Accelerate Skilled Nursing And Rehab Piscataway

Based on interviews and review of pertinent facility documents on 11/05/25, 11/06/25, and 11/10/25, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of neglect that occurred on 07/29/25. This deficient practice was identified for 1 of 4 residents reviewed for abuse and neglect (Resident #1), and was evidenced by the following:The surveyor reviewed the medical record for Resident #1. A review of the admission Record (AR) face sheet (an admission summary), revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to; multiple sclerosis (an autoimmune disorder between the brain and the body leading to symptoms such weakness, numbness, coordination problems, and vision issues), encephalopathy (a condition that affects the brain's function resulting in altered mental state), muscle weakness, atherosclerotic heart disease (heart disorder), dementia, repeated falls, and personal history of transient ischemic attack (TIA) and cerebral infarction (stroke). A review of the Minimum Data Set (MDS), an assessment tool dated 09/30/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which reflected a severely impaired cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs). A review of the Resident #1's Progress Notes included a nurse's note documented by RN #1 on 07/29/25 at 11:20AM, that the resident was seen sitting on the patio and this writer was going to do vital sign checks when they were called by RR #1 to check on the resident. The resident was initially drowsy, responded to verbal stimuli, and become unconscious with breathing present. Vital signs were taken; blood pressure 123 millimeters of mercury (mmHg) over 78 mmHg (123/78), HR 124 bpm, unlabored breathing 18 breaths per minute, temperature 103.8 degrees F, oxygen saturation 97% on room air, and blood sugar 94. The resident was assisted back to room in cool environment, ice pack was applied, the resident responded to sternum rub and regained consciousness. The resident denied pain or distress. Supplemental oxygen and cool sponge were provided, and Tylenol was administered. The physician was notified and ordered the resident transferred out to ER for further evaluation. A review of the facility's investigation report dated 07/31/25, included the following: Incident: On 7/29/25 at approximately 11:15 AM, [RN #1] noted [RR #1] was trying to get [the resident] up in the patio. [The resident] was observed drowsy but responded to verbal stimuli. Vital signs were checked, and the resident's temperature was 103.8 degrees F and heart rate was 124 bpm. The resident was immediately assisted back to their bed via wheelchair, and the resident became more alert and verbally responsive. Cooling measures were applied, and the resident was given Tylenol at 11:50 AM. The physician was notified and ordered to transfer the resident to the hospital. Resident #1's Representative (RR #2) was notified, and they agreed to the hospital transfer. Investigation: that per interview with staff, RN #1 on 07/29/25, at approximately 10:00 AM, noticed that the Certified Nursing Assistant (CNA #1) was still providing care on Resident #1, and she proceeded to give morning medications to another resident. Per CNA #1, after he provided care to Resident #1, he walked them out of their room, and another CNA (CNA #2) took the resident to the dayroom. CNA #1 stated he noted that the resident was in the dayroom at around 11:00 AM, during his dayroom assignment to watch the residents, but he did not realize if the resident's private companion (RR #1) brought the resident out of the dayroom to the patio when RR #1 arrived. RR #1 arrived at the facility at 11:03 AM. At approximately 11:15 AM, RN #1 noted the resident was at the patio with RR #1 trying to get the resident up. Resident #1 was observed sitting on the couch with some shade, drowsy but responded to verbal stimuli. Resident #1 was assisted back to their room via a wheelchair. Vital signs were checked and noted with elevated temperature and heart rate. Cooling measures were provided, and Tylenol was given. Vital signs were rechecked: blood pressure-119/70, HR-104 bpm, breathing 18 breaths per minute, oxygen saturation on room air-96%, temperature- 97.1 degrees F, and resident was back to their baseline. The physician was informed and ordered the resident to be sent to the hospital to rule/out seizure. Other CNAs that worked that day were interviewed, but no one noticed Resident #1 going out to the patio by themself. They also stated, Resident #1's family did not want the resident out to patio unless with the companion (RR #1). Transport [ name redacted] was called and the resident was picked up at 1:15 PM. They left for the hospital with no signs of distress. Resident #1 was sent to hospital [name redacted]. A review of emergency room (ER) paperwork dated 07/29/25 at 1:50 PM, included history of present illness that Resident #1 arrived at the ER by emergency medical services (EMS) for an episode of unresponsiveness. Per [Resident #1's sending facility name redacted], [Resident #1] was outside 30-40 minutes sitting on a bench on the patio when [the resident] became unresponsive, tachycardic (fast heart rate), and was found to be febrile 103.8 degrees F. The facility gave [the resident] Tylenol and wiped the resident with cold sponge and [the resident's] temperature went down to 97.1 degrees F before [they] were sent to the [ER]. The report also indicated the resident was diagnosed with transient alteration awareness (loss of normal awareness or behavior) and heat stroke. On 11/05/25 at 12:40 PM, the surveyor interviewed the Unit Manager (UM), who stated that on 07/29/25, she was in a care meeting when the nurse (RN #1) called her. The UM further stated that when she came to the floor, the resident was seen sitting outside on the patio with the companion (RR #1). The UM stated RR #1 called the nurse (RN #1) to check on the resident. The UM stated she did not know if the resident was taken outside by RR #1, and normally there was staff or a CNA in the dayroom that oversaw the residents outside on the patio as well. On 11/10/25 at 2:08 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) with the Director of Nursing (DON). The LNHA and the DON stated that it was RR #1 who took the resident out to the patio. The DON stated that after the incident, she gathered statements from the nurse and the CNA. The LNHA confirmed there was a heat wave on that day as he said he made an announcement regarding safety and precautions against extreme heat. The LNHA and DON further stated they did not report the incident to the NJDOH because they believed the incident was not an allegation of neglect. A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention policy dated 06/18/25, included Policy: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone; 2. Develop and implement policies and protocols to prevent and identify:.b. neglect of residents;.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.NJAC 8:39-9.4(f)

Based on interviews and review of pertinent facility documents on 11/05/25, 11/06/25, and 11/10/25, it was determined that the facility failed to thoroughly investigate an incident of resident heat stroke (life-threatening from environmental heat exposure) to rule out neglect. This deficient practice was identified for 1 of 4 residents reviewed for abuse and neglect (Resident #1), and was evidenced by the following:The surveyor reviewed the medical record for Resident #1. A review of the admission Record (AR) face sheet (an admission summary), revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to; multiple sclerosis (an autoimmune disorder between the brain and the body leading to symptoms such weakness, numbness, coordination problems, and vision issues), encephalopathy (a condition that affects the brain's function resulting in altered mental state), muscle weakness, atherosclerotic heart disease (heart disorder), dementia, repeated falls, and personal history of transient ischemic attack (TIA) and cerebral infarction (stroke). A review of the Minimum Data Set (MDS), an assessment tool dated 09/30/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which reflected a severely impaired cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs). A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 06/30/22, that the resident required assistance/potential to restore function for mobility as evidenced by limited mobility related to inability to move independently. Interventions included but were not limited to; one person assistance with ambulation. A review of the Resident #1's Progress Notes included a nurse's note documented by RN #1 on 07/29/25 at 11:20AM, that the resident was seen sitting on the patio and this writer was going to do vital sign checks when they were called by RR #1 to check on the resident. The resident was initially drowsy, responded to verbal stimuli, and become unconscious with breathing present. Vital signs were taken; blood pressure 123 millimeters of mercury (mmHg) over 78 mmHg (123/78), HR 124 bpm, unlabored breathing 18 breaths per minute, temperature 103.8 degrees F, oxygen saturation 97% on room air, and blood sugar 94. The resident was assisted back to room in cool environment, ice pack was applied, the resident responded to sternum rub and regained consciousness. The resident denied pain or distress. Supplemental oxygen and cool sponge were provided, and Tylenol was administered. The physician was notified and ordered the resident transferred out to ER for further evaluation. A review of the facility's investigation report dated 07/31/25, included the following: Incident: On 7/29/25 at approximately 11:15 AM, [RN #1] noted [RR #1] was trying to get [the resident] up in the patio. [The resident] was observed drowsy but responded to verbal stimuli. Vital signs were checked, and the resident's temperature was 103.8 degrees F and heart rate was 124 bpm. The resident was immediately assisted back to their bed via wheelchair, and the resident became more alert and verbally responsive. Cooling measures were applied, and the resident was given Tylenol at 11:50 AM. The physician was notified and ordered to transfer the resident to the hospital. Resident #1's Representative (RR #2) was notified, and they agreed to the hospital transfer. Investigation: that per interview with staff, RN #1 on 07/29/25, at approximately 10:00 AM, noticed that the Certified Nursing Assistant (CNA #1) was still providing care on Resident #1, and she proceeded to give morning medications to another resident. Per CNA #1, after he provided care to Resident #1, he walked them out of their room, and another CNA (CNA #2) took the resident to the dayroom. CNA #1 stated he noted that the resident was in the dayroom at around 11:00 AM, during his dayroom assignment to watch the residents, but he did not realize if the resident's private companion (RR #1) brought the resident out of the dayroom to the patio when RR #1 arrived. RR #1 arrived at the facility at 11:03 AM. At approximately 11:15 AM, RN #1 noted the resident was at the patio with RR #1 trying to get the resident up. Resident #1 was observed sitting on the couch with some shade, drowsy but responded to verbal stimuli. Resident #1 was assisted back to their room via a wheelchair. Vital signs were checked and noted with elevated temperature and heart rate. Cooling measures were provided, and Tylenol was given. Vital signs were rechecked: blood pressure-119/70, HR-104 bpm, breathing 18 breaths per minute, oxygen saturation on room air-96%, temperature- 97.1 degrees F, and resident was back to their baseline. The physician was informed and ordered the resident to be sent to the hospital to rule/out seizure. Other CNAs that worked that day were interviewed, but no one noticed Resident #1 going out to the patio by themself. They also stated, Resident #1's family did not want the resident out to patio unless with the companion (RR #1). Transport [ name redacted] was called and the resident was picked up at 1:15 PM. They left for the hospital with no signs of distress. Resident #1 was sent to hospital [name redacted]. The investigation did not include a statement from RR #1 who was with the resident at the time. A review of emergency room (ER) paperwork dated 07/29/25 at 1:50 PM, included history of present illness that Resident #1 arrived at the ER by emergency medical services (EMS) for an episode of unresponsiveness. Per [Resident #1's sending facility name redacted], [Resident #1] was outside 30-40 minutes sitting on a bench on the patio when [the resident] became unresponsive, tachycardic (fast heart rate), and was found to be febrile 103.8 degrees F. The facility gave [the resident] Tylenol and wiped the resident with cold sponge and [the resident's] temperature went down to 97.1 degrees F before [they] were sent to the [ER]. The report also indicated the resident was diagnosed with transient alteration awareness (loss of normal awareness or behavior) and heat stroke. On 11/05/25 at 12:40 PM, the surveyor interviewed the Unit Manager (UM), who stated that on 07/29/25, she was in a care meeting when the nurse (RN #1) called her. The UM further stated that when she came to the floor, the resident was seen sitting outside on the patio with the companion (RR #1). The UM stated RR #1 called the nurse (RN #1) to check on the resident. The UM stated she did not know if the resident was taken outside by RR #1, and normally there was staff or a CNA in the dayroom that oversaw the residents outside on the patio as well. The UM stated that the companion (RR #1) did not provide care to Resident #1. The surveyor requested for a copy of dayroom assignment on that day of 07/29/25. The facility document titled as Dayroom Schedule dated 07/29/25, and shift: the 7:00 AM to 3:00 PM shift revealed that CNA #1 was assigned in dayroom that day from 11:00 AM to 11:30 AM. On 11/05/25 at 1:08 PM, the surveyor interviewed RN #2, who was Resident #1's regular nurse. RN #2 stated that the companion, RR #1, did not provide care for the resident. On 11/5/25 at 3:46 PM, the surveyor interviewed CNA #1, who was assigned to the dayroom at the time of the incident as well as Resident #1's assigned aide. CNA #1 stated he was regularly assigned to the resident, and the resident could not transfer by themself but would try. CNA #1 stated the resident required one person assistance from staff and supervision during eating. CNA #1 stated that after he washed the resident, he walked the resident to the dayroom for activities. CNA #1 further stated he would sometimes catch the resident trying to go to the patio. CNA #1 stated that we had an every 30-minute rotating assignment to watch the residents in the dayroom. CNA #1 stated on 07/29/25, after washing the resident at around 10:00 AM, I took [Resident #1] to the dayroom. My scheduled dayroom assignment was from 11:00 AM to 11:30 AM. When I went back to the dayroom at 11:00 AM, I saw the resident [at] the long table. The [television] was on, I did not see the activity person. I did not see the companion (RR #1). I did not see [RR #1] taking the resident out to the patio. CNA #1 further stated that at 12:00 PM, while he was [providing] care to another resident, the nurse called [him] because they needed help outside [on] the patio to pick [up] and put [the resident] in wheelchair and back to [Resident #1's] room. [The resident] was sweating and was not talking. [The resident] looked different. [The resident] was sent out to the hospital. CNA #1 stated that the companion, RR #1, did not provide care to the resident. On 11/05/25 at 4:30 PM, the surveyor interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The DON stated that Resident #1's companion, RR #1, did not provide care to the resident. On 11/06/25 at 12:29 PM, the surveyor interviewed CNA #2, who was assigned to the dayroom on 07/29/25 from 11:30 AM to 12:00 PM. CNA #2 stated she could not recall the incident on 07/29/25, and she did not recognize the resident's companion (RR #1). CNA #2 also stated that she could not remember her schedule that day. The surveyor informed her she was assigned to the dayroom from 11:30 AM to 12:00 PM, and CNA #2 stated, it was so long ago, and the resident went out to the patio always with the family. On 11/06/25 at 12:55 PM, the surveyor interviewed CNA #3, who was assigned in the dayroom on 07/29/25 from 10:00 AM to 10:30 AM. CNA #3 stated that the resident did not go out by themself but usually with the companion. CNA #3 further said, I did not see the resident from 10:00 AM to 10:30 AM outside while I was there in the dayroom. CNA #3 stated she did not see the companion (RR #1) taking the resident out to the patio. The surveyor was not able to interview RN #1 who was reportedly out of the country. On 11/07/25 at 12:17 PM, the surveyor conducted a telephone interview with RR #2, who stated on 07/29/25, the UM called them to inform RR #2 that the facility was sending Resident #1 to the hospital for evaluation. RR #2 stated that the UM informed them of the incident, that the resident was outside for approximately 40 minutes, and the facility notified the physician who ordered to send the resident to the ER. On 11/07/25 at 2:13 PM, the surveyor conducted a telephone interview with the resident's companion, RR #1, who stated they arrived at the facility around 11 o'clock that day. RR #1 stated, I got out from the elevator and [the resident] was not there in the dayroom, so I went to check [the resident's] room, and [the resident] was not there, too. I went to look for [the resident] and going back to the dayroom, I saw [the resident] through the glass door. [The resident] was outside on the patio sitting on the right area of patio and was on [the resident's] right side. [The resident] was out open under the sun; [they were] seated in one of the chair with [their] rolling walker beside [them]. I thought [the resident] was asleep. I called [the resident's] name and [the resident] was not responding. I saw saliva from [the resident's] mouth and drainage coming out from [the resident's] nose. I rushed inside to ask for help. I met the nurse halfway in and told her the resident needed help. [The] nurse rushed to [the resident] and checked [the resident], and they assisted [the resident] back to bed. At around 1:20 PM, they took [the resident] to the hospital. RR #1 further stated sometimes they took the resident outside, and RR #1 did not leave the resident unattended, and the resident did not go outside by themself. RR #1 stated when RR #1 came out from the elevator after they arrived, there were some residents in the dayroom and there was no CNA. RR #1 said they knew because RR #1 started looking for the resident. On 11/10/25 at 10:45 AM, the surveyor interviewed the DON, who stated that the facility had CNAs assigned every thirty-minutes in the dayroom to watch the residents, providing supervision and ensuring safety. The DON further stated the CNA assigned did not leave the dayroom until the relieving CNA arrived. On 11/10/25 at 2:08 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) with the DON. The LNHA and the DON stated that it was RR #1 who took the resident out to the patio. The DON stated that after the incident, she gathered statements from the nurse and the CNA. The DON further stated she investigated but was not able to interview and obtained the statement of RR #1. The DON provided an investigation report with statements from the CNA and the RN involved only. A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention policy reviewed and signed by the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) and dated June 18, 2025, included Policy: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone; 2. Develop and implement policies and protocols to prevent and identify:.b. neglect of residents;.