first script received from the facility for R16 was on 01/05/25 at 8:09 AM, four days after admission.During an interview on 09/25/25 at 11:30 AM, the DON stated, I do not recall being made aware of this resident's medications not being available from the pharmacy. But the nurses and the nursing supervisor, once they noted the medications were not being delivered, they should have called the pharmacy back to ask about them. But to the specifics of this case regarding the pain, I will have to review this further and get back to you.During a phone interview on 09/26/25 at 10:25 AM, LPN12 stated, I do remember there was a time we had to wait for pharmacy because there was no Dilaudid in the building. I didn't have access to the Pyxis because I was within my first 90 days of being employed at the facility. During that time, if medicines were taken out of the Pyxis, another nurse would have to go and get them for me.During an interview on 09/26/25 at 1:16 PM, LPN13 stated if a resident did not have pain medications available, staff should notify the Physician for an alternative medication so the resident could have relief from the pain. LPN13 stated pain should be assessed, documented, and reassessed for effectiveness after pain medication was given. She stated if the medication was not effective, the Physician should be notified to see what else could be done.During an interview on 09/26/25 at 1:56 PM, the DON was asked if she had any additional information after reviewing R16's chart on 09/25/25 after our interview, as documented above. The DON stated she did not have any additional information.During an interview on 09/26/25 at 2:17 PM, LPN3 stated that if medications were not available for a resident, staff should pull the medications from the Pyxis, call the doctor, and call the pharmacy. LPN3 stated you could not just leave the residents in pain.Review of the undated facility's policy Pain Management indicated, . to help the resident attain or maintain his/her highest practical level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs . Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences .NJAC 8:39-27.1(a)

Complaint #: 398975Based on record review, interview, and document review, the facility failed to acquire pain medications as ordered by the physician for one of 16 sampled residents (Resident (R)16). R16 was admitted to the facility with diagnoses including pancreatic adenocarcinoma and had admitting orders for pain medications, in particular Dilaudid (an opioid pain medication used to treat moderate to severe pain), and staff failed to acquire the medication. This failure of R16 not receiving the ordered medication for pain caused harm and increased the likelihood for a painful death.The facility's Administrator, Director of Nursing (DON), and Regional Nurse Consultant (RNC) were informed on 09/25/25 at 7:40 PM an Immediate Jeopardy (IJ) existed at F755 Pharmacy Services related to the failure of not acquiring physician ordered pain medications which R16 had ordered since admission to the facility on [DATE]. The Immediate Jeopardy began on 12/31/24, the date of R16's admission to the facility.The facility provided an acceptable Removal Plan on 09/26/25 at 11:45 AM. The removal plan consisted of education to the licensed nursing staff on the Medication Procurement and Pharmacy Services Policies, timeframes for pharmacy notification when medications are not delivered, if ordered pain medications are unavailable, the nurse will immediately notify the Supervisor; if unresolved, the issue will be escalated to the DON, and if still unresolved, the Medical Director will be contacted without delay, use of the Pyxis for immediate availability of narcotics at admission, and for any resident experiencing unmanaged pain, the nurse will place a call to the physician for alternate orders, and the resident will be provided alternate physician ordered medication to ensure relief until the prescribed narcotic is available. Through interviews, and review of staff education needs, the survey team removed the IJ, effective 09/26/25 at 2:40 PM. Review of R16's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), and review of the Hospital Discharge Summary, located under the MISC (Miscellaneous) tab in the EMR, indicated R16 was admitted to the facility on [DATE] at 10:30 PM with diagnoses that included pancreatic adenocarcinoma, an upper gastrointestinal bleed, portal vein thrombosis, esophagitis, unspecified without bleeding, and esophageal varices without bleeding. The resident had a [NAME] Roth I Gastroduodenostomy (surgical procedure where the lower portion of the stomach is removed and then connected to the duodenum (first part of small intestine) with this being complicated by a biliary leak.Review of R16's admitting Physician Orders, located under the Orders tab in the EMR, revealed orders for medications including Dilaudid 2 milligrams (mg), give 0.5 tab every four hours as needed for pain and acetaminophen 325 mg three tabs every four hours as needed for mild pain.Review of R16's Nursing Progress Note, located under the Progress Note tab in the EMR and dated 01/01/25 at 1:35 PM, revealed, . patient stating in high level of pain. Called pharmacy at 1300 [1:00 PM] to confirm they received patient's medication Rx [prescription] . medication should be delivered no later than 1800 [6:00 PM]. On call physician . prescribed a PRN [as needed] for Tramadol 50 mg PO [by mouth] q 6hr [every six hours] .Review of R16's entire clinical record revealed no documented evidence that the resident received Tramadol at that time.It was documented that the resident received three 325mg acetaminophen tablets which decreased the pain to a three at 2:48 PM. The nurse documented . minimal relief noted . The resident's pain was assessed to be a 7 on the day and night shifts on 01/01/25.Review of R16's Medication Administration Record (MAR), dated 01/02/25 at 1:20 AM and located under the Orders tab of the EMR, revealed the resident's pain level was noted to be 7, on a zero to 10 scale. It was recorded R16 was administered Tramadol 50 mg. This was documented as being effective at 1:42 AM, but no pain level was documented.Review of R16's MAR, dated 01/02/25 at 11:51 AM and located under the Orders tab of the EMR, revealed the resident's pain level was noted to be 10. It was recorded the resident was administered Dilaudid, 2mg give 0.5 tab. This is the first time the resident was provided Dilaudid, and it was approximately 35 hours after arriving at the facility.Review of the facility's Pyxis system (computerized medication dispensing machine used for emergency, first-dose, and other situations where medications are not readily available from the pharmacy) report, provided by the facility, revealed this dose of Dilaudid was taken from the facility's Pyxis system to administer to R16 at the documented time.Review of R7's Practitioner Note, with a date of service of 01/02/25 at 9:56 PM and located under the Progress Notes tab of the EMR, revealed, . Presented to [hospital name] ED with coffee ground emesis. Was found in work up to have esophagitis but no bleeding and had open G tube done. During procedure was found to have changes suggestive of recurrence of cancer and IR biopsy was positive for recurrent pancreatic CA [cancer] . Patient c/o [complained of] abdominal pain . Nsg [Nursing] concerned about coffee ground emesis, uncontrolled pain . Dilaudid 1 mg not managing pain. Increased dilaudid to 2mg q4 [every four hours around the clock] . Chronic pain due to malignant neoplastic disease - increased dilaudid to 2mg q [every] 4 . Script written . Awaiting . evaluation for pain management recommendations .Review of R16's MAR, dated 01/2025 and located under the Orders tab of the EMR, revealed R16's Dilaudid 2mg every four hours was to be administered at 1:00 AM, 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM.From 01/02/25 at 2:32 PM through 01/03/25 at 9:00 PM, it was recorded R16 received the Dilaudid as ordered by the physician. Review of the Pyxis system report revealed all of these doses of Dilaudid came from the Pyxis in the facility.Review of a Provider Note, dated 01/03/25 at 8:10 PM and located under the Progress Notes tab of the EMR, indicated, . feels much better today than . did yesterday . is very appreciative that .pain medications have been adjusted along with .Zofran which are really controlling .symptoms .Review of R16's MAR, dated 01/04/25 at 1:00 AM and located under the Orders tab of the EMR revealed:1:00 AM - A 5 was documented where R16's Dilaudid was supposed to be documented as being given. The MAR indicated 5 meant Hold/See Nurse Notes. No pain level was documented. There was no documented evidence of why the Dilaudid was not administered.3:42 AM - Tramadol 50 mg was administered to R16. It was recorded the resident's pain level was 9 and the medication was ineffective.5:00 AM - A 5 was documented where R16's Dilaudid was supposed to be documented as being given. It was recorded R16 had a pain level of 9.Review of R16's eMAR-Medication Administration Note, dated 01/04/25 at 5:01 AM and located under the Progress Notes tab of the EMR, revealed, . Dilaudid . 2 mg . medication unavailable, Tramadol given, proven effective .Review of R16's Progress Note, dated01/04/25 at 5:02 AM and located under the Progress Notes tab of the EMR, revealed, . Dilaudid 2 mg . pharmacy needs script from physician, PRN Tramadol given .Review of R16's eMAR - Medication Administration Note, dated01/04/25 at 6:27 AM, revealed, . tramadol 50 mg . PRN Administration was: Ineffective Follow-up pain scale was: 7 . This was recorded as a follow-up to the 3:42 AM note. Review of R16's eMAR - Medication Administration Note, dated 01/04/25 at 9:07 AM, revealed, . awaiting pharmacy delivery of medication . SEE NOTES . There was no documented evidence why the Dilaudid was held or why no Tramadol was given Review of R16's MAR, dated 01/04/25 at 1:00 PM and located under the Orders tab of the EMR, revealed documentation Dilaudid 2mg was administered. There was no pain scale documented. Review of the Pyxis system report revealed no documented evidence Dilaudid was removed from the Pyxis system during this time period for R16.Review of R16's Progress Note, dated 01/04/25 at 2:29 PM and located under the Progress Notes tab of the EMR, revealed, . Wound Management was unable to perform due to resident staying [sic] to the resident of experiencing extreme pain . There was no documented evidence pain medications were given.Review of R16's MAR, dated 01/04/25 at 5:00 PM and located under the Orders tab of the EMR, revealed the resident's Dilaudid was not administered as ordered. There was no documented evidence the resident's pain level was evaluated.Review of R16's eMAR - Medication Administration Note, dated01/04/25 at 5:07 PM and located under the Progress Notes tab of the EMR, revealed, . Dilaudid . 