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. NJAC 8:39-4.1(a)5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of pertinent facility documents on 11/05/25, 11/06/25, and 11/10/25, it was determined that the facility failed to ensure a cognitively impaired resident (Resident #1) was protected from neglect when the resident was found unresponsive outside on the patio during a heat wave and was sent to the emergency room for heat stroke (life-threatening from environmental heat exposure). This deficient practice was identified for 1 of 4 residents reviewed for abuse and neglect (Resident #1).On 07/29/25 at 11:15 AM, Resident #1's Representative (RR #1), a companion, discovered Resident #1 outside on the second-floor patio unresponsive. RR #1 immediately informed the Registered Nurse (RN #1), who went outside and found the resident unconscious. Resident #1 was brought inside to their room, and RN #1 performed a sternal rub (rubbing the chest area) which the resident became alert, but drowsy with a temperature of 103.8 degrees Fahrenheit (F) (normal range 97.7 to 99.0 degrees F) and a heart rate (HR) of 124 beats per minute (bpm) (normal range 60-100 bpm). Resident #1 received treatment of an ice pack and Tylenol and was sent to the emergency room (ER). The resident remained in the ER for twenty-four hours being treated for heat stroke.The facility's failure to protect a cognitively impaired resident by ensuring staff provided residents supervision and oversight, placed Resident #1 as well as all residents at risk for neglect. This posed the likelihood of serious physical harm, injury, or death which resulted in an immediate jeopardy (IJ) situation.The IJ began on 07/29/25, at approximately 11:15 AM, when Resident #1 was found unresponsive outside on the patio in extremely hot weather. The facility's Administration was notified of the IJ on 11/10/25 at 2:43 PM. The facility submitted an acceptable Removal Plan (RP) on 11/13/25 at 4:52 PM. The surveyor verified the implementation of the Removal Plan on-site during the continuation of the survey 11/17/25. The deficient practice was evidenced as follows:A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention policy dated 06/18/25, included Policy: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone; 2. Develop and implement policies and protocols to prevent and identify:.b. neglect of residents;.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.A review of the facility's Extreme Heat Policy dated implemented 07/29/25, included it is the policy of the facility to maintain a safe, comfortable, and temperature-controlled environment. In periods of extreme heat, staff must take all necessary actions to prevent heat-related illness, dehydration, or other complications among resident and staff. Definitions: 1. Extreme heat: ambient indoor or outdoor temperatures that exceed 80 degrees F and/or the heat index or local heat advisory indicates hazardous conditions. 2. Heat related illness: includes heat exhaustion, heat cramps, or heat stroke caused by prolong exposure to high temperatures.The surveyor reviewed the medical record for Resident #1.A review of the admission Record (AR) face sheet (an admission summary), revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to; multiple sclerosis (an autoimmune disorder between the brain and the body leading to symptoms such weakness, numbness, coordination problems, and vision issues), encephalopathy (a condition that affects the brain's function resulting in altered mental state), muscle weakness, atherosclerotic heart disease (heart disorder), dementia, repeated falls, and personal history of transient ischemic attack (TIA) and cerebral infarction (stroke).A review of the Minimum Data Set (MDS), an assessment tool dated 09/30/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which reflected a severely impaired cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs).A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 06/30/22, that the resident required assistance/potential to restore function for mobility as evidenced by limited mobility related to inability to move independently. Interventions included but were not limited to; one person assistance with ambulation.A review of the Resident #1's Progress Notes included a nurse's note documented by RN #1 on 07/29/25 at 11:20AM, that the resident was seen sitting on the patio and this writer was going to do vital sign checks when they were called by RR #1 to check on the resident. The resident was initially drowsy, responded to verbal stimuli, and become unconscious with breathing present. Vital signs were taken; blood pressure 123 millimeters of mercury (mmHg) over 78 mmHg (123/78), HR 124 bpm, unlabored breathing 18 breaths per minute, temperature 103.8 degrees F, oxygen saturation 97% on room air, and blood sugar 94. The resident was assisted back to room in cool environment, ice pack was applied, the resident responded to sternum rub and regained consciousness. The resident denied pain or distress. Supplemental oxygen and cool sponge were provided, and Tylenol was administered. The physician was notified and ordered the resident transferred out to ER for further evaluation.A review of the facility's investigation report dated 07/31/25, included the following:Incident: On 7/29/25 at approximately 11:15 AM, [RN #1] noted [RR #1] was trying to get [the resident] up in the patio. [The resident] was observed drowsy but responded to verbal stimuli. Vital signs were checked, and the resident's temperature was 103.8 degrees F and heart rate was 124 bpm. The resident was immediately assisted back to their bed via wheelchair, and the resident became more alert and verbally responsive. Cooling measures were applied, and the resident was given Tylenol at 11:50 AM. The physician was notified and ordered to transfer the resident to the hospital. Resident #1's Representative (RR #2) was notified, and they agreed to the hospital transfer.Investigation: that per interview with staff, RN #1 on 07/29/25, at approximately 10:00 AM, noticed that the Certified Nursing Assistant (CNA #1) was still providing care on Resident #1, and she proceeded to give morning medications to another resident. Per CNA #1, after he provided care to Resident #1, he walked them out of their room, and another CNA (CNA #2) took the resident to the dayroom. CNA #1 stated he noted that the resident was in the dayroom at around 11:00 AM, during his dayroom assignment to watch the residents, but he did not realize if the resident's private companion (RR #1) brought the resident out of the dayroom to the patio when RR #1 arrived. RR #1 arrived at the facility at 11:03 AM. At approximately 11:15 AM, RN #1 noted the resident was at the patio with RR #1 trying to get the resident up. Resident #1 was observed sitting on the couch with some shade, drowsy but responded to verbal stimuli. Resident #1 was assisted back to their room via a wheelchair. Vital signs were checked and noted with elevated temperature and heart rate. Cooling measures were provided, and Tylenol was given. Vital signs were rechecked: blood pressure-119/70, HR-104 bpm, breathing 18 breaths per minute, oxygen saturation on room air-96%, temperature- 97.1 degrees F, and resident was back to their baseline. The physician was informed and ordered the resident to be sent to the hospital to rule/out seizure. Other CNAs that worked that day were interviewed, but no one noticed Resident #1 going out to the patio by themself. They also stated, Resident #1's family did not want the resident out to patio unless with the companion (RR #1). Transport [ name redacted] was called and the resident was picked up at 1:15 PM. They left for the hospital with no signs of distress. Resident #1 was sent to hospital [name redacted].The investigation did not include a statement from RR #1 who was with the resident at the time.A review of ER paperwork dated 07/29/25 at 1:50 PM, included history of present illness that Resident #1 arrived at the ER by emergency medical services (EMS) for an episode of unresponsiveness. Per [Resident #1's sending facility name redacted], [Resident #1] was outside 30-40 minutes sitting on a bench on the patio when [the resident] became unresponsive, tachycardic (fast heart rate), and was found to be febrile 103.8 degrees F. The facility gave [the resident] Tylenol and wiped the resident with cold sponge and [the resident's] temperature went down to 97.1 degrees F before [they] were sent to the [ER]. The report also indicated the resident was diagnosed with transient alteration awareness (loss of normal awareness or behavior) and heat stroke. On 11/05/25 at 12:40 PM, the surveyor interviewed the Unit Manager (UM), who stated that on 07/29/25, she was in a care meeting when the nurse (RN #1) called her. The UM further stated that when she came to the floor, the resident was seen sitting outside on the patio with the companion (RR #1). The UM stated RR #1 called the nurse (RN #1) to check on the resident. The UM stated she did not know if the resident was taken outside by RR #1, and normally there was staff or a CNA in the dayroom that oversaw the residents outside on the patio as well. The UM stated that the companion (RR #1) did not provide care to Resident #1.The surveyor requested for a copy of dayroom assignment on that day of 07/29/25. The facility document titled as Dayroom Schedule dated 07/29/25, and shift: the 7:00 AM to 3:00 PM shift revealed that CNA #1 was assigned in dayroom that day from 11:00 AM to 11:30 AM.On 11/05/25 at 1:08 PM, the surveyor interviewed RN #2, who was Resident #1's regular nurse. RN #2 stated that the companion, RR #1, did not provide care for the resident.On 11/5/25 at 3:46 PM, the surveyor interviewed CNA #1, who was assigned to the dayroom at the time of the incident as well as Resident #1's assigned aide. CNA #1 stated he was regularly assigned to the resident, and the resident could not transfer by themself but would try. CNA #1 stated the resident required one person assistance from staff and supervision during eating. CNA #1 stated that after he washed the resident, he walked the resident to the dayroom for activities. CNA #1 further stated he would sometimes catch the resident trying to go to the patio. CNA #1 stated that we had an every 30-minute rotating assignment to watch the residents in the dayroom. CNA #1 stated on 07/29/25, after washing the resident at around 10:00 AM, I took [Resident #1] to the dayroom. My scheduled dayroom assignment was from 11:00 AM to 11:30 AM. When I went back to the dayroom at 11:00 AM, I saw the resident [at] the long table. The [television] was on, I did not see the activity person. I did not see the companion (RR #1). I did not see [RR #1] taking the resident out to the patio. CNA #1 further stated that at 12:00 PM, while he was [providing] care to another resident, the nurse called [him] because they needed help outside [on] the patio to pick [up] and put [the resident] in wheelchair and back to [Resident #1's] room. [The resident] was sweating and was not talking. [The resident] looked different. [The resident] was sent out to the hospital. CNA #1 stated that the companion, RR #1, did not provide care to the resident.On 11/05/25 at 4:30 PM, the surveyor interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The DON stated that Resident #1's companion, RR #1, did not provide care to the resident.On 11/06/25 at 12:29 PM, the surveyor interviewed CNA #2, who was assigned to the dayroom on 07/29/25 from 11:30 AM to 12:00 PM. CNA #2 stated she could not recall the incident on 07/29/25, and she did not recognize the resident's companion (RR #1). CNA #2 also stated she could not remember her schedule that day. The surveyor informed CNA #2 that she was assigned to the dayroom from 11:30 AM to 12:00 PM, and CNA #2 stated, it was so long ago, and the resident went out to the patio always with the family.On 11/06/25 at 12:55 PM, the surveyor interviewed CNA #3, who was assigned in the dayroom on 07/29/25 from 10:00 AM to 10:30 AM. CNA #3 stated that the resident did not go out by themself but usually with the companion. CNA #3 further said, I did not see the resident from 10:00 AM to 10:30 AM outside while I was there in the dayroom. CNA #3 stated she did not see the companion (RR #1) taking the resident out to the patio.The surveyor was not able to interview RN #1 who was reportedly out of the country.On 11/07/25 at 12:17 PM, the surveyor conducted a telephone interview with RR #2, who stated on 07/29/25, the UM called them to inform RR #2 that the facility was sending Resident #1 to the hospital for evaluation. RR #2 stated that the UM informed them of the incident, that the resident was outside for approximately 40 minutes, and the facility notified the physician who ordered to send the resident to the ER.On 11/07/25 at 2:13 PM, the surveyor conducted a telephone interview with the resident's companion, RR #1, who stated they arrived at the facility around 11 o'clock that day. RR #1 stated, I got out from the elevator and [the resident] was not there in the dayroom, so I went to check [the resident's] room, and [the resident] was not there, too. I went to look for [the resident] and going back to the dayroom, I saw [the resident] through the glass door. [The resident] was outside on the patio sitting on the right area of patio and was on [the resident's] right side. [The resident] was out open under the sun; [they were] seated in one of the chair with [their] rolling walker beside [them]. I thought [the resident] was asleep. I called [the resident's] name and [the resident] was not responding. I saw saliva from [the resident's] mouth and drainage coming out from [the resident's] nose. I rushed inside to ask for help. I met the nurse halfway in and told her the resident needed help. [The] nurse rushed to [the resident] and checked [the resident], and they assisted [the resident] back to bed. At around 1:20 PM, they took [the resident] to the hospital. RR #1 further stated sometimes they took the resident outside, and RR #1 did not leave the resident unattended, and the resident did not go outside by themself. RR #1 stated when RR #1 came out from the elevator after they arrived, there were some residents in the dayroom and there was no CNA. RR #1 said they knew because RR #1 started looking for the resident.On 11/10/25 at 10:45 AM, the surveyor interviewed the DON, who stated that the facility had CNAs assigned every thirty-minutes in the dayroom to watch the residents, providing supervision and ensuring safety. The DON further stated the CNA assigned did not leave the dayroom until the relieving CNA arrived.On 11/10/25 at 2:08 PM, the surveyor interviewed the LNHA and DON, who stated that it was RR #1 who took the resident out to the patio. The DON stated that after the incident, she gathered statements from the nurse and the CNA. The LNHA confirmed there was a heat wave on that day as he said he made an announcement regarding safety and precautions against extreme heat. (This interview contradicted the ER report that the facility reported that the resident was outside for 30 to 40 minutes since RR #1 entered the facility that day at 11:03 AM, and RR #1 ask RN #1 for help at 11:15 AM. RR #1 was only in the facility for twelve minutes before RN #1 was called.)A Removal Plan was submitted on 11/13/25 at 4:52 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including on 07/29/25, Resident #1 was assessed and transferred to emergency room for evaluation, and the resident returned to the facility on [DATE], and was placed hourly monitoring. The nurse and CNA who were assigned to Resident #1 were in-serviced on resident safety and protection from neglect. On 11/12/25, Resident #1 was placed on one-to-one (1:1) supervision, and all cognitively impaired residents were placed on every thirty-minute monitoring. The LNHA, DON, and ADON reviewed the abuse and neglect policy, taking residents outside the facility, hot weather, enhanced supervision, and nursing round policies with no revisions made. The DON, ADON, LNHA provided the nurses and CNAs with training on the abuse and neglect policy, resident supervision, protection of resident from neglect, and resident safety. On 11/12/25, the DON, ADON, and LNHA provided non-clinical staff training on abuse and neglect and residents' rights to be free from neglect.The surveyor verified the implementation of the RP on-site during the continuation of the survey on 11/17/25.NJAC 8:39-4.1(a)5

Based on record review, interview, and review of facility policy, the facility failed to ensure that medical records were provided to residents or their legal representatives in a timely manner. This deficient practice was identified for three of six sampled residents (R)13, (R)15, and (R)16 which delayed access to essential health information. Review of the facility's policy titled Authorization for Release of Information dated 05/01/22 revealed that access to view documents must be provided within 24 hours of receipt of a request, and copies of records must be provided within two working days. 1.Review of R13's diagnosis sheet provided by the facility revealed an admission date of 05/20 and discharge date in 06/20. Review of correspondence from the New Jersey Department of Health (NJDHS) dated 04/23/25 revealed R13's legal representative made multiple medical record requests on 09/20/24, 11/08/24, and 08/13/24. During an interview on 08/04/25 at 11:30 AM with the Administrator revealed as of 02/25, all medical record requests for residents cared for under the previous facility are to be made or forwarded to Paralegal (PL)2 and this may be the cause of why requests are delayed. During an interview with (PL)1 on 08/08/25 confirmed receipt of R13's medical records from April 2024, but records for the following dates 09/20/24, 11/08/24, and 08/13/24 had not been received. 2.Review of R15's Face Sheet located in the electronic medical record (EMR) revealed an admission date of 07/24 and discharge date of 01/24. Review of a detailed timeline provided by R15's family member revealed she submitted a medical records request in person on 04/08/25 and sent a certified request on 05/27/25 addressed to the Administrator. During an interview with R15's family member on 08/08/25, she confirmed she had not received the requested records. 3.Review of R16's diagnosis sheet provided by the facility revealed an admission date of 04/24 and discharge in 05/24. Review of NJDHS correspondence dated 03/14/25 revealed multiple record requests on 09/06/24, 10/13/24, and 11/15/24. Review of email correspondence provided by the facility showed the requests remained unfulfilled until 07/25/25. During an interview with PL3 on 08/08/25 at 11:32AM the PL3 revealed they followed up with the facility on 07/23/35 expressing that R16's request was not fulfilled. She confirmed she did receive the records finally on 07/25/25.