2 mg Awaiting Pharmacy delivery of medications, Shift Supervisor made aware of the situation. SEE NOTES . There were no notes documented in the EMR and no documented evidence R16 was provided any pain medication.Review of R16's General Nurses Note, dated 01/04/25 at 5:15 PM and located under the Progress Notes tab of the EMR, revealed, . Resident currently prescribed Dilaudid 2 mg and Marinol 5 mg. Medications are currently on order. Resident did not mention pain to the writer earlier on the shift whilst awaiting pharmacy delivery of medication. However, at this time, the resident is requesting pain meds . Doctor was called for an intervention around 1645 [4:45 PM], voicemail was left to return call . Review of the Pyxis report, dated 01/04/25 at 6:24 PM and provided by the facility, revealed Tramadol 50 mg removed for R16; however, there was no documented evidence the medication was administered to R16.Review of R16's General Nurses Note, dated 01/04/25 at 7:19 PM and located under the Orders tab of the EMR, revealed, . Writer called the pharmacy to get info regarding the resident's Controlled Substances . Resident did not receive Dilaudid or Marinol on 0700-1900 shift. [Name of pharmacy] notified the writer that these medications were not listed with them. NP from . stated to the writer that shed [sic] be contacting [name of pharmacy] to rectify this matter .Review of the Pyxis system report, provided by the facility, revealed on 01/04/25 at 7:31 PM, one Dilaudid 4 mg tab was removed from the Pyxis system for R16.Review of R16's General Nurses Note, dated 01/04/25 at 8:02 PM and located under the Orders tab of the EMR, revealed, . Resident was given Tramadol 50 mg tablet as a breakthrough for pain without relief. At 1900 [7:00 PM] oncoming shift nurse located Dilauded [sic] 4 mg tab and provided 1/2 tab to the resident . Supervisor also aware of each stage of this situation . This was the first Dilaudid administered since 01/04/25 at 1:00 PM, seven hours earlier.Review of R16's MAR, dated 01/04/25 at 9:00 PM and located under the Orders tab of the EMR, revealed R16's pain was rated at 8, and Dilaudid 2mg was administered.Review of R16's MAR, dated 01/05/25 at 1:00 AM and located under the Orders tab of the EMR revealed R16 received 2mg Dilaudid.Review of R16's MAR, dated 01/05/25 and located under the Orders tab of the EMR, revealed on 01/05/25 at 5:00 AM, 9:00 AM 1:00PM, 5:00PM, and 9:00PM, R16 received 2mg of Dilaudid.Review of R16's Manifest Delivery, provided by the pharmacy and dated 01/05/25, indicated Dilaudid was received from the pharmacy at 10:21 PM, as evidenced by a nurse's signature present on this manifest.Review of R16's MAR, dated 01/05/25 at 1:00 AM through 01/06/25 at 9:00 AM and located under the Orders tab of the EMR, revealed R16 received Dilaudid 2 mg every four hours as ordered. Review of R16's Progress Note, dated 01/06/25 at 1:31 PM, revealed, . approx. 1054 [10:54 AM] writer was called to patient room by CNA. Writer found patient unresponsive . Physician made aware and assessed and pronounced patient .During an interview on 09/24/25 at 3:51 PM, the Director of Nursing stated, Everyone has access to the Pyxis except for the new employees in their first 90 days. I feel it is hard enough to learn the medication cart and the procedures in giving medications. There is always someone working with them that has access along with a nursing supervisor that is here that can get medications that they may need out of the Pyxis.During an interview on 09/24/25 at 4:30 PM, the Pharmacist stated, The facility can call us and ask for a STAT order to be delivered, and we will do that even if it is a holiday. The pharmacist stated the pharmacy did not receive a written prescription for Dilaudid when R16 was admitted to the facility and did not receive a written prescription on 01/02/25. The pharmacist confirmed the first script received from the facility for R16 was on 01/05/25 at 8:09 AM, four days after admission.During an interview on 09/25/25 at 11:30 AM, the DON stated, I do not recall being made aware of this resident's medications not being available from the pharmacy. But the nurses and the nursing supervisor, once they noted the medications were not being delivered, they should have called the pharmacy back to ask about them. But to the specifics of this case regarding the pain, I will have to review this further and get back to you.During a phone interview on 09/26/25 at 10:25 AM, LPN12 stated, I do remember there was a time we had to wait for pharmacy because there was no Dilaudid in the building. I didn't have access to the Pyxis because I was within my first 90 days of being employed at the facility. During that time, if medicines were taken out of the Pyxis, another nurse would have to go and get them for me.During an interview on 09/26/25 at 1:16 PM, LPN13 stated if medications are not available for residents, there are supervisors to help. LPN13 stated you would call the pharmacy, notify the physician for an alternative medication, call the DON, and call the Medical Director if you had no results.During an interview on 09/26/25 at 1:30 PM, LPN7 stated if an ordered medication was not available, staff should go to the Pyxis for that one time, but you do not give scheduled medications out of the backup. LPN7 stated you should call the pharmacy, obtain a prescription if one if needed, and ask for a STAT delivery if required.During an interview on 09/26/25 at 1:56 PM, the DON was asked if she had any additional information after reviewing R16's chart on 09/25/25 after our interview, as documented above. The DON stated she did not have any additional information.During an interview on 09/26/25 at 2:17 PM, LPN3 stated if medications were not available for a resident, staff should pull the medications from the Pyxis, call the doctor, and call the pharmacy. LPN3 stated you could not just leave the residents in pain.Review of the Pharmacy policy Providing Pharmacy Services dated February 2023 indicated, .When medication is needed prior to the next scheduled delivery and is not contained in the back-up box/ stat/ emergency kit drug supply, the pharmacist arranges for both the dispensing and delivery of medication to the facility within the time frame specified by contract; . Medication may be dispensed by either [Name of Pharmacy] or a back-up pharmacy and delivered by either a [Name of Pharmacy] driver, back-up pharmacy, or a courier service . NJAC 8:39-29.2(d)

Based on record review, interview, and document review, the facility failed to have an ongoing quality assurance and performance (QAPI) program demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse effects; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities to address systematic failures in recognizing a decline in a resident's change in condition for one of 16 residents (Resident (R) 7) and failing to consistently provide pain management and failing to have Dilaudid pain medication ordered upon admission for one of 16 residents (R) 16). These incidents created serious harm for R7 and R16. The lack of acknowledging the failures had the potential to affect all residents at the facility. Review of the undated facility's policy titled, Quality Assurance and Performance Improvement (QAPI) indicated, . it is the policy of the facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . 'Adverse Event' is an untoward, undesirable and usually unanticipated event that causes the death or serious injury, or the risk thereof . Medical errors and adverse events are routinely tracked. Facility staff monitor residents for medical errors and adverse events in accordance with established procedures for the type of adverse event . An investigation will be conducted on each identified medical error or adverse vent to analyze causes . Preventive actions and mechanisms will be implemented to prevent medical errors and adverse events, including feedback and education . Monitoring will be conducted to ensure desired outcomes are achieved and sustained .1. Review of R7's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R7 was admitted to the facility in 12/2024 with the diagnosis of myelodysplastic syndrome, anemia, and acute congestive heart failure.Review of R7's AUTM Admit/Readmit Screener 1.0 -V 8, dated 12/30/24, indicated R7 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R7 was cognitively intact.The facility failed to notify the physician of R7's refusal to have an immediate (STAT) laboratory test on 12/30/24 and 12/31/24; failed to obtain a Urine with Culture and Sensitivity (C&S) test when ordered on 12/31/25; failed to monitor the resident after reports of nausea without emesis for three days, decreased appetite secondary to the nausea, and continued diarrhea; and failed to act upon a critically high white blood cell (WBC) count for R7.In an interview on 09/22/25 at 12:50 PM, the Director of Nursing (DON) was asked the definition of an adverse effect and the DON stated, You don't get the expected outcome of a situation. The DON was asked if the event with R7 which occurred on 01/02/25 was an adverse outcome and the DON stated, Yes, it would. At this time, the surveyor requested the QAPI meeting minutes for January 2025. The DON returned at 1:00 PM and brought in a copy of the Performance Improvement - project assignment tool dated 01/28/25. The DON stated that the facility implemented a Performance Improvement Plan (PIP) through their quality assurance and performance improvement (QAPI) program regarding the unexpected death of R7 which had occurred in the facility on 01/02/25.Review of this PIP indicated the facility identified lack of documentation regarding adequate interventions and appropriate follow up in the EMAR [electronic medical administration record] system and PCC [Point Click Care] progress notes.Further review of the PIP identified Process to be implemented to reach an acceptable level of performance: 100% were to:-Re-educate staff on the timelines and accuracy of resident change in condition recognition-Re-educate staff on proper documentation and communication with MD [Medical Doctor]/NP [Nurse Practitioner]/PA [Physician Assistant]-Strengthening communication protocols between nursing, providers, and families-Implement clinical monitoring audit with IDT [Interdisciplinary Team] for each death-Strengthen 24-hour report review process by Unit Managers and DON-Initiate mortality review meetings with IDT for each death-Implement death log to be maintained and reviewed monthly in QAPIWith the results of these audits will be reviewed monthly by the Director of Nursing and will be reported monthly to the QAPI committee. Findings tracked, trends identified, and corrective actions revised as needed.Review of the Case Review Form (complete for EACH death) indicated the review for R7 indicated a review was conducted in the following areas:- .Date/Time of Death indicated 1/2/25 [sic]-Location Facility was marked-Code Status indicated FC [Full Code]-Advance Directives on file Yes was checked-Hospice/Palliative Care involved No was checked-Immediate Notifications & [and] [sic]-Provider Notified at 1/2/25 [sic] was written in-Next of Kin/Representative notified at 1/2/25 [sic] was written in by was left blank-Hospice notified at was marked through-Coroner/Medical Examiner notified at family notification - 1/2/25 [sic] at 10:30 was written in-State reportable event determination completed at was marked through-Post-mortem care provided per policy at 1/2/25 [sic] was written in by [Licensed Practical Nurse (LPN)4 and LPN3]-Medication secure/Accounted for (controlled count completed) was checked-Room/Belongings secured and inventory initiated was checked-Clinical Synopsis MDS was written in-Medication and Treatment Review Attached was written in-Systems Reviewed was written in-Root Cause Analysis (RCA) MDS, [arrow pointing up] WBC [White Blood Count] [unable to make out abbreviation], diarrhea, nausea was written in-Family Communication & Support was left blank-IDT [Interdisciplinary] Review Meeting Summary labs review + [and] symptom management was written in-Action Plan per PIP [Performance Improvement Plan was written in.Written in on the side of the review page was the following notation: MDS [myelodysplastic syndrome] - Gradual decline in bone marrow function - sudden death can occur, Risk mainly r/t [related to] complications of disease rather than marrow fx [function] itself. WBC [with an arrow pointing up] 26.4. During an interview on 09/23/25 at 4:56 PM, the DON was asked if she had direct interviews with the nursing staff that took care of R7 on 01/01/25. The DON stated, We worked backwards when it initially happened. I talked with the day shift nurses that were taking care of [R7], and then I talked with the overnight supervisor and to [PA2]. Asked what was found out during these interviews with the staff members and the DON stated, There was not much information outside of the diarrhea she was having. The supervisor stated that on 3-11 pm shift there as a call to the on-call provider for the lab results and the ongoing diarrhea. But nothing other those issues. Asked if the DON would expect her night shift nurse to document on her shift the condition of the resident when it was reported to her that the patient had watery stools with loss of appetite for three days, stat labs were performed and there were orders to give Imodium after each watery stool and to encourage fluids? The DON stated, Yes, there should have been documentation of this. The DON denied interviewing the night shift nurse that worked the 7 pm - 7 AM shift with R7 on 01/01/25.During an interview on 09/23/25 at 5:42 PM, the DON presented Case Study Question for documentation and change in condition and made this interactive with staff. The case studies provided the nurses with scenarios that they could encounter while working on the units. The studies were discussed with staff by presenters that were either the DON or the two unit managers. The DON stated, I didn't go and copy anyone's record or notes to go over. We just took these scenarios and discussed why you would add more to your nursing notes to show the clinical picture you are seeing of a resident that is having a change in condition for example. With this resident [R7] documentation and change in condition were the areas that were identified as weak or needed improvement in her record.2. Review of R16's undated Face Sheet located under the Profile tab in the EMR and the Discharge Summary from the hospital dated 12/31/24 and located under the MISC tab in the EMR indicated R16 was admitted to the facility on [DATE] at 10:30 PM with diagnoses that included pancreatic adenocarcinoma, an upper gastrointestinal bleed, portal vein thrombosis, esophagitis, unspecified without bleeding, and esophageal varices without bleeding. The resident had a Billroth I Gastroduodenostomy (surgical procedure where the lower portion of the stomach is removed and then connected to the duodenum (first part of small intestine) which was complicated by a biliary leak.Review of R16's Nursing Progress Note located under the Progress Note tab in the EMR indicated a note dated 01/01/25 at 12:46 AM which indicated, .Pt [patient] is alert and oriented x [times] 2 [sic] [person, place and time]. Pleasant and cooperative with care.The facility failed to consistently provide pain management for R16. R16 was admitted to the facility with diagnoses including pancreatic adenocarcinoma and had admitting orders for pain medications, in particular Dilaudid (an opioid pain medication used to treat moderate to severe pain), and staff failed to administer the medication as ordered. R16 had pain levels up to a 10 (on a zero to 10 scale, with 10 being the most intense pain possible). This failure of R16 not receiving the ordered medication for pain caused harm and increased the likelihood for a painful death.During an interview on 09/24/25 at 4:30 PM, the Pharmacist stated this written script for Dilaudid, as well as one for the admission order for Dilaudid, was not received at the pharmacy until 01/05/25.During an interview on 09/25/25 at 11:30 AM, the DON stated, I do not recall being made aware of this resident's medications not being available from the pharmacy. But the nurses and the nursing supervisor once they noted the medications were not being delivered, they should have called the pharmacy back to ask about them. But to the specifics of this case regarding the pain, I will have to review this further and get back to you.Review of the Case Review Form (complete for EACH death) indicated the review for R16 indicated a review was conducted in the following areas:-.Date/Time of Death indicated 1/6/25 [sic]-Location Facility was marked-Code Status indicated DNR [Do Not Resuscitate]/DNI [Do Not Intubate]/DNH [Do Not Hospitalize]-Advance Directives on file Yes was checked-Hospice/Palliative Care involved No was checked-Immediate Notifications & [and] [sic] Actions-Provider Notified at 1/6/25 [sic] was written in by 10:55 was written in-Next of Kin/Representative notified at 11 A [sic] [AM] was written in by was left blank-Hospice notified at was marked through-Coroner/Medical Examiner notified at was marked through and written was family notification - [name of funeral home] was written in-State reportable event determination completed at was marked through-Post-mortem care provided per policy at 1/2/25 [sic] was written in by [name of LPN4]-Medication secure/Accounted for (controlled count completed) was checked-Room/Belongings secured and inventory initiated was checked-Clinical Synopsis MDS was written in-Medication and Treatment Review Reviewed w/ [with] IDT Team was written in-Systems Reviewed Attached was written in-Root Cause Analysis (RCA) Pancreatic CA [cancer], Esophageal Varicies [sic], Cirrhosis was written in-Family Communication & Support via [by] telephone + bedside was written in-IDT [Interdisciplinary] Review Meeting Summary 1/28/25 was written in-Action Plan PIP was written in.During an interview on 09/25/25 at 4:00 PM, the DON stated, We did a mortality review, but it wasn't an in-depth review of the Dilaudid specifically being available.During an interview on 09/26/25 at 10:19 AM, the Medical Director stated his expectations of the DON and the IDT Team in regard to the PIP for the unexpected death, was to Be able to pinpoint the breakdowns and failures that have occurred and fix these along with providing education to the staff. Then after the education piece and failures have been fixed; go back and access how it is or is not working and consistently be aware of all of this to make sure the staff is properly implementing the changes. In other words, you have to drive the bus to make sure it doesn't happen again and to monitor that everything is being carried out by the staff properly. Asked what his role was in the PIP process for the unexpected death and the Medical Director stated, They ran thing by me saying this is what we are doing and is there anything else you can think of that would help in this situation.During an interview on 09/26/25 at 1:00 PM, the Administrator stated, We go over the reviews that the DON and the IDT team do for the deaths that occur in the building for each month. The PIP for this was started before I came in February, so I was told there was an unexpected death is the reason we were doing the PIP. The DON does the initial review of each death and brings to QAPI each month where we discuss the mortality reviews and he findings for each. I expect the DON to see the weaknesses that we had with each death to see what we can do better and then initiate these changes to reflect better quality of care.Review of the DON's job description indicated, . Develop, implement, and maintain an ongoing quality assurance program for the nursing service department . Assist the Quality Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies . NJAC 8:39-33.1

Based on observation, record review, and interview, the facility failed to ensure infection control was maintained during observation of medication administration for two of five residents (Resident (R)14 and R13) observed out of a total sample of 15 residents. This failure had the potential to introduce infections to the residents.1.Review of R14's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R14 was admitted to the facility in 9/2025.Observation on 09/11/25 at 5:40 AM, revealed Licensed Practical Nurse (LPN)1 was observed with her bare index and middle finger inside of the medication cup which contained R14's medication. LPN1 administered the medications from the cup to R14. 2.Review of R13's undated Face Sheet located under the Profile tab in the EMR indicated R13 was admitted to the facility in 08/2025.During an observation on 09/11/25 at 5:49 AM LPN1 was observed with her index finger touching the inside of the medication cup. LPN1 administered the medications from the cup to R13. LPN1 did not have gloves on during this observation.During an interview on 09/11/25 at 5:50 AM, LPN1 stated, I should not have touched the inside of the medication cup with my bare fingers.During an interview on 09/11/25 at 9:48 AM, the Infection Preventionist (IP) stated, The nurse should never touch the inside of the medication cup with her bare hands or fingers prior to giving the medication.During an interview on 09/12/25 at 12:10 PM, the Director of Nursing (DON) stated, She [LPN1] should not have touched her bare fingers inside of the medication cup.NJAC 8:39-19.4 (a)(1)