Based on interview, record review, and review of facility policy, the facility failed to provide care and treatment in a timely manner for an unavoidable pressure ulcer for one of three residents (Resident (R) 5) reviewed for pressure ulcers out of a total sample of 20. The wound was not properly assessed for seven days. This resulted in harm when the wound was determined to be an unstageable pressure ulcer that resulted in hospitalization for the resident with a diagnosis of sepsis, with the pressure ulcer being the possible source of the sepsis.Review of the facility's policy titled, Pressure Injury Prevention Guidelines, dated 03/04/25, revealed, . to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present . The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound . Review of R5's Face Sheet, located in the Profile tab of the electronic medical record (EMR), revealed R5 was admitted to the facility on 01/25 with diagnoses that included pressure ulcer of sacral region stage II, malignant neoplasm of unspecified part of the right bronchus or lung, secondary malignant neoplasm of mediastinum, chronic obstructive pulmonary disease, chronic viral hepatitis C, hepatomegaly, and polyneuropathy. Review of R5's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/25 and located in the resident's EMR under the MDS tab, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R5's cognition was intact for decision-making. It was recorded R5 required partial to moderate assistance with bed mobility, was occasionally incontinent of bladder and bowel, and had one stage 2 pressure ulcer. It was recorded pressure reducing devices were in use for the resident's chair and bed, a turning program was in place, and nutritional interventions were implemented. Review of R5's Initial Wound Assessment, located in the EMR under the Assessment tab and dated 01/17/25, revealed R5 was seen by the Wound Care Nurse (WCN) for an initial evaluation of a stage II sacral pressure sore. It was recorded, . Initial wound encounter measurements are 0.5cm length x 0.4cm width x 0.1 cm depth, with an area of 0.2 sq cm and a volume of 0.02 cubic cm. There is a Moderate [sic] amount of sero-sanguineous drainage noted which has no odor . Review of R5's Physician Order, dated 01/17/25 and located under the Orders tab of the EMR, revealed an order to cleanse R5's pressure ulcer with wound cleanser and to apply Calazime Skin Protectant to the sacrum once daily. It was also ordered for the resident to have weekly skin assessments on Mondays. Review of R5's Care Plan, dated 01/17/25 and located under the Care Plan tab of the EMR, revealed R5 had a documented pressure ulcer. Interventions included to evaluate ulcer characteristics and monitor ulcer for signs of progression or declination. Review of R5's Physician Orders, dated 01/30/25 and located under the Orders tab of the EMR, revealed an order for Phytoplex Z-Guard Paste to R5's sacrum twice daily for IAD (incontinence associated dermatitis). Review of R5's Progress Note, dated 01/31/25, located under the Progress Notes tab of the EMR, and written by the WCN, indicated the stage II sacral pressure ulcer was healed/resolved. It was recorded there was no slough or eschar present, there were no signs or symptoms of infection, and there was 100% epithelialization. Review of R5's eMAR PN (electronic Progress Note), dated 02/10/25 at 9:05 PM and located under the Progress Notes tab of the EMR, revealed, . Weekly skin assessment: Monday one time a day every Mon No new skin issues noted . Review of R5's eMAR PN, dated 02/14/25 at 2:41 PM and located under the Progress Notes tab of the EMR, revealed, . Phytoplex A-Guard . wound care completed as per current order and wound nurse on rounds today and patient has wound care consult and asked wound nurse to see . Review of R5's Progress Notes tab revealed no documented evidence of why the WCN was asked to see R5. There was no other documented evidence related to R5's skin integrity at this time, including if R5's sacral pressure ulcer had reopened or that R5 had developed a new pressure ulcer. There was no documented evidence R5 still had IAD. Review of R5's Orders and Progress Notes tabs of the EMR and review of the WCN's consolidated Progress Note Details revealed no documented evidence R5 was seen by the WCN on 02/14/25. Review of R5's Progress Note, dated 02/17/25 at 11:55 AM and located under the Progress Notes tab of the EMR, revealed, . Pt [patient] picked up by family for his appointment . Wound care completed prior to leaving . Review of the TAR, dated 02/17/25 at 9:00 AM, revealed R5 received Phytoplex Paste to the sacrum. Review of R5's entire EMR revealed no further information related to R5's skin integrity. There was no documentation to show if R5's pressure ulcer had reopened or if a new pressure ulcer had developed. There was no documented evidence R5 still had IAD. Review of R5's Progress Notes tab of the EMR for 02/18/25 revealed no documented evidence related to R5's skin integrity. Review of R5's Progress Note, dated 02/19/25 at 2:34 PM and located under the Progress Notes tab of the EMR, revealed, . Sacral wound was cleaned as per order. Unit manager informed to f/u [follow up] with wound care nurse as the current order isn't effective and wound is worsening and requested for air mattress which will be followed up with maintenance by UM [Unit Manager]. Patient is repositioned regularly . Review of R5's Progress Notes tab revealed no further documented evidence related to R5's skin integrity. Review of R5's Progress Note, dated 02/21/25 at 1:06 PM, revealed, . 1000 [10:00 AM] Wound care nurse came to see patient. Wound seen by wound nurse and new order placed. NP [Nurse Practitioner] was notified 2/20 [02/20/25] for worsening wound and to evaluate. Instructed to see wound care as pt has wound care consult in place . Review of R5's Progress Note, dated 02/21/25, written by the Nurse Practitioner Wound Care Nurse (NP WCN)1 and located under the Misc (Miscellaneous) tab of the EMR, revealed, . Wound #2 is an unstageable Pressure Injury, obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of 'Not healed' . Initial wound encounter measurements are 10.5cm length x9.5cm width x 0.2cm depth with an area of 99.75sq cm and a volume of 19.95 cubic cm. There is a moderate amount of sero-sanguineous drainage noted which has a strong odor . Wound bed has no granulation,100% slough, no eschar, and no epithelialization present . Review of the Emergency Department (ED) provider notes, dated 02/21/25 and provided by the facility, revealed, . deep sacral wound with surrounding erythema concerning for cellulitis as possible source or at least contributing source of sepsis . During a telephone interview on 08/08/24 at 1:00 PM, Registered Nurse (RN)1 stated on or about 02/17/25, she noticed R5 had a 2x2 cm reddened area to the sacral area. RN1 stated R5's previous pressure ulcer had opened, and she notified the doctor. She stated the pressure ulcer was red, had clear drainage, and no order. She stated the information should have been in the progress notes. She stated she had asked for a wound consult at that time and placed the order for the consult. RN1 stated she worked with R5 on 02/17/25, 02/19/25, and 02/20/25. RN1 stated she notified the NP on 02/19/25 because the wound was worsening, and the NP stated to continue with the standing order treatment. RN1 stated the NP did not ask for any wound measurements. RN1 stated on 02/20/25, she asked the UM to follow up for a wound consult. RN1 stated she took measurements on 02/20/25, wrote them on her gloves, and then accidentally threw the gloves in the trash. RN1 stated that when a pressure ulcer is found, the nurse should document an assessment of the wound. She stated she did not remember documenting an assessment on R5's pressure ulcer on 02/20/25 but should have. During an interview on 08/08/25 at 2:42 PM, the WCN stated R5's wound was completed epithelized on 01/31/25. She stated she was notified to see the resident on 02/21/25 and when she did, he had a pressure ulcer that measured 10.5 cm x 9.5cm x 0.02 cm depth with 100% slough on the wound bed. The WCN stated the ulcer was unstageable because of the slough. She stated the wound had a strong odor, and she ordered a new treatment. The WCN stated she did not know what happened to the patient. During an interview on 0 8/08/25 at 3:45 PM, the Medical Doctor (MD) stated it was his expectation that nurses would notify him of changes in skin condition. He stated he did give an order for R5 to be seen by the WCN. The MD stated that in a perfect world, the nurses would measure and assess pressure ulcers, but the WCN would be the best one to get measurements.During an interview on 08/08/25 at 6:50 PM, the Director of Nursing (DON) stated nurses conduct weekly skin assessments on the residents' shower days. The DON stated that the Certified Nurse Aides (CNAs) were instructed to report any skin irregularities/change to the nurses, and the nurses will conduct a skin assessment. The DON stated the facility's expectation was that nursing staff conduct and document weekly skin assessments and measure and describe any identified skin injury or pressure ulcer. Further interview with the DON confirmed that measurements and description of R5's unstageable pressure ulcer were not documented and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 177778
Based on observation, interview, and record review, it was determined that the facility failed to ensure a) implementation of a resident's care plan for an as needed and preventative skin care treatment (against pressure ulcer/injury) from 1/25/24 to 6/25/24, b) provide prescribed treatment, Z-guard paste in a timely and consistent manner, c) administer Clonazepam, (Klonopin; medication used for anxiety) as scheduled, and in accordance with the physician's order. The deficient practice was identified for one (1) of five (5) residents reviewed for pressure ulcer, Resident #76 and was evidenced by the following:
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
On 11/23/24 at 12:20 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that Resident #76 had hospice services when admitted to the facility. The facility identified the Stage 2 pressure ulcer with erythema and blister in the sacral region on 6/23/24.
The surveyor reviewed the closed medical record for Resident #76.
According to the admission Record face sheet, an admission summary, reflected that Resident #76 was admitted to the facility with diagnoses that included, dementia and failure to thrive.
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/29/24, reflected the resident a Brief Interview for Mental Status (BIMS) was not conducted since the resident was rarely/never understood. A review of the resident's functional range in motion reflected the resident had a lower extremity impairment (hip, knee, ankle, foot) to both sides.
Further review of the MDS revealed Resident #76 was at risk of pressure ulcers/injuries and had no documented unhealed pressure ulcers/injuries. The treatments included application of medication (other than the feet), a pressure reducing device for the bed, and was enrolled in a program that required the resident to be turned and repositioned. At that time of the assessment, the resident had not received pain medications, the resident was unable to be interviewed of their experience of pain.
1.) A review of the individual comprehensive care plan (CP) included a focus area of the resident's risk for skin alteration of their skin integrity, initiated/revised on 1/25/24. The interventions included provision of preventative skin care routinely and as needed (prn), initiated on 1/24/24.
A review of the Documentation Survey Report (an electronic log of the resident's Activities of Daily Living (ADL) used by the Certified Nursing Assistant (CNA); ADL log) reflected that the routine and as needed preventative skin care was not included in the ADL log. Further review of the ADL log revealed that the ADL log was not consistently documented as completed from January 2024 to June 30, 2024.
A review of the Treatment Administration Record (TAR) from 2/2024 to 6/2024, did not include an order for a routine and as needed preventative skin care until 6/25/24.
On 11/26/24 at 12:04, during an interview with the survey team, the DON stated that preventative skin care treatment was documented as part of the ADL log. At that time, the DON confirmed and acknowledged that the ADL care was not consistently documented on and that the preventative skin treatment was not reflected on the 1/2024 log.
2.) A review of the facility provided skin evaluation for Resident #76 from 1/31/24, indicated the resident had no skin issues. The skin evaluation dated 2/10/24, reflected the resident had a new skin issue of stage 2 pressure ulcer/injury on the generalized are of the buttocks. The subsequent skin evaluations dated 2/17/24, 2/24/24, and 6/25/24 reflected the resident had no skin issues.
A review of the nursing progress note dated 6/23/24 at 10:00 AM, revealed a documentation by the nurse that indicated the resident was found with a small opening in the sacral area, that was red and blistered on both sides of the groin (the area between the abdomen and the thigh on either side of the pubic bone). The NP was made aware and ordered a treatment of Zinc, to be applied to sacral and bilateral groin areas three (3) times a day after care.
A review of the physician's orders did not reflect an order for Zinc oxide paste on 6/23/24.
A review of the Nurse Practitioner's progress note dated 6/25/24, reflected that nursing had reported that during the morning care, the resident was found with a small opening in the sacral area that was erythematous (abnormal redness on the skin) and the groin area had a rash and erythema (skin condition, appearance of redness, inflammation or discoloration, [NAME] about by an allergy, exposure to heat, yeast or bacterial infection). The Nurse Practitioner's assessment and plan included to administer Z guard paste (Phytoplex Z-guard paste) to the sacral area twice a day.
A review of the TAR from 6/25/24 to 7/31/24 revealed that order for Phytoplex -Z guard paste, to be applied on the sacrum topically twice a day for skin care was not administered on the following dates and times:
-6/25/25 at 9:00 AM and 9:00 PM
-7/3/24 at 9:00 AM
-7/5/24 at 9:00 AM
3.) A review of the administrative progress note dated 7/26/24, reflected the resident's family member voiced their complaint to the DON.
A review of the complaint investigation dated 7/26/24, reflected that the resident's representative informed the staff that Resident #76 had not received a dose of Clonazepam at 11:00 AM. The investigation indicated that there was a delay in with the delivery from the pharmacy and once the Clonazepam was delivered, it was administered.
A review of the Medication Administration Audit Report (MAAR) for the week of 6/23/2024 to 6/29/2024, included the following:
-on 6/25/24 Quetiapine 25 milligram (mg), 1 tablet one time day for psychosis was scheduled for administration at 9:00 AM and was instead administered at 12:46 PM.
- on 6/25/24 Clonazepam 0.5 mg, give 1 table by mouth one time a day for anxiety disorder was scheduled for administration at 11:00 AM and was instead administered at 12:46 PM.
-on 6/29/24 Quetiapine 25 milligram (mg), 1 tablet one time day for psychosis was scheduled for administration at 9:00 AM and was instead administered at 10:32 AM.
-on 6/29/24 Fluoxetine 10 milligram (mg), 1 capsule one time day for depression was scheduled for administration at 9:00 AM and was insteadadministered at 10:32 AM.
-on 6/29/24 Macrobid 100 mg, 1 capsule twice a day for dysuria for 7 days was scheduled for administration at 9:00 AM and was instead administered at 10:32 AM.
-on 6/29/24 Keppra 1000 mg, 1 tablet two times a day for seizure disorder was scheduled for administration at 9:00 AM and was instead administered at 10:32 AM.
A review of the MAAR for July 2024, included the following:
- on 7/3/24 Clonazepam 0.5 mg, give 1 table by mouth one time a day for anxiety disorder was scheduled for administration at 11:00 AM and was instead administered at 4:54 PM.
- on 7/5/24 Clonazepam 0.5 mg, give 1 table by mouth one time a day for anxiety disorder was scheduled for administration at 11:00 AM and was instead administered at 8:33 PM.
- on 7/26/24 Clonazepam 0.5 mg, give 1 table by mouth one time a day for anxiety disorder was scheduled for administration at 11:00 AM and was instead administered at 2:26 PM.
On 11/26/24 at 11:54 AM, during an interview with the survey team, the DON confirmed and stated that the Klonopin was administered late, the physician was informed of the late administration on 7/26/24. The DON also acknowledged the late administrations of the medications on June 2024 and July 2024. At that time, the DON stated that the facility was short staffed which contributed to the reason for the late administration of medications.
On 11/27/24 at 9:27 AM, during a follow-up interview with the surveyor, the DON stated that she and her team were working hard to convert agency staff to facility staff. The DON added that with approval from upper management, she was able to offer higher incentives against the competition and made progress from the past.
A review of the provided facility policy, Physician Advanced Practice Provider Orders dated/revised on 3/1/22, included the following: Orders will be accepted only from authorized, credentialed physician . or other authorized credentialed practitioner in accordance with state regulations .Each medication order is documented in the resident's medical record with the dare, time, and signature of the person receiving the order. The order is recorded on the MAR and the TAR.
No further information was provided.
NJAC 8:39-11.2(f), 27.1 (a) 29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 00168225; NJ 00172462; NJ 00161955, NJ 00177778; NJ00169881; NJ 00168886
Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 4 of 4 residents (Resident #66, #44, #49 and #29) observed for incontinence care on 1 of 2 units, 2nd-floor Unit.
This deficient practice was evidenced by the following:
a. On 11/22/24 at 8:20 AM, the surveyor and CNA #1 entered Resident #66's room and observed the resident in bed. The surveyor and CNA #1 noted a strong malodorous smell of urine. CNA #1 exposed Resident #66's pull-up which was saturated with urine.
The surveyor reviewed the medical record for Resident #66.
A review of the admission Record reflected Resident #66 was admitted to the facility with diagnoses which included but were not limited to dementia, diabetes mellitus, and hypertension.
The admission Minimum Data Set (MDS), an assessment tool dated 9/11/24 reflected Resident #66 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated the resident had a severe cognitive impairment. The MDS further assessed that the resident required maximum assistance from staff for personal hygiene and was always incontinent of bowel and bladder.
A review of the medical record revealed there were no Care Plans initiated that addressed the resident's incontinence care.
b. On 11/22/24 at 8:34 AM, the surveyor and CNA #1 entered Resident #44's room and observed the alert and oriented resident in bed. CNA #1 exposed Resident #44's incontinence brief which revealed a bladder pad inserted within the incontinence brief, both saturated with urine. Resident #44 stated that their last diaper change was 10:30 PM, last night.
The surveyor reviewed the medical record for Resident #44.
A review of the admission Record reflected Resident #44 was admitted to the facility with diagnoses which included but were not limited to severe chronic kidney disease, diabetes mellitus, and left leg below-knee amputation.
A review of the annual MDS dated [DATE] reflected Resident #44 had a BIMS score of 14 out of 15 which indicated Resident #44's cognition was intact.
The MDS further assessed the resident was dependent on staff for Activities of Daily Living (ADL) care and was frequently incontinent of bowel and bladder.
A review of the CP included a focus area that indicated the resident had urinary incontinence with interventions that included but were not limited to providing incontinence care as needed and identifying voiding patterns to establish a toileting program.
On 11/25/24 at 9:29 AM, the DON confirmed that even though Resident #44 was alert and oriented, the CNA assigned to the resident's care should have made incontinence rounds and changed the resident.
c. On 11/22/24 at 8:40 AM, the surveyor and CNA #1 entered Resident #49's room and observed the resident in bed. CNA #1 exposed Resident #49's incontinence brief which was soiled with urine and feces.
The surveyor reviewed the medical record for Resident #49.
The admission Record revealed Resident #49 was admitted to the facility with diagnoses which included but were not limited to aphasia and diabetes mellitus.
A review of the quarterly MDS dated [DATE] reflected the resident had a long-term and short-term memory problem and had a severe cognitive impairment. The MDS further assessed that Resident #49 was dependent on staff for all ADLs and was frequently incontinent of bowel and bladder.
d. On 11/22/24 at 9:00 AM, the surveyor and CNA #2 entered Resident #29's room and observed the resident in bed. CNA #2 exposed Resident #29's incontinence brief which was saturated with urine. CNA #2 stated that incontinence rounds should have been conducted every two hours.
The surveyor reviewed the medical record for resident #29.
A review of the admission Record reflected Resident #29 was admitted to the facility with diagnoses which included but were not limited to diabetes mellitus, hypertension, and chronic kidney disease.
A review of the quarterly MDS dated [DATE] reflected Resident #29 had a BIMS score of 1 out of 15 which indicated the resident had a severe cognitive impairment. The MDS further assessed that Resident #29 required staff assistance for ADL care and was frequently incontinent of bowel and bladder.
A review of the CP included a focus area that indicated the resident was incontinent of urine and unable to participate in a retraining program cognitively or physically with interventions that included but were not limited to assisting with perineal care as needed, utilizing the appropriate continent product.
On 11/22/24 at 1:19 PM, the survey team met with the administration to discuss the above observations and concerns. The DON stated that incontinence rounds should be done every 2 hours on all shifts.
On 11/26/24 at 10:00 AM, the surveyor conducted a phone interview with the 11-7, 2nd floor LPN. The LPN stated that she expected the CNAs to perform incontinence care every two hours.
The 11:00 PM-7:00 AM, CNAs were unavailable to be interviewed.