Complaint #: NJ00180094 Based on interviews, medical record review, and review of other pertinent facility documentation on 11/26/2024 and 11/27/2024, it was determined that: the facility failed to provide the correct therapeutic diet to a cognitively impaired resident (Resident #3) with a known diagnosis of dysphagia, pharyngeal phase who had a physician's order and plan of care for ground diet and required feeding assistance. It was determined that on 11/12/2024 a Certified Nursing Assistant (CNA) delivered a meal tray containing a regular texture meal to Resident #3, who had orders for a ground diet. The regular texture meal was left with Resident #3. The CNA confirmed that Resident #3's meal tray included corn and tortillas that were not ground texture. The resident's family arrived shortly after the tray was left with Resident #3 and observed the resident with food in her/his mouth. The family reported to facility staff that Resident #3 was choking. The facility also failed to follow its policies titled Therapeutic Diet Orders and Comprehensive Care Plans. This deficient practice was identified for 1of 3 residents (Resident #3) reviewed for therapeutic diet orders and posed a hazard to residents with the need for mechanically altered diets. This deficient practice had the potential to result in serious injury or death. The past noncompliance and Immediate Jeopardy began on 11/12/24 and ended on 11/13/2024 after the facility implemented a systemic plan before this complaint survey began. The facility's plan included the following: On 11/12/2024 Resident #3 was assessed for aspiration precautions. On 11/12/2024 Resident #3's physician was notified of the incident. On 11/12/2024 the DON (Director of Nursing) was notified of the incident. On 11/12/2024 at 2:00 P.M., the CNA was in-serviced regarding verification of tray and ticket information. On 11/13/2024 resident care staff was in-serviced regarding meal tray accuracy. On 11/13/2024 kitchen staff were in-serviced regarding ensuring resident meals are of the correct texture. On 11/13/2024 the [NAME] on shift at the time of the incident was given an Employee Corrective Action related to failure to follow the meal tracker ticket as read. On 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, and 11/17/2024 tray accuracy audits were performed for Resident #3's breakfast, lunch, and dinner trays. 100% accuracy was documented. On 11/13/2024 the facility initiated weekly meal tray audits for texture meals and tray accuracy for all residents. On 11/13/2024 a system compliance plan was developed to submit texture meals and tray accuracy results to Quality Assurance and Performance Improvement (QAPI) on an ongoing basis. According to the Admission Record, Resident #3 was admitted to the facility with diagnoses which included but were not limited to dysphagia, pharyngeal phase (difficulty swallowing); other lack of coordination; and need for assistance with personal care. According to the most recent Minimum Data Set (MDS), an assessment tool, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 5 out of 15, which indicated the Resident #3's cognition was severely impaired. Review of the facility's untitled document dated 11/12/2024 and timed 21:55 (9:55 PM) under Incident Description revealed Aid identified that resident received the incorrect tray. Tray was removed and a new diet tray was provided to resident. Review of Resident #3's Progress Notes (PNs) revealed an undated and untimed LATE ENTRY authored by the facility's Director of Nursing (DON) that revealed Patient was assessed and monitored for aspiration precautions. Review of Resident #3's Care Plan (CP), undated, included a focus of, nutritional status (Resident #3) is at nutrition risk due to inadequate oral intakes, chewing difficulties, self feeding deficits and recent wt [weight] loss. Dysphagia pharyngeal phase [.] mechanically altered diet Ground. The CP included an undated intervention to Provide diet as ordered: 2 gm [gram] Na [sodium] ground, 1500cc [cubic centimeter] FR [fluid restriction]. Review of the facility document Order Summary Report (OSR), dated 11/26/2024, revealed an order, dated 11/05/2024 for a ground texture diet with sodium and fluid restrictions. The OSR also revealed an order dated 11/06/2024 which indicated that Resident #3 required assistance and extra time for feeding. Review of Resident #3's dinner meal ticket, dated 11/12/2024, revealed 2 Gm Na- Ground at the top of the ticket in bold lettering. The items selected for Resident #3 included mashed potatoes, pureed stewed tomatoes, and pureed cinnamon brown sugar blondie. During an interview on 11/26/2024 at 12:52 PM, Licensed Practical Nurse (LPN) #1 stated that there should be a diet order for each resident. LPN #1 stated that CNAs passed trays to each resident at mealtimes. LPN #1 stated that the expectation was that trays were checked at the residents' bedside and matched to the meal ticket. LPN #1 stated that the CNA should have notified a nurse if a tray seemed wrong for any reason. The nurse should then address the issue with the kitchen. LPN #1 further stated that CNAs did the feedings and should have notified nurse with any feeding concerns. During a telephone interview on 11/26/2024 at 3:56 P.M., the CNA informed the surveyor that on 11/12/2024 she delivered a regular texture tray to Resident #3. The CNA stated that Resident #3 got tortillas, corn, and something else. The CNA stated that she set the tray up for Resident #3 and the resident started eating. The CNA further stated that she was not aware that Resident #3 was on a altered texture diet or that the resident required feeding assistance. The CNA further stated that 10 minutes later Resident #3's family reported that the resident was choking. The CNA stated, The resident had food in (their) mouth, I think (they) just couldn't chew it. During an interview on 11/27/2024 at 11:00 AM, the Food Service Director (FSD) stated that tray accuracy was important because getting the wrong food could have caused harm and possibly death to a resident because of choking or allergies. The FSD stated that the current process was for nursing staff to complete diet slips for each resident. The diet slips included name, room number, allergies, diet, and preferences. The FSD further stated that the FSD then entered the diet slip information into MealTracker (a nutrition management software) and printed a ticket to ensure accuracy. The FSD stated that as a tray was prepared it moved down a tray line where a Dietary Aide (DA) placed liquids and condiments. The [NAME] would have then looked at the ticket to determine what went on the resident's plate. The last person working on the tray line was usually a DA who was supposed to verify that the meal matched the ticket. The FSD stated that the expectation was for the [NAME] to make sure the correct texture food went on the residents' meal tray. The FSD stated that the facility did not follow its policy related to resident diet because a resident received the wrong meal. The FSD went on to state that the [NAME] on the P.M. shift on 11/12/2024 was given a verbal warning due to the meal ticket not being followed. During an interview on 11/27/2024 at 1:15 PM, LPN #2 stated that it was important to follow doctors' orders to make sure that residents received the care that they needed. LPN #2 stated that it was the expectation that residents' care plans (CPs) were followed by all staff. LPN #2 stated that if care plans were not followed errors or neglect could have happened. During an interview on 11/27/2024 at 1:49 P.M., the DON stated that it was expected that meals received by residents were in accordance with physician orders. The DON further stated that the expectation was that staff verified the ordered diet to what came on the meal tray to ensure accuracy. The DON stated that if a resident received the wrong diet and consumed it the outcome would have to be evaluated on a case-by-case basis. The DON stated that resident CPs were individualized to every resident and tailored to their needs. The DON further stated that CPs should have been followed by all staff and that there could be a hindrance to the resident if their CPs were not followed. Review of the facility's Therapeutic Diets policy, revised 10/2022, revealed under the Policy Statement All residents have a diet order [.] that is prescribed by the attending physician, physician extender, or credentialed practitioner. Under Procedures the policy revealed Diets are prepared in accordance with guidelines in the approved Diet Manual and the individualized plan of care. Review of the facility policy titled Comprehensive Care plans revealed Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the facility document titled Diet and Nutrition Care Manual IDDSI Level 5: Minced and Moist with ground handwritten at the top of the pages was conducted on 11/27/2024. This section of the Diet and Nutrition Care Manual revealed This diet may be appropriate for individuals with swallowing or dental problems and requires no chewing or biting. The list of food examples in this category included but were not limited to Vegetables cooked, finely mashed or use a blender to finely chop it into 4mm [millimeter] lump size pieces and Breads are gelled or pureed following a recipe. NJAC 8:39-17.4(a)(2)

Complaint #: NJ00180094 Based on observation, interview, and record review, it was determined that the facility failed to appropriately respond to a resident family's request regarding resident food preferences and follow the facility policy related to resident self-determination. This deficient practice was identified for 1 of 1 resident reviewed for choices (Resident #3) and was evidenced by the following: A review of the Admission Record (AR) reflected that Resident #3 was admitted to the facility with diagnoses which included but were not limited to dysphagia, pharyngeal phase (difficulty swallowing); other lack of coordination; and need for assistance with personal care. According to the most recent Minimum Data Set (MDS), an assessment tool, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 5 out of 15, which indicated the resident's cognition was severely impaired. During a unit tour on 11/26/2024 at 11:57 A.M., the surveyor observed a large sign with large writing that read please do not feed pudding or milk on the room door of Resident #3. No milk, no pudding was also observed written on the whiteboard in Resident #3's room. The same signage remained in place during a meal observation on 11/27/2024. During a lunchtime meal observation on the third floor on 11/27/2024 at 12:44 P.M., the surveyor observed Resident #3's meal tray arrive. The tray contained a clear plastic cup filled with a creamy appearing yellow substance. The Assistant Director of Nursing (ADON) confirmed that the creamy yellow substance was pudding. During an interview on 11/27/2024 at 1:01 P.M., the ADON stated that Resident #3's family placed the signs about pudding on the resident's door. The ADON stated that if pudding was against the family's preferences, then it should not have been on the resident's tray. The ADON further stated that Nurses or Dieticians were responsible to notify the kitchen of this type of preference. During an interview on 11/27/2024 at 1:15 P.M., Licensed Practical Nurse (LPN) #2 stated everyone should follow resident preferences. LPN #2 went on to state that the person who was notified of a resident's preference should have made other staff aware. LPN #2 stated that everyone could have passed Resident #3's preference for no pudding along to dietary. The undated facility policy Resident Self Determination and Participation (Schedules) was reviewed. Under the section titled Policy Explanation and Compliance Guidelines the document revealed According to federal regulations the resident has the right to [.] c. Make choices about aspects of his or her life in the facility that are significant to the resident. Review of the Policy Explanation and Compliance Guidelines section of the Resident Self Determination and Participation (Schedules) policy document further revealed If the resident is unable to communicate preferences, the resident's family members should be asked for input. NJAC 8:39-17.4 (a)1

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to develop an individualized person-centered comprehensive care plan to address the needs of the resident for 4 of 25 sampled residents (Resident #1, #6, #96, and #99). This deficient practice was evidenced by the following: 1). On 10/23/2024 at 11:04 AM during the initial tour of the facility the surveyor observed Resident #1 who was seated on their bed eating breakfast. According to the admission record Resident #1 was admitted to the facility with the following but not limited to diagnoses: Type 2 diabetes mellitus. alcohol abuse, anxiety disorder, encounter for surgical aftercare following surgery on the circulatory system, and acute embolism and thrombosis of right tibial vein (conditions that disrupt blood flow). A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 09/29/2024, revealed under section Section V the following areas were to be care planned as checked off in column B: ADL/Functional Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Mood State, Activities, Falls, Nutritional Status, Pressure Ulcer, Psychotropic Drug Use, and Pain. On 10/28/2024 at 10:38 AM the surveyor conducted a review of the electronic medical record (EMR) of Resident #1. The EMR revealed under the care plan tab that Resident #1 had a comprehensive care plan that consisted of pain. The comprehensive care plan had the following Focus: The resident has (Specify: acute/chronic) pain r/t (related to) Date Initiated: 09/23/2024. Resident #1's care plan Goal was the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Date Initiated: 09/23/2024 Target Date: 10/08/2024 Cancelled Date: 10/29/2024.A further review of the comprehensive care plan (CP) revealed that Resident #1 had no care planned interventions for pain. There were no other Focus areas on the CP for Resident #1 prior to discharge from the facility. 2.) Resident #99 was reviewed by the surveyor for activities of daily living. On 10/24/2024 at 12:43 PM the surveyor reviewed Resident #99's EMR. A review of the Admission Record revealed that Resident #99 was admitted to the facility with the following but not limited to diagnoses: Cardiac arrest, fracture of right foot, fall, pain in left knee, protein-calorie malnutrition, and type 2 diabetes mellitus. A review of the MDS dated [DATE], revealed that according to Section V of the MDS, Resident #99 was triggered and proceeded to care plan for the following care areas according to column B: ADL (activities daily living) Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Nutritional Status, and Pressure Ulcer. On 10/24/2024 at 01:02 PM, the surveyor reviewed Resident #99's individualized comprehensive care plan. The care plan revealed that Resident #99 had only one (1) care planned area (nutritional status). 41442 3.) On 10/23/2024 at 11:50 AM, during the initial tour, Resident #6 was identified by the nurse as having advanced dementia. A review of Resident #6's Admission Record revealed that he/she had a diagnosis that included but not limited to, Dementia, Depression, Chronic Kidney Disease, Urinary Tract Infection, Cognitive Communication deficit, and history of Transient Ischemic Attacks and Cerebral Infarction. A review of the most recent comprehensive MDS dated [DATE], under section V: Care Area Assessment (CAA) Summary; the following care areas were identified as problems to address in the Individual Comprehensive Care Plan: Cognitive Loss/Dementia, Communication, Urinary Incontinence and Indwelling Catheter, Falls, Nutritional Status, Pressure Ulcer, and Psychotropic Drug Use. A review of Resident #6's Individualized Comprehensive Care Plan with an initiation date 09/25/2024, only included the following focus areas: [resident name] is at risk for behavior symptoms r/t Alzheimer's disease/dementia, mental illness, inappropriate comments. The CP further showed a Focus area of Nutritional status [resident name] is at nutrition risk due to inadequate oral intakes. 34423 4.) A review of Resident # 96's EMR was completed on 10/30/2024 at 08:35 AM, as follows: According to the Admission Record Resident #96 was admitted to the facility with diagnoses including but not limited to: Traumatic Subarachnoid Hemorrhage (bleeding in the brain), Pulmonary Embolism (blood clot in the lung), Type 2 Diabetes Mellitus with Diabetic Neuropathy, and colostomy status. A review of the most recent comprehensive MDS dated [DATE], revealed under section V the CAA Summary under A. Care Area Triggered the following areas were triggered Cognitive Loss/Dementia, ADL Function/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Psychosocial well-being, Activities, Falls, Nutritional Status, Pressure Ulcer, and Psychotropic Drug Use. Under B. Care Planning Decision Of the triggered areas, the CP decision was marked as yes for all except psychosocial well-being. A review of Resident #96's Individualized Comprehensive Care Plan revealed a Focus area of [resident name] has a potential nutritional problem r/t Diet restrictions for diabetes and weight gain. The CP also showed a Focus area of [resident name] is independent in his/her recreational choice. There were no other Focus areas that were identified in section V for care planning decision. There were no other Focus areas prior to Resident #96's discahrge from the facility. During an interview with the surveyor on 10/28/2024 at 12:33 PM, the Licensed Practical Nurse /Unit Manager (LPN/UM #1) said I was told to open it (CP) once the base line care plan is closed out within 48 hours of admission and then the comprehensive care plan is opened. LPN/UM #1 confirmed that the baseline care plan is closed out 48 hours after admission. When questioned as to what should be on the CP LPN/UM #1 said that is done as related to patient. If they are on psychotropic meds, anticoagulant, diagnoses and whatever else arises while they are here. LPN/UM #1 went on to say also Skin, ADL's, pain, catheter, ostomies, ABT, PICC line. I believe it is with in 21 days of patient being here the comprehensive care plan needs to be completed. During an interview with the surveyor on 10/29/2024 at 11:36 AM, LPN/UM #2, stated that the Comprehensive Care Plan is due after 26 days. The LPN/UM #2 was unable to speak to the Care Area Assessment (CAA) Summary or its role in developing the Comprehensive Care Plan. On 10/29/2024 at 01:53 PM, the surveyors team conducted an interview with the facility administrative staff which included the Licensed Nursing Home Administrator, Director of Nursing, and two (2) Regional Directors of Nursing (RDON). When interviewed both RDON's agreed that any Care Area Assessment (CAA) areas that are triggered should be care planned. The RDON's told the surveyors that comprehensive care plans should be completed within 7 days after the comprehensive assessment (MDS). A review of a facility policy on 10/29/2024 at 10:07 AM, an undated facility policy titled, Care Plans, Comprehensive Person-Centered, under #2: The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. NJAC 8:39-11.2(f)

Based on interview and record review, it was determined that the facility failed to complete a comprehensive Minimum Data Set (MDS), an assessment tool, within 14 days of resident admission to the facility. This deficient practice was identified for 1 of 25 sampled residents, (Resident #241) and was evidenced by the following: On 10/24/2024 at 09:55 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #241. The surveyor accessed the MDS tab in the EMR and reviewed the following: 10/17/2024 Admission/Medicare - 5 Day Status: In Progress In addition, review of the Next Tracking/Dischrg bar revealed that Resident #241's ARD (assessment reference date) was 10/24/2024 and was 5 days overdue. On 10/29/2024 at 09:42 AM, the surveyor conducted an interview with the facility MDS coordinator. The surveyor asked the MDS coordinator what the timeframe for completion of a comprehensive admission assessment for residents was admitted to the facility. The MDS coordinator told the surveyor that the residents admitted are either mostly Medicare or private insurance. We do get some Medicaid. The MDS coordinator went on to explain that a 5-day assessment must be completed within 14 days of admission. The surveyor asked the MDS coordinator to look up Resident #241's comprehensive admission assessment in the EMR. The MDS coordinator after viewing Resident #241's MDS admission assessment told the surveyor, I haven't completed the admission assessment. The surveyor asked the MDS coordinator if the MDS admission assessment was overdue and the MDS coordinator replied, Yes, according to the admitted , the admission assessment should've been completed on 10/24/2024. On 10/29/2024 at 1:20 PM, the Regional Director of Nursing confirmed to the surveyor that the admission assessment should have been completed on or before the 17th (of October) and stated that they had a MDS coordinator recently had resign. A review of the facility policy titled MDS 3.0 Completion, undated, revealed the following: 2. Types of OBRA (Omnibus Budget Reconciliation Act of 1987) Assessments: b. Admission Assessment - completed within 14 days of admission counting the day of admission as day #1 when: i. The resident has no prior admission, or ii. The prior admission was less than 14 days and no admission assessment was completed during the prior admission, or iii. Prior admission ended with a Discharge Return Not Anticipated; or iv. Prior admission ended with a Discharge Return Anticipated and re-entry occurred > 30 days after the discharge date . NJAC 8:39-11.2(e)

Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident. This deficient practice was identified for 2 of 25 sampled residents (Resident #90, #241) and was evidenced by the following: 1.) According to the Admission Record, Resident #90 was admitted to the facility with diagnoses including but not limited to: Malignant Neoplasm of the Mandible, Type 2 Diabetes, unspecified Protein-Calorie Malnutrition, and Tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway and help with breathing). A review of the [facility initials] Baseline Care Plan -V4 revealed that there are seven (7) sections to the baseline care plan as follows: 1. General Information and Initial Goals 2. Functional abilities 3. Health conditions 4. Dietary 5. Therapy 6. Social Services 7. BCP summary and signatures. A review Resident #90's baseline care plan revealed that section #2 and #3 were not completed within 48 hours of admission. The BCP summary was incomplete, Signature of Resident and Representative was blank, as well as representative signature and date. The only staff who signed was the Director of Rehab and Director of Social Services. 40039 2.) On 10/23/2024 at 11:24 AM during the initial tour of the facility Resident #241 told the surveyor that he/she had a urinary catheter, but they removed it yesterday and I haven't gone to the bathroom yet. It's been almost 24 hours. According to the Admission Record Resident #241 was admitted to the facility with the following but not limited to diagnoses: Rhabdomyolysis (a condition in which damaged skeletal muscle breaks down rapidly), sepsis (a condition in which the body responds improperly to infection), type 2 diabetes mellitus, urinary tract infection and pressure ulcer of sacral region. A review of the [facility initials] Baseline Care Plan - V4 revealed that there are seven (7) sections to the baseline care plan as follows: 1. General Information and Initial Goals 2. Functional Status 3. Health Conditions 4. Dietary 5. Therapy 6. Social Services 7. BCP Summary and Signatures. On 10/24/2024 at 10:13 AM, the surveyor reviewed the baseline care plan for Resident #241. During the review of the baseline care plan on this date revealed that sections 1-7 were not completed within 48 hours of admission. On 10/29/2024 the surveyor again reviewed the baseline care plan for Resident #241 via the EMR. On this date the baseline care plan revealed that sections 1-7 had been completed on 10/24/2024. During an interview with the surveyor on 10/28/2024 at 12:27 PM, Licensed Practical Nurse (LPN #1) When is the baseline care plan to be completed. LPN #1 said LPN's don't do the care plans. The Unit Manager is responsible for the care plans. During an interview with the surveyor on 10/28/2024 at 12:33 PM, Licensed Practical Nurse/Unit Manager (LPN/UM #1) said baseline care plan should be initiated by the admitting nurse. I will then go in and make corrections as needed. We have up to 48 hours for base line to be completed. Dietary, therapy and nursing complete this and I make sure it is signed and completed. I make sure the whole baseline care is appropriate and then I sign as completed. During an interview with the survey team on 10/29/2024 at 01:44 PM, the Director of Nursing (DON) was asked when is the baseline care plan to be completed. The DON replied within 48 hours of admission. The Regional Registered Nurse confirmed the timeframe of 48 hours for completion of the baseline care plan. The surveyor questioned what is expected to be on a baseline care plan. The DON replied initial assessment and care needs until comprehensive cae plan is done. It does not carry over to the comprehensive care plan, it is a tool and some of the items trigger and then carry over to comprehensive care plan. A review of a facility policy titled Baseline Care Plan with revised date of October 2022 revealed under the Policy Statement section The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. Under the Policy Interpretation and implementation section 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission., b. Include the minimum healthcare information necessary to properly care for a resident including but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders iv. Therapy Services. v. Social services Under 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. NJAC 8:39-11.2(d)

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that the Infection Preventionist was at 1 of 1 Quality Assurance Performance Improvement (QAPI) quarterly meeting and that QAPI meetings were held on a quarterly basis . This deficient practice was identified for 1 of the last 3 quarters and 2 of the last 3 quarters and was evidenced by the following: During a review of the facility QAPI 2024 book on 10/29/2024 at 08:44 AM, there was a sign in sheet with the topic of QAPI/QA Quarter 3. There was no signature or name for the Infection Preventionist. On 10/29/2024 at 09:25 AM the surveyor requested all of the last 3 quarter sign in sheets from the Regional DON (RDON) who said I came to the building in April and I asked where is the QAPI. There was nothing done since last year for QAPI. I have a QAPI that identified this concern for there being no QAPI. I provided all department heads and staff with education and power points to all staff on QAPI requirements in April of 2024. As new department heads and staff start they get trained and CNA's as well. We also have a QAPI board so families can see what we are doing. I sat with each department and assisted them to identify concerns, use audits, and process and structure changes. We met weekly for 1st month to make sure they are capturing the data and then we moved to monthly. When asked was there a quarterly meeting in July, the RDON said I guess we could have had a quarterly but the team wasn't there yet. A review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) undated revealed 2. the QAA committee shall be interdisciplinary and shall: a. consists at a minimum of: i. The Director of Nursing ii. The Medical director iii. At least 3 other members of facility staff, at least one of which must be the Administrator, owner, a Board Member or other individual in a leadership role and the Infection Preventionist. must meet at least quarterly, develop and implement appropriate plans of action to correct identified quality deficiencies. NJAC 8:39-33.1(b)

Complaint # NJ 015 Based on interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to ensure: a.) the facility policy for the management of residents at risk for falls was followed, b.) a resident admitted to the facility with a known history of falls was assessed as a fall risk, c.) staff developed a care plan (CP) for falls and implemented interventions to reduce the risk for injury from falls. This deficient practice was identified for 1 of 1 residents reviewed for accidents (Resident #262), who fell on [DATE] at 18:40 hours (6:40 PM) and hit his/her head. The resident had a subsequent fall on 04/25/21 at 15:56 (3:56 PM) and sustained a laceration to the left elbow. The resident was then transferred to the emergency roiagnom on [DATE] at approximately 3:37 PM, and was diagnosed with an acute left subdural hematoma (a type of bleeding in the brain usually associated with traumatic injuries). This deficient practice was evidenced by the following: The surveyor reviewed the medical record for Resident #262 which revealed the following: According to the Admission Record Report (ARR), Resident #262 was admitted to the facility with a diagnosis of unspecified fracture resulted from a fall at home. The Diagnosis Sheet reflected Resident #262 had an unspecified fracture of the third [MEDICATION(S)] vertebra (spine) and subsequent encounter for fracture with routine healing. The Progress Note (PN) dated 04/23/21 at 14:11 (2:11 PM) revealed, No Indication of [CONDITION(S)] and was based on the following questions/results: There was no evidence of an acute change in mental status and behavior did not fluctuate during the day. The patient did not have difficulty focusing attention. The patient's thinking was not disorganized or incoherent and overall, the level of consciousness appeared alert. The Admission/Re-Admission Evaluation (AE) dated 04/23/21 at 14:30 PM (2:30 PM), indicated that Resident #262 was admitted to the facility from an acute care hospital with pain in the left rib area. The AE indicated that the resident was oriented to situation, place, person, and time and was able to understand verbal content and express ideas and wants. It also indicated that Resident #262's pupils were equal and reactive; the resident had generalized weakness and was unable to determine standing balance. The AE clinical evaluation of the musculoskeletal system indicated that Resident #262 had an impairment of the upper extremities range of motion (ROM) on both sides related to pain. There was no documentation on the AE that a fall risk assessment was performed. Review of the initial admission Care Plan (CP) dated 04/23/21, revealed that the resident had alterations in: a.) The musculoskeletal system with decreased range of motion (ROM) related to (r/t) pain. b.) Altered in the respiratory status r/t chest compression caused by the resident wearing a back brace. c.) Difficulty communicating due to hearing impairment. d.) Expressed wishes to discharge home. e.) Nutritional status r/t pain. f.) Pain r/t inoperable rib fracture. The surveyor was unable to locate evidence in the resident's medical record that indicated Resident #262 was assessed as a fall risk, or that a CP for falls was developed upon admission that included interventions implemented to reduce the risk for falls and injury for a resident who had a history of a fall with injuries. The untimed History and Physical (H&P) dated 04/24/21, completed by the physician, indicated that Resident #262 had a past medical history of [CONDITION(S)] (CAD), hypertension (HTN), [CONDITION(S)], [CONDITION(S)] (AF), [CONDITION(S)], [CONDITION(S)], peripheral vascular disease, [CONDITION(S)], frequent UTIs (bladder infections), and valvular heart disease, who presented to the hospital after sustaining a fall at home. The H&P indicated that the resident had an acute burst fracture of the third [MEDICATION(S)] (T3) vertebral body, acute T3 spinous process fracture, and a compression fracture of fifth [MEDICATION(S)] (T5). The resident was evaluated by a neurosurgeon and no surgical interventions were required at that time. The H&P indicated that the resident was transferred to the facility for subacute rehabilitation and medical management. The surveyor reviewed the Occupational Therapy (OT) Initial Evaluation dated 04/24/21 and signed 4:46 PM, which indicated that Resident #262 was hallucinating throughout the session and required redirection to task constantly for safety. The evaluation also reflected that the resident had full ROM to all extremities and was within normal limits, however strength was weak and standing balance was poor. The surveyor reviewed an untimed Physical Therapy (PT) Initial Evaluation dated 04/24/21, that revealed an assessment summary. The summary indicated that Resident #262 required skilled therapy services to address the following functional areas to include: bed mobility, transfers, ambulation, and stair negotiation. The summary also indicated that these functional deficits were a result of the resident's pain, impaired strength and impaired balance and due to the documented physical impairments and associated functional deficits, without skilled therapeutic interventions, the resident was at risk for falls, decreased ability to return to prior living arrangements, decreased participation in functional task, hospitalization and inability to return home. 1. The general Progress Note (PN) dated 04/24/21 at 18:40 hours (6:40 PM), indicated that the nurse heard Resident #262 calling out for help. The nurse found the resident lying on the floor, close to bathroom door, and the resident stated I fell . The resident told the nurse that he/she had gone to the bathroom