A review of the facility policy entitled, Activities of Daily Living (ADLs) with a review date of 5/1/23 indicated .the purpose of the policy is to ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the patient's choices and preferences .the care plan will address the patient's ADL needs and goals, including the provision of ADLs if the patient is unable to perform ADLs .a patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene .
No further information was provided by the facility.
NJAC 8:39-27.1 (a), 27.2 (h)

Based on observation, interview and record review, it was determined that the facility failed to provide a specialty device, darco boots, that was recommended as a change to provide support and pressure relief for pressure ulcers in a timely manner for one (1) of five (5) residents, Resident #14, reviewed for pressure ulcers. This deficient practice was evidenced by the following:
On 11/21/24 at 10:53 AM, the surveyor interviewed Resident #14 in their room. The surveyor observed dressings and booties to both feet that were on footrests of the wheelchair. The resident stated that they were waiting for darco boots (a specialty wound care shoe with multi-density insoles for customization and off-loading and an ultra-soft lining to reduce friction) that the wound consult physician had recommended and thought it was taking a long time.
On 11/25/24 at 10:56 AM, the surveyor interviewed the LPN#1 who stated that she was familiar with Resident #14. The LPN #1 stated that resident #14 was alert and oriented and could verbalize their needs. The LPN#1 added that the resident will tell you exactly what they want and was very specific as to which nurses perform wound care and when the wound care was to be done. The LPN#1 also stated that the resident went to a wound consult every two weeks but was unable to speak to any recommendation for darco boots.
On 11/25/24 at 11:05 AM, the surveyor interviewed the Unit Manager/LPN (UM/LPN) who stated that she has been the UM/LPN for the past 90 days. The UM/LPN added that Resident #14 goes out to a wound consult and that the resident keeps the updates from the wound clinic. The UM/LPN added that the resident was very particular, and it was difficult to get the updates from the resident. The UM/LPN stated that she had gone through the chart looking for the wound consult recommendations. The UM/LPN could not speak to any recommendation for darco boots and that they would come from the Rehab department.
The surveyor reviewed the medical record for Resident #14.
A review of the admission Record revealed diagnoses which included but not limited to, acute osteomyelitis (a serious bone infection), right tibia and fibula (shin bone/calf bone-the 2 that make up the lower leg between the knee and ankle), paraplegia (chronic condition that involves loss of muscle function in the lower half of the body), peripheral vascular disease (PVD) (a circulatory condition which narrowed blood vessels reduce blood flow to the limbs) and type 2 diabetes Mellitus (high blood sugar) with diabetic neuropathy (a type of nerve damage that is caused by diabetes).
A review of the most recent comprehensive quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/21/24, reflected the resident had a brief interview for mental status (BIMS) score of 14 out of 15, indicating that the resident had an intact cognition.
A review of the resident's individualized plan of care had a focus area that the resident was at risk for actual/potential alteration in skin integrity related to: Diabetes, PVD/edema (swelling)/osteomyelitis; osteoarthritis (arthritis of the bone); paraplegia with an initiation date of 3/16/24 and a revision date of 5/22/24. The interventions listed included but not limited to Pressure redistributing device on bed/chair.
A review of the Order Summary Report revealed a physician's order (PO) with a start date of 3/4/24 for PRAFO boot (a custom fitted device that helps manage foot and ankle conditions and designed to provide support and pressure relief) to left foot/leg per wound center recommendations.
A review of the nursing progress note completed by the Licensed Practical Nurse (LPN#1) revealed that on 10/8/24 Resident went out for wound care, came back stable. Wound dressing intact. No acute distress/concerns. No new orders.
A review of an undated wound consult that was uploaded electronically by the facility indicated that the reason for consultation was bilateral foot wounds and extensive debridement was performed. Recommendations indicated to continue current care with a follow up in one month 11/5/24 8:15 AM. In addition, there was a prescription dated 10/8/24 by the wound consult for Offloading darco shoe to bilateral feet with a date of 10/14/24 that had been scanned into the facility electronic system.
On 11/25/24 at 1:40 PM, the surveyor interviewed the Director of Rehab (DOR) who stated that she was familiar with Resident #14 and that the darco boots were originally ordered on 11/4/24 and there was a back order and came in just last week but the darco boots were too small for the resident and she had to order a different size that would be coming in tomorrow. The DOR stated that she was not aware of the prescription for the darco boots until 11/4/24 when Resident #14 came to ask her where the boots were. The DOR stated that the usual procedure was that a nurse would notify her of the prescription, and she would order the boots within 48 hours after the consult recommendation. The DOR added that she had confirmed with nursing to verify the prescription and was aware the date of the prescription was 10/8/24 but was unable to speak to why she had not received the prescription earlier than 11/4/24. In addition, the DOR stated that the resident was to continue using the PRAFO boots until the darco boots arrived.
On 11/26/24 at 10:17 AM, the surveyor interviewed the Interim Director of Nursing (IDON) who stated that the procedure for a resident that goes out to a consult was that there were forms provided in an envelope for the physician to complete and upon return the form would be given to the nurse and the nurse would verify any recommendations with the resident's physician or nurse practitioner. The IDON stated that Resident #14 has to give the paperwork from the wound consult to the nurse and that the resident does not want to do that. The IDON stated that she was trying to find an explanation as to what happened on 10/8/24 but was unable to. The IDON added that there was several changes and previous Directors of Nursing had resigned and there had been no nurse manager on the floor. The IDON acknowledged that the nurse should have reached out to the wound consult for any recommendations. The IDON also could not speak to why the prescription was scanned into the facility electronic system on 10/14/24 and the DOR had no knowledge of the prescription until 11/4/24.
A review of the facility policy with a revision date 3/1/22 for Physician/Advanced Practice Provider (APP) Orders provided by Regional Clinical Nurse reflected that for Consult Recommendation/Orders the Findings and recommendations will be documented on the Consultation Form; The Nurse will notify the attending physician of findings and recommendations; The attending physician, if in agreement, will order the specific treatments as outlined by the consultant.
NJAC 8:39-27.1(e)

Based on observation, interview, and record review it was determined that the facility failed to administer oxygen therapy according to the physician's order for 1 of 1 resident, Resident #6, reviewed for respiratory care and services. The deficient practice was evidenced by the following information.
The surveyor observed Resident #6 on 11/21/24 at 10:36 AM seated in the hallway in a wheelchair outside their room. The resident was receiving oxygen therapy from a portable oxygen concentrator at a rate of 3 liters per minute (LPM) through a nasal cannula.
The surveyor observed the resident on 11/22/24 at 10:45 AM seated in their room in a wheelchair receiving oxygen at 3 LPM.
The surveyor observed the resident on 11/26/24 at 9:50 AM seated in a wheelchair in the hallway receiving oxygen at 4.5 LPM.
The surveyor interviewed the resident's assigned nurse on 11/26/24 at 9:51 AM. The nurse checked the physician's order for oxygen for Resident #6. The nurse stated the rate should be 2 LPM continuously. She stated she is reponsible for setting and monitoring the oxygen flow rate.
The nurse checked the flow rate and confirmed it was set at 4.5 LPM, the wrong setting. She stated she checked the flow rate when she started her shift. She stated someone may have accidently turned it up.
A review of the medical record revealed the resident was admitted with congestive heart failure, chronic obstructive lung disorder, and anemia.
The physician initiated an order for oxygen therapy shortly after admission at a flow rate of 2 LPM continuously through a nasal cannula.
The resident was care planned for chronic obstructive pulmonary disease with an intervention to administer oxygen therapy as ordered at a flow rate of 2 LPM continuously via a nasal cannula.
The surveyor discussed the oxygen delivery concerns on 11/26/24 at 10:38 AM with the Administrator and the Director of Nursing.
The facility procedure titled Oxygen: Concentrator, revised 8/7/23, instructed staff to verify the physician's order prior to setting the liter flow rate.
NJAC 8:39-27.1(a)

Complaint# NJ 177778
Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure sufficient staff were available to administer medications in a timely manner in accordance with the physician's order. This deficient practice was identified for one (1) of two (2) resident investigated for Activities of Daily Living (ADL).
Refer 658 E
Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21:
One Certified Nurse Aide (CNA) to every eight residents for the day shift.
One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and
One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties.
For the week of Complaint staffing from 6/23/2024 to 6/29/2024, the facility was deficient in CNA staffing for residents on 4 of 7-day shifts, deficient in total staff for residents on 1 of 7 evening shifts, and deficient in CNAs to total staff on 1 of 7 evening shifts as follows:
-06/23/24 had 6.5 total staff for 71 residents on the evening shift, required at least 7 total staff.
-06/24/24 had 3.7 CNAs for 71 residents on the day shift, required at least 9 CNAs.
-06/24/24 had 3.6 CNAs to 7.2 total staff on the evening shift, required at least 4 CNAs.
-06/25/24 had 4.7 CNAs for 71 residents on the day shift, required at least 9 CNAs.
-06/26/24 had 8.4 CNAs for 71 residents on the day shift, required at least 9 CNAs.
-06/29/24 had 8.3 CNAs for 72 residents on the day shift, required at least 9 CNAs.
A review of the Medication Administration Audit Report (MAAR) for the week of 6/23/2024 to 6/29/2024, included the following:
-on 6/25/24 Quetiapine 25 milligram (mg), 1 tablet one time day for psychosis was scheduled for administration at 9:00 AM and was instead administered at 12:46 PM.
- on 6/25/24 Clonazepam 0.5 mg, give 1 table by mouth one time a day for anxiety disorder was scheduled for administration at 11:00 AM and was instead administered at 12:46 PM.
-on 6/29/24 Quetiapine 25 milligram (mg), 1 tablet one time day for psychosis was scheduled for administration at 9:00 AM and was instead administered at 10:32 AM.
-on 6/29/24 Fluoxetine 10 milligram (mg), 1 capsule one time day for depression was scheduled for administration at 9:00 AM and was instead administered at 10:32 AM.
-on 6/29/24 Macrobid 100 mg, 1 capsule twice a day for dysuria for 7 days was scheduled for administration at 9:00 AM and was instead administered at 10:32 AM.
-on 6/29/24 Keppra 1000 mg, 1 tablet two times a day for seizure disorder was scheduled for administration at 9:00 AM and was instead administered at 10:32 AM.
On 11/26/24 at 12:04 PM, in the presence of the survey team, the surveyor and the Director of Nursing reviewed the MAAR together for the week of 6/23/2024 to 6/29/2024. At that time, the DON stated that the administration was late several times in June because of short staffing due to the mass exit of staff.
A review of the provided facility policy, Staffing Center Plan, dated/revised on 8/7/23, included the following: Purpose; to assure appropriate staffing are scheduled and maintained.
A review of the provided facility policy, Facility Assessment, dated/revised 8/7/24, included under Practice Standards, subsection 3.1.1
Determine staffing levels to ensure sufficient number of qualified staff are available to meet each patient's needs.
No further information was provided.
NJAC 8:39- 4.1(a)11; 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation performed on 11/22/24, the surveyor observed three (3) nurses administer medications to five (5) residents. There were 25 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 12 %. This deficient practice was identified for two (2) of five (5) residents, (Residents #38 and #46), that were administered medications by one (1) of three (3) nurses. The deficient practice was evidenced as follows:
1. On 11/22/24 at 7:53 AM, the surveyor observed the Registered Nurse (RN#1) preparing to administer the morning medications to Resident #46. The RN#1 stated that according to the electronic medication administration record (EMAR), the resident had a physician's order (PO) for insulin (a medication used to lower blood sugar). The RN#1 removed the resident's Humalog KwikPen (insulin lispro) (a fast-acting insulin) 100 units (U)/milliliter (ML) solution pen-injector (a disposable single-patient-use prefilled insulin pen) from the medication cart, then removed the pen cap and replaced the cap with a needle cap. The surveyor observed the RN#1 dial the pen-injector dose selector to two (2) U and pushed down on the injection button while the pen-injector was in a slightly slanted downward horizontal position aiming toward the garbage on the side of the medication cart and a click was heard. The RN#1 explained that the pen injector had to be primed with two (2) U to make sure the needle was functioning which meant that two (2) U were wasted. The RN#1 then stated that the resident was to receive four (4) U according to the blood sugar results that he had just obtained and dialed the dose selector to four (4) U.
On 11/22/24 at 8:04 AM, the surveyor observed the RN#1 inject Resident #46's left abdominal area subcutaneously (SC) with the insulin lispro pen-injector that was dialed to 4 U by pushing down on the injector button and a click was heard. The surveyor observed the RN#1 hold the injector button down after the click for two (2) seconds and removed the pen-injector from the skin.
On 11/22/24 at 8:20 AM, the surveyor interviewed the RN#1 who stated that he was aware that insulin pen-injectors had a specific technique and thought he had performed the technique. The RN#1 explained that he had primed the pen-injector by wasting two (2) U. The RN#1 was unable to speak to the direction the needle should in when priming. The RN#1 further explained that when he pushed down on the injection button of the pen, he listened for the click and held the pen-injector in the skin for one (1) to two (2) seconds. The RN#1 further explained that he did not immediately remove the pen injector because it was possible that you would see liquid come out on the resident's skin. The RN#1 was unable to speak to whether there was a specific timeframe required to hold the pen-injector in place before removing from the skin. (ERROR #1) The RN#1 stated that there was a Nurse Educator who had done inservices but that she was no longer employed at the facility.
The surveyor reviewed the electronic medical record for Resident #46.
A review of the resident's admission Record reflected that the resident had diagnoses which included but not limited to, Type 2 Diabetes Mellitus (DM) (high blood sugar).
A review of the resident's Order Summary Report (OSR) reflected a PO with a start date of 11/11/24 for Humalog KwikPen Subcutaneous Solution Pen-Injector 100 U/ML (insulin lispro), Inject as per sliding scale: if 0-150 =0 U; 151-200 =2 U; 201-250 =4 U; 251-300 = 6 U; 301-350 = 8 U; 351-499 =10 U Greater than 400. Call MD/NP., subcutaneously with meals for DM.
A review of the EMAR reflected the same PO as above in the OSR and the RN#1 had documented the insulin lispro as administered on 11/22/24 to the resident's abdomen left upper quadrant for the morning dose.
On 11/22/24 at 1:17 PM, the survey team met with Licensed Nursing Home Administrator (LNHA), the Interim Director of Nursing (IDON) and the Regional Clinical Nurse (RCN). The surveyor reviewed the above observation of the insulin pen-injector technique performed by RN#1. The IDON acknowledged that there were specific insulin pen-injector techniques that were required when using a pen-injector. The IDON also acknowledged that when priming the pen-injector the nurse was to hold the pen-injector upright and that after pushing down on the injection button and hearing the click the pen-injector needed to be held in place for a slow count of at least five (5) seconds. The IDON and RCN acknowledged that by not following the manufacturer's specifications for correctly priming an insulin pen-injector and by not following the manufacturer's specifications for holding the pen-injector in place for at least five (5) seconds could affect the dosage of the insulin. (ERROR#1) The IDON stated that she would have to check if there was a medication observation performed prior to 11/22/24 for RN#1.
On 11/25/24 at 9:08 AM, the IDON provided a Med Pass Observation form dated 11/20/25 for RN#1 that was performed by a Unit Manager/Licensed Practical Nurse (UM/LPN). The form had not indicated that an insulin pen-injector technique was observed. In addition, the form was not completed for a Reviewer Summary of Technique or a Calculated Error Rate.
On 11/25/24 at 1:56 PM the survey team met with LNHA, IDON, RCN and the Administrator In Training. The IDON stated that the facility policy for Medication Administration Subcutaneous Insulin that was provided to the surveyor included the instructions used for inservicing the nurses on the proper insulin pen-injector technique. The IDON explained that there was a Nurse Educator/Infection Preventionist (NE/IP) who recently was terminated. The IDON stated that the task of performing medication pass observations was delegated to her team if she was unable to perform them herself and the Consultant Pharmacist (CP) also helped perform med pass observations. The IDON was unable to speak to the actual date that the med pass was performed for RN#1 since the date on the form indicated 2025.
A review of the facility policy dated January 2023 for Medication Administration Subcutaneous Insulin provided by the IDON reflected To administer subcutaneous insulin as ordered and in a safe, accurate and effective manner. The policy indicated for the procedures to Review manufacturer specific administration and storage instructions for pen devices. Further review reflected the procedure to Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly, removing air bubbles. The safety test instructions reflected Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip. Further review of the policy indicated for the injection procedure to Keep the injection button pressed all the way in. Slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered.
On 11/26/24 at 10:38 AM, the surveyor interviewed the CP via the telephone. The CP stated that there were several medication observations performed for the facility but had not done an observation on RN#1. The CP added that any time a medication observation was performed there was an inservice with that individual nurse. The CP also stated that a group inservice regarding medication pass techniques had not been done for the nurses at the facility. The CP stated that she utilized a form when she completes a medication pass observation and that was reviewed as the inservice with the individual nurse. The CP explained that there was an insulin pen-injector technique which included priming the pen-injector. The CP thought the pen-injector could be held in the downward position when priming and was unsure if the direction of holding the pen-injector made a difference. The CP also stated that after the plunger was pushed down and the click was heard, then the pen-injector could be removed. The CP was unable to speak to whether the pen-injector had to be held down for a specific timeframe.
A review of the Consultant Pharmacist Services Med Pass Audit Tool revealed areas that were listed for Injectables which included Primes needle per manufacturer recommendation and Holds pen in place for time recommended by manufacturer.
A review of the facility policy with a revision date of 7/1/24 for Insulin Pens reflected for Practice Standards that Insulin Pens are to be primed prior to each use to prevent collection of air in the insulin reservoir.
A review of the manufacturer specifications for Instructions for Use Humalog KwikPen (insulin lispro) revealed instructions for priming the pen included Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Also included in the instructions for priming To Prime your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with the Needle pointing up. Push the Dose Knob in until it stops and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the needle. Further review of the manufacturer specifications revealed instructions for giving the injection which included Insert the needle into your skin. Push the Dose Knob all the way in. Continue to hold the Dose Knob in and slowly count to 5 before removing the Needle.
2. On 11/22/24 at 8:11 AM, the surveyor observed the RN#1 preparing to administer the morning medications to Resident #38. The RN#1 stated that according to the EMAR, the resident had a PO for two different types of insulin, insulin lispro and insulin glargine (a long-acting insulin). The RN#1 removed the resident's Humalog KwikPen (insulin lispro) 100 units (U)/milliliter (ML) solution pen-injector from the medication cart, then removed the pen cap and replaced the cap with a needle cap. The surveyor observed the RN#1 dial the pen injector dose selector to 2 units and pushed down on the injection button while the pen-injector was in a slightly slanted downward horizontal position aiming toward the garbage on the side of the medication cart and a click was heard. The RN#1 stated that there was a standing PO for five (5) U of the insulin lispro and according to the blood sugar results that he had just obtained, an additional one (1) U was to be added, giving a total dose of 6 U. The RN #1 dialed the insulin lispro pen-injector to 6 U. The RN#1 then removed the resident's Lantus SoloStar (insulin glargine) 100 U/ML pen-injector from the medication cart and used the same procedure to prime the pen-injector. The RN#1 then stated that the resident was to receive 15 U of insulin glargine and dialed the dose selector to 15 U.
On 11/22/24 at 8:14 AM, the surveyor observed the RN#1 inject Resident #38's left upper arm SC with the insulin lispro pen-injector that was dialed to 6 U by pushing down on the injector button and a click was heard. The surveyor observed the RN#1 hold the injector button down after the click for one (1) second and removed the pen-injector from the skin. The surveyor then observed the RN#1 use the same procedure to inject the insulin glargine pen-injector. (ERROR #2 and #3)
On 11/22/24 at 8:20 AM, the surveyor interviewed the RN#1 who stated that he was aware that insulin pen-injectors had a specific technique and thought he had performed the technique. The RN#1 explained that he had primed the pen-injector by wasting two (2) U. The RN#1 was unable to speak to the direction the needle should in when priming. The RN#1 further explained that when he pushed down on the injection button of the pen, he listened for the click and held the pen-injector in the skin for one (1) to two (2) seconds. The RN#1 further explained that he did not immediately remove the pen injector because it was possible that you would see liquid come out on the resident's skin. The RN#1 was unable to speak to whether there was a specific timeframe required to hold the pen-injector in place before removing from the skin. The RN#1 stated that there was a Nurse Educator who had done inservices but that she was no longer employed at the facility.
The surveyor reviewed the medical records for Resident #38.
A review of the resident's admission Record reflected that the resident had diagnoses which included, but not limited to, Type 2 DM.
A review of the resident's OSR reflected the following POs with start dates of 11/13/24:
-Humalog KwikPen Subcutaneous Solution Pen-Injector 100 U/ML (Insulin Lispro), Inject as per sliding scale: if 0-180 = 0 U; 181-200 =1 U; 201-250 =2 U; 251-300 = 3 U; 301-350 = 4 U; 351-400 =5 U Greater than 400. Call MD/NP., subcutaneously before meals for DM.
-Humalog KwikPen Subcutaneous Solution Pen-Injector 100 U/ML (Insulin Lispro), Inject 5 U subcutaneously with meals for DM.
- Lantus SoloStar Subcutaneous Solution Pen-Injector 100 U/ML (Insulin Glargine) Inject 15 U subcutaneously every morning and at bedtime for type 2 diabetes.
A review of the EMAR reflected the same POs as above in the OSR and the RN#1 had documented the insulin lispro and insulin glargine were administered on 11/22/24 to the resident's left arm for the morning doses.
On 11/22/24 at 1:17 PM, the survey team met with LNHA, the IDON and the RCN. The surveyor reviewed the above observation of the insulin pen-injector technique performed by RN#1. The IDON acknowledged that there were specific insulin pen-injector techniques that were required when using a pen-injector. The IDON also acknowledged that when priming the pen-injector the nurse was to hold the pen-injector upright and that after pushing down on the injection button and hearing the click the pen-injector needed to be held in place for a slow count of at least five (5) seconds. The IDON and RCN acknowledged that by not following the manufacturer's specifications for correctly priming an insulin pen-injector and by not following the manufacturer's specifications for holding the pen-injector in place for at least five (5) seconds could affect the dosage of the insulin. (ERROR#2 and #3) The IDON stated that she would have to check if there was a medication observation performed prior to 11/22/24 for RN#1.
On 11/25/24 at 9:08 AM, the IDON provided a Med Pass Observation form dated 11/20/25 for RN#1 that was performed by a Unit Manager/Licensed Practical Nurse (UM/LPN). The form had not indicated that an insulin pen-injector technique was observed. In addition, the form was not completed for a Reviewer Summary of Technique or a Calculated Error Rate.
On 11/25/24 at 1:56 PM the survey team met with LNHA, IDON, RCN and the Administrator In Training. The IDON stated that the facility policy for Medication Administration Subcutaneous Insulin that was provided to the surveyor included the instructions used for inservicing the nurses on the proper insulin pen-injector technique. The IDON explained that there was a NE/IP who recently was terminated. The IDON stated that the task of performing medication pass observations was delegated to her team if she was unable to perform them herself and the CP also helped perform med pass observations. The IDON was unable to speak to the actual date that the med pass was performed for RN#1 since the date on the form indicated 2025.
A review of the facility policy dated January 2023 for Medication Administration Subcutaneous Insulin provided by the IDON reflected To administer subcutaneous insulin as ordered and in a safe, accurate and effective manner. The policy indicated for the procedures to Review manufacturer specific administration and storage instructions for pen devices. Further review reflected the procedure to Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly, removing air bubbles. The safety test instructions reflected Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any air bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of the needle tip. Further review of the policy indicated for the injection procedure to Keep the injection button pressed all the way in. Slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered.
On 11/26/24 at 10:38 AM, the surveyor interviewed the CP via the telephone. The CP stated that there were several medication observations performed for the facility but had not done an observation on RN#1. The CP added that any time a medication observation was performed there was an inservice with that individual nurse. The CP also stated that a group inservice regarding medication pass techniques had not been done for the nurses at the facility. The CP stated that she utilized a form when she completes a medication pass observation and that was reviewed as the inservice with the individual nurse. The CP explained that there was an insulin pen-injector technique which included priming the pen-injector. The CP thought the pen-injector could be held in the downward position when priming and was unsure if the direction of holding the pen-injector made a difference. The CP also stated that after the plunger was pushed down and the click was heard, then the pen-injector could be removed. The CP was unable to speak to whether the pen-injector had to be held down for a specific timeframe.
A review of the Consultant Pharmacist Services Med Pass Audit Tool revealed areas that were listed for Injectables which included Primes needle per manufacturer recommendation and Holds pen in place for time recommended by manufacturer.
A review of the manufacturer specifications for How to use your Lantus SoloStar pen revealed instructions for performing a safety test included to Dial a test dose of 2 Units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the sir bubbles rise to the top of the needle. This will help you get the most accurate dose. In addition, the review of the manufacturer specifications for How to use your Lantus SoloStar pen further revealed instructions for injecting the dose which included to Use your thumb to press the injection button all the way down. When the number in the dose window returns to 0 as you inject, slowly count to 10 before removing. (Counting to 10 will make sure you get your full insulin dose.) Release the button and remove the needle from your skin.
NJAC 8:39-11.2(b), 29.2(d)

Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a COVID-19 Immunization. This deficient practice was identified for 3 of 5 residents reviewed for immunization (Resident #9, Resident #41, and Resident #55).
The deficient practice was evidenced by the following:
1. A review of the resident #41's admission record reflected the resident was admitted to the facility with diagnoses that included but were not limited to, urinary tract infection.
A review of Resident #41's quarterly Minimum Data Set (MDS), an assessment tool, dated 9/27/24, revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognitive functioning.
A review of the electronic medical record (EMR) indicated that Resident #41 had received Covid vaccines on 9/14/2/1 and 10/5/21. A review of the EMR and the hard (paper) chart revealed no information indicating the facility had offered an additional Covid vaccine.
2. A review of Resident #9's admission record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; hypothyroidism and type 2 diabetes.
A review of the EMR indicated that Resident #9 had received Covid vaccines on 5/4/21, 6/1/21,1/11/22, and 11/4/22. A review of the EMR and the hard chart revealed no information indicating the facility had offered an additional Covid vaccine.
3. A review of Resident #55's admission record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; severe malnutrition and diabetes.
A review of the EMR indicated that Resident #55 had received Covid vaccines on 12/28/21 and 2/23/22. A review of the EMR and the hard chart revealed no information indicating the facility had offered an additional Covid vaccine.
On 11/25/24 at 9:24 AM, the surveyor interviewed the Director of Nursing (DON) regarding infection control practices and procedures. She stated that Covid vaccines are offered, they are pre ordered from the pharmacy based on the resident's choice of the Pfizer or the Moderna vaccines. She further stated that residents are assessed to see what vaccines they have had and what vaccines they are due for. The acceptance/refusal/education are documented in the immunology tab in the EMR or in the hard (paper) chart.
On 11/26/24 at 10:36 AM, the surveyor asked the DON where to find the documentation regarding education after refusal of vaccines. She stated she was not sure it was done.
A review of facility policy COVID-19 Vaccination revised 2/7/24 includes:
Purpose
To prevent the spread of SARs-CoV-2 infection and its complications to patients/staff
Process
1. Obtain COVID-19 vaccination history
1.2 On admission, document patient COVID-19 vaccination status (receipt or lack of receipt of COVID-19 vaccine) in the medical record Immunization Record
3 Based on the patient's COVID-19 vaccination history, offer the vaccination following the manufacturer's recommended schedule
3.1 Subject to availability, the Center offers the COVID-19 vaccine (unless the vaccination is medically contraindicated, or the individual has already been fully vaccinated).
5. Obtain consent
5.1 Patient Immunization Record in PCC and Patient Informed Consent of Declination COVID-19 form
7. Document refusals
7.1 If a patient/patient representative refuses vaccination, document declination on the Immunization record
N.J.A.C. 8:39-19.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer residents a pneumococcal vaccine or document the reason for ineligibility for the pneumococcal vaccine for 2 of 3 residents reviewed for immunizations (Resident #58 and Resident #41).
The deficient practice was evidenced by the following:
Reference:
Centers for Disease Control (CDC) recommends pneumococcal vaccination (PCV) for many adults based on age, having certain risk conditions, and pneumococcal vaccines already received .
CDC recommends PCV15, PCV20, or PCV21 for adults who never received a PCV and are
Ages 65 years or older
Ages 19 through 64 years with certain risk conditions.
Chronic conditions and other factors that increase someone's risk for pneumococcal disease include Chronic heart, kidney, liver, or lung disease (Chronic lung disease includes chronic obstructive pulmonary disorder (COPD), emphysema, and asthma); Diabetes; Immunocompromising condition (having a weakened immune system).
1. On 11/25/24 at 10:40 AM, the surveyor reviewed the medical record for Resident #58.
A review of the resident's admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to dementia and diabetes mellitus.
A review of the quarterly Minimum Data Set, dated [DATE] reflected Resident #58 had a BIMS score of 7 out of 15 which indicated a severe cognitive impairment. Further review of the MDS revealed Section O did not indicate whether Resident #58's Pneumococcal Vaccine was up to date. The MDS further indicated that the vaccine was offered and declined. There was no documented evidence that the resident received an education about the risks and benefits of the vaccine. The surveyor requested the declination form from the Director of Nursing (DON).
A review of the immunizations tab in the electronic medical record (EMR) revealed there was no documentation to indicate the administration, declination, or not eligible status of the pneumococcal vaccine. An additional review of Resident #58's medical record revealed no documentation of the resident's vaccination status being assessed or the pneumococcal vaccine being offered.
On 11/27/24 at 10:56 AM, the surveyor conducted a phone interview with the DON and requested documentation that the resident had been administered, offered, and/ or refused the pneumococcal vaccine. The DON confirmed Resident #58 had not been administered or offered the pneumococcal vaccine and therefore she was unable to provide a declination letter.
The facility did not provide any additional information.
2. On 11/22/24 at 11:37 AM, the surveyor introduced self to Resident #41, who became annoyed and did not wish to speak to anyone from the Department of Health and instructed surveyor not to come back again.
A review of the resident's admission record reflected the resident was admitted to the facility with diagnoses that included but were not limited to, urinary tract infection.
A review of Resident #41's quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognitive functioning and coding that indicated the pneumococcal vaccine was offered and declined.
On 11/25/24, the surveyor interviewed the Director of Nursing (DON), who indicated that on admission the staff determines what vaccines the resident has had and what vaccines the resident is due for. She further stated that the acceptance/refusal/education is documented in the immunology tab in the electronic medical record of in the hard (paper) chart.
A review of the electronic medical record and the hard chart revealed no information regarding the pneumococcal vaccine.
On 11/26/24 at 9:57 AM, the surveyor reviewed the pneumococcal vaccine consent provided by the facility, for Resident #41 which was dated 11/25/24, and indicated the resident refused the vaccine.
On 11/26/24 at 10:36 AM, the surveyor asked the DON where to find the documentation regarding education after refusal of vaccines. She stated she was not sure it was done for this resident.
A review of facility policy Pneumococcal Vaccination revised 09/13/24 included:
Purpose
To prevent pneumococcal disease and its complications to patients
Process
1. Upon admission, obtain the pneumococcal vaccination history of all patients
1.2 Document pneumococcal vaccination history in the electronic health record
2. Based on the patient's pneumococcal vaccination history, offer (unless the vaccination is medically contraindicated, or the patient has already been vaccinated) the appropriate vaccination following the recommended schedule
2.2 Adults aged greater than or equal to 65 years who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine PCV20.
2.4 Provide the patient/representative education (Vaccine Information Statement(VIS)) regarding the benefits and potential side effects of vaccination
6. If patient/representative refuses pneumococcal vaccination, provide information and counseling regarding the benefit of vaccination (VIS). Document education in the medical record including VIS version date
6.1 If vaccination refused, document patient's and/or representative's reason for refusal of vaccination
6.1.1 Notify attending physician/provider of patient's or resident representative's refusal and document accordingly in the medical record
NJAC 8:39-19.4 (a,4)(d)(h)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 11/22/24 at 7:53 AM, during the morning medication pass, the surveyor interviewed the Registered Nurse (RN#1) who stated that he had two (2) glucometers (a glucose meter -a device used to determine the approximate concentration of glucose (sugar) in the blood by reading a test strip with the resident's blood on it) in the medication cart that were used for any resident that he needed to obtain a blood sugar result. The RN#1 explained that there were two glucometers in each medication cart in case one malfunctioned.
On 11/22/24 at 8:02AM, the surveyor observed the RN#1 obtain a blood sample from Resident #46 on a test strip using the glucometer to read the blood sample results.
On 11/22/24 at 8:10 AM, the surveyor observed the RN#1 obtain a blood sample from Resident #38 on a test strip using the same glucometer that was used for Resident #46.
The surveyor had not observed the RN#1 clean the glucometer before use on Resident #48 and in between the two residents.
On 11/22/24 at 8:20 AM, the surveyor interviewed the RN#1 who stated that he cleaned the glucometer with a sanitizing wipe after the morning medication pass and after the lunch medication pass. The RN#1 acknowledged that he had not cleaned the glucometer in between the two residents. The RN#1 explained that he did not need to clean the glucometer in between residents because the glucometer does not touch the resident and he uses gloves.
On 11/22/24 at 1:17 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Interim Director of Nursing (IDON) and Regional Clinical Nurse (RCN). The IDON stated that the glucometer should be disinfected with a sanitizing wipe before each use and in between each resident.
A review of the facility procedure for Fingerstick Glucose Measurement with a revision date of 6/15/22 provided by the RCN reflected Clean and disinfect meter before use with EPA approved disinfectant, following manufacturer's instructions. In addition, the procedure included Clean and disinfect the blood glucose meter after use with EPA approved disinfectant, following manufacturer's instructions.
On 11/25/24 at 9:08 AM, the IDON provided the surveyor with the manufacturer's instructions for the glucometer used at the facility. The IDON stated that she used the manufacturer's instructions to explain the importance of cleaning the glucometer in between residents.
A review of the manufacturer's instructions [name redacted] Caring for the Meter reflected for Cleaning your [name redacted] Meter Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface, so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface.
Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to follow Center for Disease Control recommendations and guidelines for Hand Hygiene.
This deficient practice was evidenced by the following:
According to the CDC Hand Hygiene in Healthcare Settings, Hand Hygiene Guidance, last reviewed on January 30, 2020, included that Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:
Immediately before touching a patient
Before performing an aseptic task or handling invasive medical devices
Before moving from work on a soiled body site to a clean body site on the same patient
After touching a patient or the patient's immediate environment
After contact with blood, body fluids, or contaminated surfaces
Immediately after glove removal.