and was walking back to the bed when he/she fell . The nurse also documented that the resident told the nurse that he/she hit his/her head and had pain in his/her head. The nurse documented that the resident had no bumps, lacerations, or bleeding, and a Neurological evaluation flow sheet (NEFS) (an assessment tool used to assess an individual's neurological function and level of consciousness). The documentation indicated that the resident was assisted off the floor with the help of staff into the bed. The note revealed that the resident was experiencing hallucinations and appeared to be in a conversation with an unseen participant. The nurse then documented that pain medications were administered for pain. The surveyor reviewed the facility form titled, Incident Report-Patient Involved (IR) and dated 04/24/21 at 18:30 (6:30 PM), which reflected that Resident #262 had an unwitnessed fall at 18:30 hours (6:30 PM). According to the report, the assigned nurse heard Resident #262 calling out for help and observed the resident was on the floor. The nurse then interviewed Resident #262 and the resident stated that he/she had gone to the bathroom and was walking back to the bed when he/she fell . The resident told the nurse that he/she hit her head but denied pain. No other injuries were noted. A NEFS was initiated, the family and the medical doctor (MD) were notified and the MD did not provide the reporting nurse with any new orders for Resident #262 at that time. According to the report the resident was alert and was forgetful with confusion noted. The surveyor reviewed LPN#1's undated written Witness Statement (WS) which was attached to the IR for the fall of 04/24/21. The LPN #1's WS revealed that Resident #262 was heard calling for help and was found lying on the floor close to the bathroom and when LPN #1 approached the resident the resident stated I fell . LPN#1 was told by the resident that he/she had gone to the bathroom and was walking back to bed and fell and that he/she hit his/her head and felt pain (WS did not specify where the resident felt pain). LPN #1 documented that there were no bumps, lacerations or bleeding assessed and neuro-checks (neurological examination assesses motor and sensory skills, hearing and speech, vision, coordination, and balance) were initiated. LPN#1 also documented that the resident appeared to be hallucinating and was in a conversation with an unseen participant. The NEFS dated 04/24/21 indicated that the initial neurological evaluation was performed and then was performed every 15 minutes for the first 2 hours, then every 30 minutes for 2 hours, then evaluate every 4 hours, and then every 8 hours. According to the NEFS the resident was alert, oriented to person, could follow simple commands, normal response to pain, pupils were equal and reactive to light, and was able to move all extremities with equal strength and vital signs were within normal limits. The Situation Background Assessment Recommendation (SBAR) dated 04/24/21and untimed, indicated that Resident #262 had a change in condition and was evaluated for falls. The SBAR Background area was blank for the Diagnosis, Medication Alert section which included anticoagulants (blood thinner). The SBAR indicated that the resident had signs of [CONDITION(S)] and had a fall. Section ten under Neurological Evaluation indicated that the resident was confused. There was no documentation under the section Summarize your Observations and Evaluation and there were no new interventions listed for fall reduction or injury reduction documented on the SBAR Interventions section. The entire Intervention section was blank. The surveyor reviewed the Telehealth Evaluation (TE) dated 04/24/21 at 8:21 PM which revealed: Resident #262 was being evaluated for the Primary Chief Complaint: Fall with Head Injury. The TE indicated that Resident #262 was walking in the hallway with his/her four wheeled walker and accidentally tripped while walking. When he/she fell he/she hit his/her head without (w/o) loss of consciousness (LOC). The TE indicated that the resident did not have LOC, was awake, alert, speaking in full, fluent sentences, and had no complaints of pain, had no facial [CONDITION(S)], was moving all extremities equally with normal ROM and was without deficits. The TE Diagnosis and Assessment/Plan indicated that the resident had a history of falls and had a fall with a head injury without change in LOC. The TE further revealed that staff were to continue with fall precautions, neuro-checks and the resident was advised to call for assistance when getting out of bed. The surveyor reviewed the clinical medical record and could not locate documentation regarding the development of a CP which included fall prevention interventions after Resident #262 sustained a fall with injury on 04/24/21 at 6:30 PM. 2. According to a PN dated 04/25/21 at 13:00 (1:00 PM), Resident #262 was heard calling for help and was found lying on the floor near the bathroom. The resident told the nurse I fell . The PN indicated that Resident #262 was not able to verbalize what transpired before the fall and during the assessment the Resident was noted to have a laceration to the left elbow. No other injuries were documented on the PN. The PN further indicated that the resident was not able to state if he/she bumped his/her head. Neuro-checks were initiated and the laceration of the left elbow was covered with a dressing. Resident #262 was provided with first aid at that time. The surveyor reviewed the IR dated 04/25/21 at 13:00 hours (1:00 PM), and according to the IR report, Resident #262 was heard calling for help and was found on the floor near the bathroom. The resident was unable to verbalize where he/she was going. Resident #262 was assessed and was noted to have a laceration to his/her left elbow. According to the IR the resident denied hitting his/her head. The IR also indicated that the Resident did not have any other injuries and that a neuro-check was initiated. The IR indicated that the resident was seen by the Nurse Practitioner (NP) and was ordered a treatment for the left elbow skin tear. The IR reflected that the responsible party for Resident #262 was notified and requested that the resident was sent to the emergency room for an evaluation. The untimed WS, dated 04/25/21, and was attached to the IR was written by a Registered Nurse (RN #2). The WS revealed that Resident #262 had no complaints of pain after the fall and was able to ambulate with a walker without difficulty. The WS dated 04/25/21 at 13:00 hours (1:00 PM) was written by a Certified Nursing Assistant (CNA #1), indicated that that she observed Resident #262 ten minutes prior to the fall and the resident was sitting in a chair and looking outside the window. The WS dated 04/25/21 at 13:00 hours (01:00 PM) and written by LPN#1, indicated that she heard the resident calling for help and found the resident on the floor near the bathroom. The resident was unable to verbalize why he/she fell . An assessment showed that Resident #262 sustained a laceration to the left elbow and no other injuries. No head injuries or bumps were noted, and neuro-checks were initiated. The undated and untimed WS written by RN#2 and attached to the IR dated 04/25/21, indicated that Resident #262 sustained a laceration on the left forearm and first aid was applied. The MD and family were notified of the fall and that Resident #262 had ROM to bilateral upper and lower extremities and the resident had no complaints of pain after the fall and was able to ambulate with a walker without difficulty. The nurse put the bed in a low position and the call bell was put within the resident reach. This intervention was not added to the CP to ensure consistent implementation. The NEFS dated 04/25/21 at 13:00 (1:00 PM), reflected that a neurological checks initial evaluation was performed and then was performed every 15 minutes for the first 2 hours. The NEFS indicated that Resident #262 was alert, oriented to person, could follow simple commands, normal response to pain, pupils were equal and reactive to light, and was able to move all extremities with equal strength. The resident's vital signs were within normal limits up to 15:00 (3:00 PM), and then the resident was sent to the hospital emergency room (ER) for evaluation. The untimed SBAR dated 04/25/21, indicated that Resident #262 was being evaluated for falls. There was documentation on the SBAR that revealed Resident #262 was on an anticoagulant medication and had signs and symptoms of [CONDITION(S)]. Under section 10 Neurological Evaluation, there was a check mark that indicated, Not clinically applicable to the change in condition being reported. There were no new interventions for fall reduction documented in the Intervention section of the SBAR for this second fall. The PN dated 4/25/2021 at 15:12 hours (3:12 PM), revealed that Resident #262 had a obtained a skin tear on the left forearm after a fall. The PN reflected that the Nurse Practitioner (NP) was made aware and ordered the LPN #1 to cleanse the left forearm skin tear with normal saline solution (NSS), pat dry, apply an antibiotic cream, and cover with a clean, dry dressing (CDD) daily until resolved. The PN also indicated that the responsible party requested to have a one-on-one aid put in place for Resident #262 and the administrator had denied the request. Per the PN the responsible party then requested that the resident be sent to the hospital for evaluation and was then approved by the NP. According to the CP initiated after the second fall on 04/25/21, the resident was noted to be at risk for falls due to a history of falls, had impaired balance and poor coordination. Interventions included: 1.) Bed in low position. 2.) Encourage to transfer and change positions slowly. 