1. On 11/22/24, in the presence of the Food Service Director (FSD), the surveyor observed two hand washing sinks located inside the kitchen. Both hand washing sinks were located on one side of the wall in the kitchen, and the paper towel dispensers were located on the other side of the wall. The FSD stated that the staff would wash their hands and then walk to the other side of the wall to get paper towels. The surveyor observed that both of the paper towels dispensers were located directly above the kitchen food preparation surface and there were drips of water on that surface.
3. On 11/21/24 at 12:09 PM, the surveyor observed the Nursing Assistant (NA) wash her hands in the sink across from the 2nd-floor nurse's station. The NA turned on the water, applied soap, and immediately placed her hands under the stream of running water without lathering them. The NA turned off the faucet with her bare hands.
On 11/25/24 at 9:55 AM, the surveyor observed the Certified Nursing Assistant (CNA) enter the soiled utility room with a large plastic bag of soiled linens. The surveyor observed the CNA sorted through the soiled linens. The CNA removed and discarded her gloves, then exited the room and went across the hall to wash her hands. The CNA turned on the faucet, applied soap and immediately placed her hands under the stream of running water. The CNA dried her hands and used the same paper towel to turn off the faucet. At that same time, the surveyor interviewed the CNA who acknowledged that she should have washed her hands by applying soap and rubbing her hands for 10 seconds outside the stream of water and should have used a clean paper towel to turn off the faucet. The CNA stated that she had received two in-services on proper hand hygiene but didn't do it properly because she was nervous. The surveyor asked the CNA if she should have lathered outside of the water for 20 seconds. The CNA stated that she thought it was 10 seconds.
On 11/25/24 at 10:10 AM, the surveyor observed signage outside room [ROOM NUMBER] which instructed to STOP VERY IMPORTANT! ENHANCED BARRIER PRECAUTIONS; Attention caregivers, staff, and visitors:
Perform hand hygiene before and after patient contact, contact with the environment, and after removal of PPE.
Wear a gown and gloves prior to these activities:
Dressing
Bathing/showering
Transferring
Providing hygiene
Changing linens
Changing briefs or assisting with toileting
Device care or use of device ( i.e. central lines, urinary catheters, feeding tubes, tracheostomy, ventilators)
Wound care; any skin opening requiring a dressing.
At that same time, the surveyor observed the agency Registered Nurse (RN) entered room [ROOM NUMBER] holding a cup. The RN opened the lid to the garbage can with her bare hands and as she discarded the cup into the trash some liquid spilled onto the floor. The surveyor observed the RN used a paper towel and wiped up the spillage with her bare hands. The surveyor observed the RN proceeded into the bathroom turned on the faucet, rinsed her hands under the stream of water, dried her hands, and used the same paper towel to turn off the faucet. At that same time, the surveyor asked the RN why she didn't use soap. The RN replied, Because there was no soap. The surveyor then placed her hands under the soap dispenser which dispensed soap. The RN stated, I guess I didn't put my hand under correctly.
11/25/24 at 10:18 AM, the surveyor interviewed the NA who stated that she had two in-services on proper hand hygiene. The NA stated that she should wet her hands, apply soap and wash her hands outside of the stream of water for 20 seconds before rinsing her hands and should use a clean paper towel to turn off the faucet.
The NA acknowledged she should have performed hand hygiene using the above technique but was very rushed when the surveyor observed her.
On 11/25/24 at 10:42 AM, the surveyor observed the Phlebotomist on the 2nd floor unit wearing gloves in the hallway. The surveyor observed the phlebotomist placed a urine specimen which was contained in a bag, on the treatment cart; wrote the resident's name on the bag, and then proceeded to walk through the unit wearing the same gloves holding the urine specimen. The surveyor asked the Phlebotomist if it was acceptable to wear gloves and carry a urine specimen throughout the facility. The phlebotomist replied, The bag is wet with urine so I can't touch the bag with my bare hands and I can't put it in my bag with all of the other samples . The phlebotomist acknowledged that she should have placed the contaminated bag of urine into another clean bag so that she could store it in her properly in the bag used to transport the specimens.
On 11/25/24 at 1:56 PM, the survey team met with the administration to discuss the above observations and concerns. The DON confirmed that staff should practice appropriate hand hygiene and wash hands with soap for 20 seconds outside the stream of running water. The DON confirmed the phlebotomist should have transported the urine specimen appropriately and that gloves should not be worn in the hallways.
A review of the facility's Hand Hygiene policy dated as revised on 5/1/23 and reviewed on 5/1/24, included .wash hands with soap and water .wet hands with warm water, apply soap to hands, and rub hands vigorously outside the stream of water for 20 seconds covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with a disposable towel .use towel to turn off the faucet.
No further information was provided by the facility.
NJAC 8:39-19.3(b); 19.4(a)

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following:
On 11/22/24 at 10:56 AM, in the presence of the Food Service Director, the surveyor observed the following:
1. On the shelf holding the water dispenser, the surveyor observed that the shelf was soiled with brown and white colored debris and the drip tray underneath the water dispenser spout was soiled with built up dried grown substance.
2. The surveyor observed the Boiler handle covered in cream colored debris lifted with the tip of the surveyor's pen.
3. The surveyor observed six of six oven knobs soiled with a thick brown substance which was easily lifted with the tip of the surveyor's pen.
4. The surveyor observed four of seven sprinklers above the cook top area soiled with a brown grease-like substance.
5. The surveyor observed one of four convection oven knobs soiled with a brown substance which was easily lifted with the tip of the surveyor's pen.
6. In the food preparation area, on the surveyor observed an a white cutting board with multiple deep scratches.
7. In the walk in refrigerator, the surveyor observed a ¾ full bag of shredded cheddar cheese on a shelf with a use by date of 11/21/24, the FSD stated this should have been removed from the refrigerator.
8. In the dry storage room, the surveyor observed an undated plastic bin which was ¼ full of white sugar. The FSD stated that the bin should have been dated.
The surveyor reviewed the facility's policy titled Cleaning Schedule for Food and Nutrition services, which revealed for the facility to maintain a clean and sanitary food and nutrition services department and prevent the growth of bacteria.
The surveyor reviewed the facility's policy titled Food and Nutrition services Use By dating guidelines, which revealed cheese which is opened would be used within the use by date.
NJAC 8:39-17.2(g)

3. On 11/22/24 at 11:43 AM, the surveyor observed an interaction between Resident #35 and a staff member. Resident #35 walked up the nursing station with an envelope in his/her hand. Resident #35 spoke to the staff person who was seated behind the desk at the nursing station. The resident asked for assistance with taping the envelope closed and obtaining a stamp.
The staff person raised her head from the computer screen, looked at the resident, but did not respond to the resident. A Rehabilitation staff person who was walking by and observed the interaction told the resident she would assist the resident. She guided the resident away from the nursing station.
The surveyor approached the staff person, introduced herself, and asked for the name of the staff person. She responded with her name and stated she was a CNA (CNA #2). When asked why she did not respond to the resident when he/she asked for assistance, she stated she did not know where to get tape or stamps. She said she was sorry she did not respond to the resident.
On 11/22/24 at 1:00 PM, the surveyor went to the resident's room and interviewed the resident. The resident said he/she received tape and a stamp from the DON.
On 11/22/24 at 1:26 PM, the surveyor relayed the above information to the Licensed Nursing Home Administrator and the DON. They stated CNA #2 should have responded to the resident and that CNA #2 would be re-educated.
NJAC 8:39-4.1(a)
Complaint # NJ00169291
Based on observation, interview, and record review it was determined that the facility failed to maintain the dignity of 3 of 20 residents reviewed (Resident # 62, Resident # 34, Resident #35). This deficient practice was found with 3 Certified Nursing Aides (CNA) observed during the survey.
The deficient practice was evidenced by the following:
1. On 11/22/24 at 1:15PM, the surveyor observed Resident # 62's representative ask CNA # 1 to help the resident. At that time CNA # 1 walked up to the representative and stood about 12 inches away from the representative. The CNA # 1 stated in a loud voice that she cannot help that resident right now as that resident will hit her since the resident is aggressive. The surveyor interviewed the CNA # 1 who stated that the resident hurts her and the resident refuses care. The CNA # 1 did not acknowledge that the response she had with the resident's representative was considered undignified.
At 2:30PM, the surveyor discussed the above concerns with the Director or Nursing (DON), who stated that this behavior was unacceptable.
2. On 11/22/24 at 11:08 AM, during the resident council meeting, Resident #34 stated that she/he had lung surgery about a month ago. Resident # 34 stated that they put their call light on last night at approximately midnight to call the nurse for pain medication. The staff did not answer the call light so at approximately 1:30 AM, the resident stated he/she went out into the hallway and asked the nurse for pain medication. Resident #34 stated that the nurse replied, Don't make me work a lot, I'm tired.
The surveyor reviewed the medical record for Resident #34.
A review of the admission Record reflected Resident #34 was admitted to the facility with diagnoses that included but were not limited to neoplasm of the left lung, surgical procedure of part of the lung, and Parkinson's Disease.
A review of the quarterly Minimum Data Set (MDS) an assessment tool dated 8/23/24 reflected Resident #34 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact.
A review of the Individualized Care Plans (CP) reflected Resident # 34 did not have a CP that addressed their post-surgical care.
On 11/22/24 at 1:19 PM, the survey team met with the administration to discuss the above concern.
On 11/25/24 at 9:12 AM, the surveyor interviewed the DON who confirmed that the LPN's behavior was unacceptable and that the LPN would receive training on acceptable customer service. The DON further confirmed that Resident #34 should have had a CP in place which addressed their post-surgical care.
On 11/26/24 at 10:00 AM, the surveyor conducted a phone interview with the Licensed Practical Nurse (LPN) who had been assigned to Resident #34's care. The LPN stated that she would never want to be rude to any resident, and planned to apologize to Resident #34.

Based on interview and record review it was determined that the facility failed to implement their Abuse Prohibition policy by: a) ensuring a newly hired employee's criminal background investigation report (CBI) was reviewed in a timely manner by Administration prior to their date of hire for 1 of 10 employee records reviewed, Employee #4, and b) ensuring all newly hired employees were appropriately screened by conducting reference checks prior to their date of hire for 8 of 10 employee records, Employee #1, 3, 4, 5, 6, 7, 8, 9, reviewed. The deficient practice is evidenced by the following information.
The surveyor performed the Abuse Prohibition Employee Pre-Screening Task on 11/27/24. The surveyor randomly selected 10 newly hired employees who began employment after the last standard recertification inspection.
1. A review of CBIs revealed 1 of 10 employees, Employee #4 - a dietary aide, had a CBI which included 2 felony offenses and 3 misdemeanor offenses during the time period of 2014 through 2016. The employee began their employment on 7/16/24. The CBI search for New Jersey Criminal and Other Offenses was noted to be conducted on 7/12/24. There were no offenses found for New Jersey. The CBI search for Other States' Criminal and Other Offenses was conducted on 8/28/24 (43 days after the date of hire) and revealed 3 misdemeanor offenses (2 for theft) between 2014 and 2016. The CBI search for County Criminal and Other Offenses was conducted on 7/31/24 (15 days after the date of hire)revealing 2 felony offenses for burglary in 2014.
An 8/30/24 facility interoffice email from the Human Resources Background Compliance Team to the Licensed Nursing Home Administrator indicated due to the offenses of theft and burglary outlined in the CBI, the employee was to be suspended immediately. An additional facility document was reviewed which indicated the dietary aide's employment was terminated effective 8/30/24 due to their background check. A review of actual days worked revealed the dietary aide worked 6 shifts in July, 2024 and 5 shifts in August, 2024 in the facility's kitchen.
The surveyor interviewed the Licensed Nursing Home Administrator (LNHA) on 11/27/24 at 11:30 AM. He stated it is the practice of the facility to review all CBIs before hire date. He stated sometimes they come in a little late, a few days after employment. He stated the resident started employment on 7/16/24. He was employed until 8/30/24 when the LNHA received notification of the CBI findings from Human Resources.
2. A review of reference checks by previous employers for newly hired employees revealed none were not conducted for 8 of the 10 files reviewed, Employees #1, 3, 4, 5, 6, 7, 8, 9. There was no documentation in the files to indicate reference checks were attempted. On 11/27/24 at 10:50 AM the surveyor interviewed the Director of Nursing (DON) regarding employee reference checks. She stated she has been working with the new Scheduler, who also in responsible for reference checks. The Scheduler has been employed for 3 months. The DON stated she is aware that reference checks had not been consistently done prior to 3 months ago.
A review of the facility's Abuse Prohibition policy, revised 10/24/22, noted in Section 3, the facility will screen potential employees for a history .attempting to obtain information from previous employers and/or current employers Section 3.1 noted the facility will not employ individuals who have been found guilty of .misappropriation of property .
A review of the facility's Hiring policy, revised 7/1/22, noted in the Pre-Offer section 1.2, the facility will check at least two professional references prior to hire.
NJAC 8:39-13.4(c)

NJ Complaint #174731
Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey State Department of Health (NJDOH) an injury of unknown origin for an incident on 6/4/24. This deficient practice was identified for 1 of 1 resident (Resident #75) reviewed for accident/incident, and was evidenced as follows:
On 11/23/24 at 12:20 PM, during an interview with the surveyor, the Director of Nursing informed the surveyor that there was no reportable on file for Resident #75 (report filed with the NJDOH) but would reach out to the previous management for clarification.
The surveyor reviewed the medical record for Resident #75.
A review of the admission Record, (an admission summary) reflected the resident was admitted to the facility diagnoses that included, legal blindness, contractures (hardening or shortening of muscles) on the right and left knee and spinal stenosis (narrowing of the spaces within the spinal canal causing back and neck pain).
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 7/12/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of the resident's functional range in motion reflected the resident had a lower extremity impairment (hip, knee, ankle, foot).
A review of the facility provided Occupational Therapy Discharge Summary (OT/DS) dated 6/13/24, included the resident's functional skills assessment that indicated Resident #75 was dependent, required 100 % assistance with two (2) or more helpers for hygiene, toileting, bathing, upper and lower body dressing. Toilet transfer was not attempted due to safety concerns. The resident was discharged from rehabilitation services with a documented reason that the resident went to the hospital.
A review of the investigation report (IR) dated 6/4/24 without an indicated time, reflected Resident #75 had an unwitnessed fall. The resident was last seen in bed, alert, and verbally responsive on 6/4/24 at 7:30 AM by the Registered Nurse. At 8:00 AM, the resident was found on the floor, laying on their left side, with a small abrasion noted on the forehead, complained of neck pain and a headache. A statement from the resident was not included.
A review of the nurse's Progress Note (NPN) dated 6/4/24 at 11:52 AM, reflected the resident was sent to the hospital and at 6:45 PM, the nurse documented that the resident was admitted for encephalopathy (a brain condition with causes that includes brain injury, or infection).
On 11/26/24 at 10:53 AM, during an interview with the DON, the surveyor asked for the conclusion of the IR dated 6/4/24, which was not included and the reason why the resident was not interviewed.
At that time, the DON stated that the resident had upper and lower extremity spastic movements which she personally observed. The DON could not provide documented evidence prior to the accident/incident of the resident's spastic movements.
At that time, the DON confirmed and acknowledged that the spastic movements were not previously documented and should have been care planned to prevent an accident/incident. The DON also stated that the resident could not be interviewed at the time of the accident/incident because the resident was incoherent. The DON informed the surveyor that she was still looking to see if a report was made to the NJDOH for the injury of unknown origin.
On 11/27/24 at 9:25 AM, in the presence of the survey team, the DON confirmed that there was not report filed with the NJDOH for the unwitnessed injury of unknown origin.
A review of the facility provided policy; Abuse Prohibition dated/revised 10/24/22, included the following:
Injuries of unknown source are defines as an injury with both of the following conditions.
- The source if the injury was not observed by any person or the source of the injury could not be explained by the patient; and
- The injury is suspicious because of the extent of the injury or the location of the injury .or the number of injuries observed at one particular point in time or the incidence of injuries over time. Report allegations to the appropriate state and local authority(s) involving neglect, exploitation, or mistreatment (including injuries of unknown source) .within 24 hours if the event does not result in serious bodily injury.
A review of the facility provided policy; Accidents/Incidents dated/revised 3/1/24, included the following:
The Administrator and/or DON will verify that state reporting occurs within required time frames and via appropriate method of reporting.
The Administrator, DON or designee will review all accidents/incidents to determine if Accident/Incident or allegations have been appropriately and timely reported; Interventions to eliminate if possible and, if not reduce the risk of the accident/incident have been identified and implemented.
NJAC 8:39-4.1(a)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 1of 5 residents reviewed (Resident #41). This deficient practice was evidenced by the following:
On 11/22/24 at 11:37 AM, the surveyor introduced self to Resident #41, who became annoyed and did not wish to speak to anyone from the Department of Health and instructed surveyor not to come back again.
A review of the resident's admission record reflected the resident was admitted to the facility with diagnoses that included but were not limited to, urinary tract infection.
A review of Resident #41's quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognitive functioning and coding that indicated the pneumococcal vaccine was offered and declined.
On 11/25/24, the surveyor interviewed the Director of Nursing (DON), who indicated that on admission the staff determines what vaccines the resident has had and what vaccines the resident is due for. She further stated that the acceptance/refusal/education is documented in the immunology tab in the electronic medical record of in the hard (paper) chart.
A review of the electronic medical record and the hard chart revealed no information regarding the pneumococcal vaccine.
On 11/26/24 at 9:57 AM, the surveyor reviewed the pneumococcal vaccine consent provided by the facility, for Resident #41 which was dated 11/25/24, and indicated the resident refused the vaccine.
On 11/26/24 at 11:28 AM, the surveyor interviewed the MDS Coordinator, who was asked about the asked about pneumococcal vaccine coding for Resident #41. She looked through a book and stated she was unable to find this resident. She stated that if there were no declination, she would need to correct the MDS.
On 11/26/24 at 12:23 PM, the MDS Coordinator stated it must have been a typo and she was modifying the MDS to reflect the pneumococcal vaccine was not offered.
A review of facility provided policy Pneumococcal Vaccination revised 09/13/24 included:
Purpose:
To prevent pneumococcal disease and its complications to patients
Process:
1. Upon admission, obtain the pneumococcal vaccination history of all patients
1.2 Document pneumococcal vaccination history in the electronic health record
2. Based on the patient's pneumococcal vaccination history, offer (unless the vaccination is medically contraindicated or the patient has already been vaccinated) the appropriate vaccination following the recommended schedule
2.2 Adults aged greater than or equal to 65 years who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine PCV20.
2.4 Provide the patient/representative education (Vaccine Information Statement(VIS)) regarding the benefits and potential side effects of vaccination
6. If patient/representative refuses pneumococcal vaccination, provide information and counseling regarding the benefit of vaccination (VIS). Document education in the medical record including VIS version date
6.1 If vaccination refused, document patient's and/or representative's reason for refusal of vaccination
6.1.1 Notify attending physician/provider of patient's or resident representative's refusal and document accordingly in the medical record
N.J.A.C 8:39-11.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** COMPLAINT #NJ00170353
Based on interview, medical record review, and review of other pertinent facility documents on 2/15/24, it was determined that the facility failed to provide written notice of discharge to the resident, resident representative, and the Office of the Long-Term Care Ombudsman (LTCO) for 3 of 3 residents (Resident #3, Resident #5, and Resident #6), reviewed for facility-initiated discharges.
This deficient practice was evidenced by the following:
1.) The surveyor reviewed the medical records of Resident #3.
Review of the Resident #3's admission Record (AR) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to hypertension, dysphagia (difficulty swallowing), and cognitive communication deficit.
Review of Resident #3's Progress Notes (PN) revealed the following:
-10/31/23 Physician Note that indicated that a discharge summary was completed
-11/01/23 Nursing Notes that indicated that the resident was discharged to another facility.
Review of Resident #3's the Discharge Minimum Data Set, an assessment tool used to facilitate the management of care, dated 11/01/23, indicated that the resident had a discharge assessment with return not anticipated.
Review of Resident #3's electronic medical record (EMR) did not include a notification letter to the resident, resident representative, and the LTCO of the facility-initiated discharge.
2.) The surveyor reviewed the medical records of Resident #5.
Review of the Resident #5's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to hypertension, dysphagia (difficulty swallowing), and hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body).
Review of Resident #5's PN revealed a progress note that indicated that the resident was transferred to another facility.
Review of Resident #5's MDS, dated [DATE], indicated that the resident had a discharge assessment with return not anticipated.
Review of Resident #5's electronic medical record (EMR) did not include a notification letter to the resident, resident representative, and the LTCO of the facility-initiated discharge.
3.) The surveyor reviewed the medical records of Resident #6.
Review of the Resident #6's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to hypertension, generalized weakness, and anxiety disorder.
Review of Resident #6's Progress Notes (PN) revealed the following:
-10/30/23 Physician Note that indicated that a discharge summary was completed.
-11/01/23 Nursing Note that indicated that the resident was discharged to another facility.
Review of Resident #6's MDS, dated [DATE], indicated that the resident had a discharge assessment with return not anticipated.
Review of Resident #6's electronic medical record (EMR) did not include a notification letter to the resident, resident representative, and the LTCO of the facility-initiated discharge.
On 02/15/24 at 2:20 P.M., the surveyor interviewed the Administrator who stated that the facility is to provide thirty-day notice to a resident, and/or the resident's representative, as well as the LTCO in the event of a facility-initiated discharge. The surveyor asked the Administrator to provide proof of notification of discharge for Resident #3, Resident #5, and Resident #6. The Administrator stated that he would investigate further. No additional information was provided to this surveyor during the survey.
Review of the facility's OPS404 Discharge and Transfer policy, dated 11/15/22, indicated A Notice of Involuntary Discharge (NOID) must be provided at least 30 days in advance of a proposed involuntary discharge (facility initiated).
NJAC 8:39-4.1(a)32; 5.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to develop and/or implement a person-centered comprehensive care plan that addressed all of the resident's medical needs and diagnosis for 6 of 14 residents (Residents #52, #235, #14, #21, #56 and #50) reviewed for comprehensive care plans.
The deficient practice was evidenced by the following:
1. On 1/3/23 at 11:05 AM, the surveyor observed Resident #52 lying in the bed, alert and awake. Resident #52 stated they were admitted to the facility to receive intravenous (IV) antibiotic therapy and showed to the surveyor the IV access site to the right arm.
The surveyor reviewed the hybrid medical record of Resident #52 which revealed the following:
The admission Minimum Data Set (MDS) assessment, dated 12/7/22, which indicated the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 15 out of 15 which indicated that that the resident was cognitively intact. The MDS assessment also indicated the resident had active diagnoses of chronic frontal sinusitis and other local infections of the skin and subcutaneous tissue.
Physician's orders for Resident #52, dated 12/10/22, which read: Ertapenem [an antibiotic medication] Sodium Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for Sinus Infection until 01/11/2023.
A review of the resident's progress notes, dated 12/16/22, indicated the resident had a midline [a long, thin flexible tune that is inserted into a large vein in the upper arm to give IV treatments] access site to the right upper arm.
A review of the resident's care plans, revealed there was no care plan related to the resident's sinus infection diagnosis or receiving an antibiotic medication.
On 1/9/23 at 12:49 PM, the surveyor interviewed Registered Nurse #3 (RN #3) about care plans and Resident #52. RN#3 stated care plans were initiated by nurses upon admission and triggered on the resident's admission assessment. RN# 3 stated residents on antibiotics should have care plans based on their infection. The surveyor with RN #3 reviewed the care plans for Resident #52. There was no care plan for the resident's antibiotic treatment or primary diagnosis of sinusitis (sinus infection).
RN#3 acknowledged Resident #52 should have had a care plan for their antibiotic treatment. RN# 3 further stated the Director of Nursing (DON), managers, and charge nurses were responsible for reviewing and updating care plans.
On 1/12/23 at 10:46 AM, the surveyor interviewed the Infection Preventionist (IP) about care planning and Resident #52. The IP stated it would be expected for residents receiving antibiotic treatment to have a care plan. The surveyor informed the IP of discussion with RN#3 and that there was no care plan for Resident #52 who was receiving IV antibiotic treatment.
On 1/12/23 at 1:54 PM, the surveyor informed the Administrator, Quality Assurance Consultant #1 (QAC #1), QAC #2, and Regional Director of Operations of the care plan concerns for Resident #52. There was no verbal response provided.
On 1/13/23 at 10:44 AM, the surveyor met with the Administrator, Medical Director, QAC #1, and IP. QAC #1 stated the resident was discharged home that morning and no further information could be presented.
2. On 1/3/23 at 12:32 PM, the surveyor observed Resident #235 sitting at the bedside, alert and awake. Resident #235 was on Transmission-Based Precautions (TBP) [for known or suspected individuals with infectious agents which require additional measures to prevent transmission] for COVID-19. Resident #235 was aware they had been quarantined on TBP for a couple of days due to testing positive for COVID-19.
The surveyor reviewed the electronic medical record (EMR) of Resident #235 which revealed the following:
The admission Minimum Data Set (MDS) assessment, dated 12/7/22, which indicated the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 10 out of 15 which indicated that the resident had moderate cognitive impairment. The MDS assessment also indicated the resident had active diagnoses that included: Diabetes Mellitus with foot ulcer, coronary artery disease, and heart failure.
Physician's order for Resident #235, dated 1/2/23, which read: Paxlovid Tablet Therapy Pack 20 x 150 MG & 10 x 100 MG (Nirmatrelvir &Ritonavir) Give 3 tablet by mouth two times a day for COVID infection for 5 Days. There was no physician order for TBP for the resident.
A review of the resident's progress notes indicated the resident had tested positive for COVID-19 on 1/2/23 after reporting symptoms that included chills, muscle aches, and cough. The resident was placed on TBP and started on Paxlovid medication treatment.
A review of the resident's care plans, revealed there was no care plan related to the resident's COVID-19 diagnosis and having TBP in place.
01/09/23 11:08 AM, the surveyor interviewed RN #3 about care plans. RN#3 stated care plans were initiated by nurses upon admission and triggered on the resident's admission assessment. RN# 3 stated residents should have care plans based on their infection and treatment. RN#3 acknowledged residents who were COVID positive or who were on TBP should have a care plan in place.
On 1/11/23 at 12:53 PM, the surveyor informed the DON of the interview with RN#3 and that there was no COVID-19 care plan for Resident #235. The DON stated there should be a care plan for COVID-19 positive residents and residents on TBP. The surveyor informed the DON that there were no care plans found for Resident #235 related to COVID-19 positive diagnosis or TBP. The DON acknowledged the resident should have had a care plan and would review.
On 1/12/23 at 1:54 PM, the surveyor informed the Administrator, Quality Assurance Consultant #1 (QAC #1), QAC #2, and Regional Director of Operations of the care plans concerns for Resident #235. There was no verbal response.
On 1/13/23 at 10:44 AM, the surveyor met with the Administrator, Medical Director, QAC #1, and IP. QAC #1 stated no further information could be presented as the resident was already discharged home.
3. During the initial tour of the facility on 01/03/23 at 10:03 AM, the surveyor observed Resident #14 sitting in the wheelchair with oxygen administered by nasal tubing. The oxygen tubing was dated 01/03/23.
According to the admission Record, Resident #14 was admitted to the facility with diagnoses which included, but were not limited to, Atherosclerotic Heart Disease (buildup of plaque in arteries causing reduced blood flow), muscle weakness, and reduced mobility. The resident's most recent Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/31/22, reflected that Resident #14 was confused.
A review of the Electronic Medical Record physician orders on 01/06/23 at 10:02 AM, did not include a physician order for oxygen administration. A review of the January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include orders for oxygen administration. A review of the resident's Care Plan did not identify that Resident #14 used oxygen.
The Director of Nursing (DON) provided Resident #14's Care Plan which revealed a Creation Date of 01/09/23 that the resident requires oxygen, with interventions that included, encourage resident positioning upright, and maintain oxygen use as ordered.
During an interview with the surveyor on 01/09/23 at 12:03 PM, the assigned Licensed Practical Nurse (LPN) #1, reported that the unit manager was responsible for creating and updating care plans. LPN #1 further advised, There isn't one (a unit manager). If something needs to be added, I try to do it myself. But I don't have time. When asked if oxygen is a common care planned topic, LPN #1 reported, Yes, how long, when, how much. Upon reviewing the resident's care plan LPN #1 confirmed, I don't see it on the care plan.
During an interview with the surveyor on 01/09/23 at 12:55 PM, the DON identified that oxygen should be identified on the care plan. Upon reviewing Resident #14's care plan, the DON confirmed, Yes, I don't see it on the care plan.
4. During the initial tour of the facility on 01/03/23 at 10:03 AM, the surveyor observed Resident #21 with a contracture to the right hand. The surveyor observed a hand roll located on the resident's bedside table. Resident #21 stated that they can apply and remove it without assistance.
According to the admission Record, Resident #21 was admitted to the facility with diagnoses which included, but were not limited to, Atherosclerotic Heart Disease (buildup of plaque in arteries causing reduced blood flow), and muscle weakness.
The resident's most recent Annual Minimum Data Set (MDS), dated [DATE], reflected Resident #21 was identified as being cognitively intact. The MDS also indicated that Resident #21 had functional limitation in range of motion on one side of the upper and lower extremities. The MDS further revealed that Resident #21 required extensive assistance and was dependent on staff for most activities of daily living.
During the resident's Record Review on 01/06/23 at 10:02 AM, it was observed that Resident #21's ongoing Care Plan did not identify the right-hand contracture and the hand roll intervention.
During an interview with the surveyor on 01/09/23 at 12:03 PM, the assigned LPN #1, reported the unit manager was responsible for creating and updating care plans. LPN #1 further advised, There isn't one (a unit manager). If something needs to be added, I try to do it myself. But I don't have time. When asked if splinting/devices are common care planning topics, LPN #1 responded, Yes. When asked to identify what would be documented, LPN #1 stated, The interventions to prevent worsening condition, how long for splinting, how often. When asked if the resident had a care plan for a splinting/orthotic device, LPN #1 responded, Well, that would be night shift; but no, I do not see any.
During an interview with the surveyor on 01/09/23 at 12:55 PM, the DON identified that the care plans were auto populated upon admission and updated by the nurses. When asked if splinting, palm guards, and orthotics should be identified on a resident's care plan, the DON responded, Yes, absolutely. Upon review of Resident #14's care plan, the DON confirmed, I don't see it. It should be on there.
5. On 01/03/23 at 11:30 AM during the initial tour of the facility, the surveyor observed Resident #56 lying in bed awake. The resident had a left below the knee amputation and wore a plastic splint that supported the affected area. The resident proceeded to inform the surveyor that last evening he/she was on the bed side commode and pressed the call bell for assistance when an aide responded and had an attitude about the resident using the call bell for commode assistance. The resident stated that he/she pressed the call bell a second time and when the resident asked the aide to empty the commode the aide stated, You are not the only .one! The resident stated that the incident was reported immediately, and the Director of Nursing (DON) and was satisfied with how the facility handled the incident.
According to the admission Record Report (an admission summary, Resident #56 was admitted to the facility in December of 2022 with diagnosis which included but were not limited to: chronic pain, atherosclerotic heart disease (a build up of cholesterol plaque in the walls of the arteries causing an obstruction of blood flow), anemia (results from a lack of red blood cells), and depression.
Review of Resident #56's admission Minimum Data Set (MDS), an assessment tool dated 12/13/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident was fully, cognitively intact. The Functional Status portion of the MDS indicated that the resident required extensive assistance for bed mobility of one person and total dependence of one person for toileting.
Review of Resident 56's care plan revealed an entry that was initiated on 12/16/22, Focus: The resident was at risk for ADL (activities of daily living) self-care deficit as evidenced by impaired mobility related to physical limitations/left BKA (below knee amputation), Goal: Resident to receive assistance necessary to meet ADL needs, Interventions: included: resident to have paired care (initiated on 12/16/22). The entry was revised by both the DON and the Infection Preventionist (IP).
Further review of Resident #56's care plan revealed that on 01/04/23, the IP created an entry which revealed: Focus:Verbal agitation/aggression towards staff AEB (as evidenced by) using profanity and yelling to get out of his/her room. Goal: Will not be verbally aggressive towards others. Interventions included but were not limited to paired care.
On 01/04/23 at 12:38 PM, the DON provided the surveyor with an investigation that was dated 12/22/22 at 6:00 PM, that was sent to the New Jersey Department of Health (NJDOH). Review of the investigation revealed that Resident #56 alleged that a nurse aide was rough while care was provided after the resident had diarrhea and felt that the aide had a bad attitude. The DON specified that the resident was placed on paired care going forth and a toileting schedule. The DON documented that the Certified Nursing Assistant (CNA) was suspended until the investigation was completed. Further review of the investigation revealed that the conclusion which included review of statements, and follow-up with the resident, the allegation was unsubstantiated, and the resident stated, I am receiving good care and I feel safe. Seven residents were interviewed, and no concerns were noted.
During an interview with the surveyor on 01/11/23 at 11:41 AM, the surveyor interviewed the DON who stated that Paired Care was implemented after the resident's first allegation which occurred on 12/22/22. The DON stated that when the second allegation occurred on 01/02/22, the CNA admitted that she had not looked at the [NAME] (a medical patient information system) prior to providing resident care, and went into the resident's room alone, instead of with another CNA as required in accordance with the resident's care plan. The DON stated that she had given the aides an in-service about paired care, but hand not provided them with any reference materials.
On 01/11/23 at 12:35 PM, the surveyor observed Resident #35 lying in bed awake. The resident complained that his/her belly had not felt good but the nurse, Licensed Practical Nurse (LPN #3) checked the resident's vitals and performed a COVID test which was negative. The surveyor asked if the nurse attended to the resident alone or with another staff member. The resident stated that one nurse or one aide responded when the call bell was pressed. The resident stated that he/she had only seen the nurse today and the person who delivered the lunch tray. The resident further stated that everything had been great and there had been no further issues.
During an interview with the surveyor on 01/11/23 at 12:45 PM, CNA #2 stated that she cared for Resident #56 quite a few times before. She described the resident as independent with care and stated that the resident required set up for care and transfers. She stated that when the resident had to get out of bed, she just locked the wheels on the chair and stood there for supervision. CNA #2 stated that she worked for an agency and floated throughout the facility where needed. CNA #2 stated that she had not reviewed Resident #56's [NAME] since she began working at the facility on 01/03/23, as she had not gained access to the system. CNA #3 stated that she looked through other staff's access and did not see anything special noted for Resident #56. CNA #2 stated that they did not give any type of report at the facility otherwise.