3.) Low bed. The NP PN dated 04/25/21 and signed at 3:37 PM, indicated that the NP examined Resident #262 after sustaining two falls. The NP documentation revealed that the resident was confused, denied having a headache and a neuro exam was nonfocal (no neurologic deficit is a problem with nerve, spinal cord, or brain function). The PN also indicated that Resident #262 was on a blood thinner for [CONDITION(S)] (DVT) (blood clots) prophylaxis (action taken to prevent disease) and complained of back pain at a 4/10 on the pain scale. The PN also indicated that the resident's family requested that the resident be sent to hospital for evaluation. On 06/03/21 at 11:40 AM the surveyor conducted a telephone interview with the Registered Nurse (RN #3) who signed and prepared the IR dated 04/24/21 at 9:52 PM for a fall that occurred at 06:30 PM. The RN #3 stated that she did not remember any details of the incident and was not able to speak any further. On 06/03/21 at 11:21 AM, the surveyor interviewed the Registered Nurse Care Manager (RN CM #1) for the 2nd floor 3:00 PM - 11:00 PM shift. The RN CM #1 stated that she could not recall the fall incidents that occurred on 04/24/21 and 04/25/21 and would like to review Resident #262s clinical medical record prior to being interviewed. RM CM #1 was not able to be contacted after the initial interview. On 06/03/21 at 11:33 AM, the surveyor conducted a telephone interview with an agency Licensed Practical Nurse (LPN#1), who was assigned to Resident #262 on 04/24/21 and 04/25/21, and found Resident #262 lying on the floor after both falls. LPN#1 stated that she did not know all the details of the events because she worked at many different places. LPN #1 stated that she was unaware if the facility had a policy regarding residents who had an unwitnessed fall, hit their head and were also on anticoagulant medications. LPN #1 stated that if a resident hit their head and was on anticoagulant medication, then the resident would not automatically go to the hospital. She stated neuro-checks would be completed and the nurse would then call the MD. LPN #1 then stated the MD would evaluate the resident via telehealth (internet video) and then the MD would make the determination if the resident needed to be sent to the hospital. She further stated that when Resident # 262 fell and hit his/her head on 4/24/21 and was seen by the MD on telehealth and the MD made the determination that the resident did not need to be examined at the hospital because the neuro-checks were within normal limits (WNL) and there was no change in mental status. LPN #1 stated to the surveyor to refer to her witness statement (WS) that she wrote and that was included in the IR for any further information. On 06/03/21 at 12:30 PM the surveyor requested to interview the NP that examined Resident #262 on 4/25/21, and the NP was not available for an interview. On 06/03/21 at 12:23 PM the surveyor interviewed the Director of Nursing (DON), in the presence of the survey team. The DON stated that Resident #262 had a fall prior to admission to the facility and had vertebrae fractures. The DON stated that she did not know if a fall risk assessment needed to be completed upon admission and the facility treated all the residents as if they were at risk for falls. The DON stated that she did not know why the nurses did not add fall prevention interventions to the CP for Resident #262 at the time of admission, or after the resident fell on [DATE] at 06:30 PM. The DON stated if a resident had a fall, interventions should be added to the resident's care plan to reduce the risk for falls or injury. The DON also explained that the facility did not have a specific policy for nurses to follow regarding falls for the residents taking blood thinning medications. On 06/04/21 at 10:22 AM the DON stated, in the presence of the survey team, that the fall risk assessment was part of the CP process. The DON confirmed that this was not completed for Resident #262 at the time of admission, or after the resident's first fall on 04/24/21 at 06:30 PM. She further stated the resident should have been assessed for falls at the time of admission and a CP should have been initiated with interventions to reduce risk for falls. The DON stated this was especially important after the first fall and interventions should have been put in place to prevent additional falls. On 06/04/21 at 11:06 AM the surveyor interviewed a Registered Nurse (RN #4) about the admission process. RN #4 stated she has been employed with the facility for 8 years. RN #4 explained the admission process to the surveyor and stated when residents were admitted to the facility that the resident's vital signs (VS) were taken and an admission assessment was performed. She added that staff were provided with an intake sheet or report from the hospital which explained why the resident was being admitted including the diagnoses and that helped to prepare the facility for the admission. She stated that the facility was made aware that any resident was a fall risk even before admission, because it was usually written on the hospital report. RN#4 added that if the resident was a fall risk, fall precautions would be implemented and a CP would be formulated with interventions to prevent falls. RN#4 revealed that when a resident had a fall in the facility an incident report was completed, neuro-checks were completed, the MD and family were notified, and employee statements were obtained. RN #4 stated the CP would also be updated to include new interventions to reduce the risk for falls. RN#4 also stated, if a resident was on blood thinners and fell , and hit their head, we would let the MD know and then monitor the resident for bleeding. She stated the MD would then make the determination if a resident needed to be sent to the hospital or not. On 06/04/21 at 11:16 AM the surveyor interviewed CNA #1 who was employed in the facility for 3 years and provided care for Resident #262. CNA #1 stated she took care of Resident #262 on Friday night 04/23/21 (3:00 PM - 11:00 PM) and Saturday 04/24/21 (7:00 AM-3:00 PM), and on 04/25/21 (7:00 AM - 3:00 PM). CNA #1 explained to the surveyor that Resident #262 was very confused, and she had thought he/she was at risk for falls and ambulated with an unsteady gait. CNA #1 explained that the resident had a decreased cognitive status upon admission, and this was unchanged during the resident's time at the facility. CNA #1 stated that she told one of the nurses at the nurse station that Resident #262 needed a baby monitor because he/she was at risk for falls and was unsteady at times. She further stated that the facility did not have CNA care plans and the CNA's obtained report from the nurses and that was how they knew what care the residents required. CNA#1 added that she did not remember any fall interventions that were in place for Resident #262 and she did not witness the fall. She also added that she did not remember if the resident had any head injuries or complaints of pain in any extremities. On 06/04/21 at 11:45 AM the surveyor interviewed the Director of Rehabilitation (DOR) who confirmed to the surveyor that during the initial PT evaluation for Resident #262 that the therapist identified Resident #262 was at risk for falls related to reduced dynamic balance, decreased strength and limited painful movements. The DOR stated that Resident # 262 was also evaluated by OT on 4/24/21, and the resident had function ROM WNL of bilateral upper extremities, but strength was weak and was at a risk for falls. On 06/07/21 at 9:27 AM, the surveyor interviewed the Physical Therapy Assistant (PTA) who treated Resident #262 on 04/25/21, after the resident's 2nd fall. The PTA explained that the resident was a fall risk and the he/she complained of back pain. The PTA added that she notified the nurse about the resident's complaint of pain but was unable to provide the nurse's name. The PTA stated, if she noticed any bruising or swelling of the resident's face or complaints of pain in any of the resident's extremities, she would have documented that in the treatment note. The PTA then added that if she did not document it, then she did not see it. The PTA added that she always documented anything that was unusual going on with the resident and that she did not notice anything unusual in Resident #262's upper and lower body extremity movements. She stated to the surveyor that she did not observed any bruising or swelling on the resident's face or head. On 06/08/21 at 10:01 AM, the surveyor interviewed the Administrator who stated that if a resident was admitted to the facility with a history of falls then the staff should have implemented interventions on the CP to reduce the risk for falls/injury and a CP should have been initiated. He added that if a resident fall after admission in the facility then the nurses should have developed a CP for falls with interventions to reduce the risk for falls. He admitted that the staff should have followed the facility policy for Falls Management and initiated a CP with fall reduction interventions for Resident #262 on admission and after the 1st fall on 04/24/21 at 6:30 PM. On 06/10/21 at 08:47 AM, the surveyor interviewed the Administrator and DON who agreed that Resident #262 should have had a CP developed on admission and after fall of 04/24/21, which included interventions to reduce the risk for falls. Resident #262 sustained a fall at the facility on 04/24/21. The resident had a subsequent fall on 04/25/21 and was transferred to the hospital for evaluation. The hospital records were reviewed and reflected that a computerized tomography scan (CAT) scan was performed of Resident #262's head on 04/25/21 at 5:20 PM and the resident was diagnosed with an acute left subdural hematoma measuring up to 7 mm thick. The facility policy titled, Falls Management with a revision date of 11/01/19, revealed that policies and procedures are guidelines and are not intended to replace the informed judgement and professional discretion of individual clinicians, nor are they intended to establish the standard of care applicable to the assessment or treatment of any particular condition and unique needs of each patient. The policy indicated that patients will be assessed for falls risk and will receive appropriate interventions to reduce risk and minimize injury. The purpose of the policy was to reduce risk for falls and minimize the actual occurrence of falls. The policy by addressed the Practice Standards to identify the patient's fall risk by reviewing the Nursing Assessment, Fall Risk Evaluation, Communicate the patient's fall risk, develop an individualized plan of care and Review the Care Plan regularly. The policy indicated that if a resident falls the Care Plan should be updated to reflect a new intervention. The facility policy titled, Falls Care Delivery Process dated 07/25/16, revealed that the process was designed to assist the nursing staff in: Recognizing patients at risk for falls, Identifying appropriate interventions to reduce risk and minimize injury and initiating appropriate care and investigating the cause for patients that experience a fall. a.) Problem Management: 1.) Document the Care Plan focus. 2.) Develop a plan of care including general and specific interventions to address all areas of risk. Ensure that patient and family expectations and wishes are compatible with plan of care. 3.) Refer to following tools to develop an individualized plan of care which addresses environmental modifications, sensory capacity, functional deficits, [CONDITION(S)], and medications that affect balance or level of consciousness, and appropriate restorative/rehabilitation services. b.) Response to a patient Fall: 1.) Evaluate and monitor the resident for 72 hours after a fall and perform Neurological assessment for all unwitnessed falls and witnessed fall with a head injury complete change in condition note and review the residents medical record and assessments to identify any causes that may have contributed to the fall. 2.) Investigate. 3.) Implement new interventions immediately after the fall. 4.) Notify physician and family. 5.) Update the care plan with new interventions and communicate interventions to the staff. 6.) Monitor the resident's response. NJAC 8:39-27.1(a)