During an interview with the surveyor on 01/11/23 at 12:49 PM, LPN #3 stated that Resident #56 had behaviors and depression. LPN #3 stated the DON stated that two CNAs and two nurses must respond to the call bell when the resident called. When LPN #3 was asked if she went into the resident's room with another nurse she stated, I never had problems with the resident, I just help him/her right away. When the surveyor asked LPN #3 if she delegated to CNA #2 that two staff were required to respond to Resident #56's call bell, she stated that she did not think that CNA #2 who was assigned to the resident, knew that two aides were supposed to respond to the resident. LPN #3 stated that one day, she was unsure of the date, a CNA on the night shift was rude to the resident and she had reported it to the DON. LPN #3 stated that the DON did an in-service and told us to answer the light with two people after the incident.
During an interview with the surveyor on 01/12/23 at 11:24 AM, the IP stated that Resident #56 was placed on paired care after an incident was called into the NJDOH. The Administrator who was present stated that the facility could not substantiate the resident's allegations and implemented the care plan. The facility was unable to provide the surveyor with documented evidence that care paired care was implemented as described within the resident's care plan.
6. During the initial tour of the facility on 01/03/23 at 11:45 AM, the surveyor observed Resident #50 seated in a wheelchair at the bedside. The resident had a left upper extremity dialysis access site that was covered with a 4 x 4 dressing that was not dated. The resident stated that he/she attended dialysis treatments on Monday, Wednesday and Friday from 11 AM to 3 PM. The resident stated that he/she was unsure if the facility staff monitored the access site post-treatment.
According to the admission Record Report (an admission summary), Resident #50 was admitted to the facility in November of 2022 with diagnosis which included but were not limited to: Type 2 Diabetes Mellitus (condition in which the body does not produce enough insulin or resists insulin), essential hypertension (high blood pressure) and depression.
Review of Resident #50's admission Minimum Data Set (MDS), an assessment tool dated 11/24/2022, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was fully cognitively intact. Active diagnosis included but were not limited to: Amputation, renal insufficiency, renal failure or End-Stage Renal Disease (ESRD). Review of Section O of the MDS, Special Treatments, Procedures, and Programs included Dialysis.
Review of Resident #50's care plan revealed an initial entry that was dated 11/21/22, three days after the resident was admitted to the facility, with a Focus aimed at: Renal insufficiency related to kidney disease. Goals included: Will be free from infection and resident will have no signs or symptoms of complications related to fluid deficit. Interventions included: Assist resident with ADLS (activities of daily living) and ambulation as needed. Watch for SOB (shortness of breath) and match level of assistance to resident's current energy level, Encourage rest periods as resident requires. Monitor and report changes in mental status: lethargy, tiredness, fatigue, tremors and seizures. The entry failed to specify the resident's scheduled dialysis days and time, method of transport, the type of dialysis access site that the resident had and related required interventions to ensure the dialysis access remained patent and free from specific signs and symptoms of infection.
Review of Resident #50's Admission/re-admission Evaluation, assessment dated [DATE], revealed that the resident required dialysis while a patient, but failed to specify whether the resident received Peritoneal (completed daily through a catheter in the abdomen) or Hemodialysis (completed three to five times per week through an access in the arm). Further review of the evaluation revealed that a Base Line Care Plan-Dialysis which was available for selection was not initiated, which provided the following options for selection: Focus: The resident needs dialysis (specify type hemo/peritoneal), Goal: The resident will have no s/sx (signs and symptoms) of complications from dialysis, Some of the Interventions that were available for selection included but were not limited to: Do not draw blood or take b/p (blood pressure) in arm with graft, Encourage resident to go for the scheduled dialysis appointments, monitor/report to MD s/sx of infection to access site: Redness, swelling, warmth or drainage, Monitor/report to MD s/sx of the following: Bleeding/Hemorrhage.
Review of Resident #50's Order Summary Report (OSR) revealed that on 12/06/22, an order was placed for the resident to be NPO (nothing permitted orally) post-midnight Sunday 12/5/22, for procedure of revision of AV fistula (arteriovenous fistula, a connection created between an artery and a vein to form a dialysis access graft) on 12/6/22 at 7:00 AM. Further review of the OSR revealed that an order was placed on 12/13/22 for the resident to attend dialysis on Monday, Wednesday, Friday at 11 AM p/u (pick up) time 10 AM.
Review of Resident #50's PN dated 12/5/22 at 12:44 PM, which was written by Licensed Practical Nurse/Charge Nurse (LPN/CN #1) and revealed that she received a call from a Physician's Group regarding the resident having an upcoming procedure scheduled on 12/12/22 at 7 AM, due to issues with his/her AV Fistula (possible clog). Further review of the PN revealed that on 12/13/22, the Nurse Practitioner (NP) documented that the resident underwent angioplasty and stent placement of left subclavian vein after he/she was found to have almost complete vascular occlusion per vascular evaluation yesterday during a fistulogram (an x-ray study of fistula to detect a clot or narrowing) of the left upper extremity .Left upper extremity swelling unchanged, S/P angioplasty, stent placement of left subclavian vein by vascular surgery yesterday.
During an interview with the surveyor on 01/10/23 at 11:47 AM, the Registered Nurse Supervisor (RNS) stated that whoever served in the role of Supervisor initiated the care plans which included dialysis care plans. The RNS explained that a dialysis care plan should have included the dialysis location and scheduled days, and fistula check which included assessment for bleeding, bruit and thrill. The RNS stated that nurses were responsible to update the care plan in response to a new event such as a fall or skin tear.
During an interview with the surveyor on 01/13/23 at 9:50 AM, the Infection Preventionist (IP) stated that the dialysis care plan should have been implemented upon admission to the facility and should have included site, inspection, monitor for signs and symptoms of bleeding, and note any fluid intake or dietary restrictions.
During an interview with the surveyor on 01/13/23 at 10:45 AM, the Quality Assurance Consultant (QAC #1) stated that the dialysis care plan for Resident #50 was implemented on 01/12/23 at 11:51 AM, into the Electronic Health Record (EHR), but it should have been implemented upon admission to the facility and should have included the dialysis site location.
The surveyor reviewed the facility policy titled, Care plan preparation, long term care, with a reviewed date of 5/20/2022. Under Introduction, it read: A care plan is an individualized, written action plan for a resident's care, treatment, and services that is based on the resident's medical, nursing, physical, mental, and psychosocial needs and preferences. The care plan must include: interventions that describe the services the interdisciplinary team employs to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. Under Documentation, it read: Document all pertinent resident problems, expected outcomes, interventions, and evaluations of expected outcomes.
Both the DON and Administrator provided the surveyor with the same copy of an undated facility policy titled, Dialysis Guidelines. Review of the policy revealed that the Purpose: To provide guidelines for centers providing dialysis services in house. This includes hemodialysis and peritoneal dialysis. When the surveyor inquired to see if there was a specific policy for residents whose dialysis treatments were completed at an off-site dialysis center, the Administrator stated that was the only policy she had. Further review of the policy revealed the following: If a center provides dialysis services, there is collaboration between the center and a Medicare certified dialysis facility. The center remains responsible for the overall quality of care the patient receives. A coordinated comprehensive care plan for dialysis treatments is developed with input from both the interdisciplinary team (IDT) and dialysis facility staff. The patient's plan of care identifies the patient specific parameters ordered by the medical practitioner for nutritional and fluid needs, lab results, blood pressure, weights, and other vial signs as well as who to notify of concerns and which medications should be given or not given. In order to assure that the dialysis needs of the patient are met in the case of an emergency, the care plan should identify acute care settings that would be able to meet the patient's need for dialysis Both the center and dialysis facility are responsible for shared communication regarding patients receiving dialysis services, either offsite or onsite .Collaborative communication includes information regarding: .dialysis adverse reaction/complications and/or recommendations for follow up observations and monitoring including those related to the vascular access site or peritoneal dialysis catheter .
NJAC 8:39-27.1 (a), 11.2 (d)
NJAC 8:39-11.2 (f)

2.) On 01/05/23 at 9:22 AM, the surveyor observed Licensed Practical Nurse (LPN #3) as she reviewed the Electronic Medication Administration Record (EMAR) and prepared medications to administer to Resident #185 which included but were not limited to: Diltiazem HCL ER (Extended-release) Beads Oral Capsule 24 Hour 180 milligrams (mg) Give 1 (one) capsule by mouth one time a day for afib (atrial fibrillation, irregular heartbeat), Hold for a systolic blood pressure (SBP, top number of blood pressure reading) less than 105 and an order for Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 30 mg Give one tablet by mouth one time a day for HTN (hypertension, high blood pressure) Hold for SBP less than 100. LPN #3 stated that although Resident #185's SBP was 103/70 and met the parameters to hold the Diltiazem HCL ER and could give the Isosorbide Mononitrate ER, she would hold both dosages of Diltiazem and Isosorbide as she wanted to wait until the resident returned from physical therapy to re-check the resident's blood pressure and administer the medications at that time if the resident's blood pressure reading was within the physician's specified parameters. LPN #3 did not sign either of the medications that were scheduled at 9:00 AM as not administered and did not phone the physician to obtain permission to administer the medications later in the day to coordinate with the resident's physical therapy schedule as described.
At 9:56 AM, the surveyor observed LPN #3 as she reviewed the EMAR and prepared medications to administer to Resident #187 which included but were not limited to: Potassium Chloride Packet 20 mEq (milliequivalent) Give 1 (one) packet by mouth one time a day for hypokalemia (deficiency of potassium (electrolyte) in the blood stream). The order failed to specify how the medication should be prepared for administration. LPN #3 then proceeded to open the packet of Potassium Chloride and emptied the contents, a powder, into a medicine cup which contained apple sauce. LPN #3 stated that it was the resident's preference to mix the medication in apple sauce since the resident did not like the taste.
At 10:20 AM, LPN #3 informed the Nurse Practitioner (NP) who was present on the nursing unit at that time, that she was unable to administer Resident #187's Thiamine Vitamin B 100 mg that was scheduled for 9:00 AM, as the order specified to give two 50 mg tablets scheduled to be administered at 9:00 AM and there was only one 100 mg tablet in stock. The NP granted permission for LPN #3 to instead give Thiamine 100 mg and noted that she planned to change the administration time to five PM instead. LPN #3 failed to address clarification of orders with the NP for Resident #187's Potassium Chloride order which failed to contain directions for administration or the blood pressure medications that were not administered to Resident #185 at 9:00 AM in accordance with the physician's orders.
At 10:25 AM, LPN #3 reviewed the EMAR as she prepared medications for Resident #186 which included but were not limited to: Voltaren (relieves arthritis joint pain) Gel 1% Apply to right hip topically two times a day (9:00 AM and 5:00 PM) for right hip pain 4-gram dose. LPN #3 stated that she would not administer Voltaren as directed because the resident had not yet received AM care. LPN #3 stated that she did not chart Voltaren as not administered, as she intended to sign the entry later after she administered the medication. LPN #3 also administered: Furosemide (diuretic) 20 mg by mouth one time a day for HTN hold for SBP <110 and Losartan Potassium Oral Tablet 100 mg Give 1 (one) tablet by mouth one time a day for HTN hold for SBP <110. LPN #3 maintained that the resident's blood pressure this AM was 150/85 and she based medication administration on that blood pressure value.
At 11:00 AM, LPN #3 concluded signing out Resident #186's medications that were administered which included Polyethylene Glycol 3350 Oral Powder 17 GM/Scoop, Give 1 (one) scoop by mouth one time a day for constipation. LPN #3 stated that she was required to advise the NP that the Polyethylene Glycol was administered late, as the medication that was scheduled for administration at 9:00 AM, turned red on the computer screen of the EMAR when she attempted to sign the medication out as administered at 11:00 AM.
At 11:01 AM, The surveyor interviewed LPN #3 post-medication administration observation. LPN #3 stated that she obtained the resident's blood pressures at 8:00 AM and utilized the readings for blood pressure medication administration during the medication pass observation. When the surveyor asked LPN #3 what the facility policy was for the timing of blood pressure reading values used for blood pressure medication administration based on physician ordered parameters LPN #3 stated, I do not know what the policy allowed for.
During a later interview with the surveyor on 01/05/23 at 3:07 PM, LPN #3 stated that at 9:00 AM, Resident #185 had an order to hold the dosage of Diltiazem HCL ER 180 mg to be held for a SBP less than 105, and the resident had a SBP of 103 and the medication was not held as indicated. LPN #3 stated that she instead waited until the resident returned from therapy and rechecked the resident's blood pressure which was 122/70's and both HTN medications (Diltiazem HCL ER and Isosorbide Mononitrate ER) were administered. LPN #3 further stated that she notified the NP before that, about 30 minutes ago. LPN #3 stated that she feared the resident's blood pressure would drop too low during physical therapy LPN #3 stated that she should have gotten an order to change the medication administration time to be given when the resident returned from physical therapy.
LPN #3 further stated that the order for Resident #187's Potassium Chloride 20 mEq, did not specify how to the medication was required to be prepared for administration and the order should have been clarified prior to administration to ensure that it was ok to mix the medication in applesauce.
LPN #3 further stated that Resident #186's administration time for Voltaren, ordered twice daily, should have been adjusted so that the medication could have been administered after AM care had been completed after 11 AM.
LPN #3 further stated that she obtained resident blood pressure readings at 8 AM, and it was better if she repeated the blood pressure reading at the time of blood pressure medication to ensure accuracy.
During an interview with the surveyor on 01/06/23 at 10:53 AM, the Licensed Practical Nurse/Charge Nurse (LPN/CN #1) stated that blood pressure medications were required to be held according to physician ordered parameters at the time the medication was due as you only had one hour before or one hour after the medication time was scheduled to administer it and are not permitted to administer the medication beyond that time frame because it interfered with the medication schedule. LPN/CN #1 stated that LPN #3 should have notified the NP that the Resident #185's blood pressure medications interfered with physical therapy and documented the conversation, and checked for new orders.
LPN/CN #1 explained blood pressures should be rechecked if it had been more than one hour since the value was obtained and scheduled blood pressure medications were due to ensure that there had not been any blood pressure fluctuations.
LPN/CN #1 further stated that a request for a time change should have been requested to change Resident #186's order for Voltaren administration to coordinate with the resident's care.
LPN/CN #1 further stated that, An order for KCL (potassium chloride) 20 mEq should have specified to administer the medication in 8 (eight) ounces of water and should have been clarified prior to administration in applesauce as it was never assumed.
During an interview with the surveyor on 01/11/23 at 11:00 AM, the Infection Preventionist (IP) who stated she was also responsible for Staff Development, stated that LPN #3 should have decided not to administer medications one hour after the scheduled administration time. The IP stated that the residents blood pressures should have been repeated prior to medication administration as it had been approximately 90 minutes and vital signs (blood pressure readings) should have been obtained prior to blood pressure medication administration to ensure accuracy.
The IP further stated that LPN #3 should have obtained an order to change the time of administration of Voltaren if she was concerned about giving it prior to AM care or administered the medication within parameter guidelines of a one-hour window (one hour before scheduled due time, or one hour after scheduled due time).
The IP concluded the interview by stating that the order for KCL should have been clarified with the physician prior to administration in applesauce. The surveyor requested to view a copy of LPN #3's medication pass observation competency at that time which was not provided by the facility.
During an interview with the surveyor on 01/13/23 at 10:45 AM in the presence of the survey team, the Administrator stated that. She had nothing further to provide regarding medications that were administered to residents outside of the scheduled parameters during the medication pass observation at this point.
Review of the facility policy titled, Medication Administration: Medication Pass (06//21) revealed the following:
.Procedure: .If medication is new for resident, or if medication is unfamiliar or physician order is questioned: Read original physician order, Compare original physician order with MAR (Mediation Administration Record) for accuracy, Remove medication from cart, Compare MAR with medication label for accuracy, verify allergy status, Contact physician for clarification, if needed, Read special medication administration instructions, Obtain vital signs, if applicable, and record results on MAR (Medication Administration Record), Prepare medications for administration Medications are administered in accordance with standards of practice and state specific and federal guidelines.Communities are responsible for establishing a community medication time schedule and communicating the standard schedule for the center with attending medical practitioners.Licensed nurses and medication aides are oriented upon hire and evaluated annually in medication and treatment administration techniques and medication and treatment documentation requirements. Medication and Treatment Orders: A complete medication order includes: Date and time, Name of resident, Name of medication, Form, formula, and route of administration, Dosage or strength, Frequency, including end date orders if applicable, Directions for use including the reason for use, diagnosis, or clinical indication, Medication specific parameters if applicable .Orders are transcribed then noted by the licensed nurse. The licensed nurse noting an order is responsible for accurate transcription and initiation of orders .Documentation: Medications and treatments administered are documented immediately following administration or per state specific standards. Vital signs are taken and recorded prior to the administration of vital sign dependent medications in accordance with medical practitioner's orders .Medications not administered according to medical practitioner's orders are reported to the attending medical practitioner and documented in the clinical record including the name and dose of the medication and reason the medication was not administered The licensed nurse or medication aide is responsible for validating documentation is completed for any medication administered during the shift.
NJAC 8:39-11.2(b), 17.2 (g), 27.1 (a)
3.) During the initial tour of the facility on 01/03/23 at 10:03 AM, the surveyor observed Resident #14 sitting in the wheelchair with oxygen administered by nasal tubing. The oxygen tubing was dated 01/03/23.
On 01/06/23 at 10:15 AM, the surveyor observed Resident #14 sitting in a reclining chair with oxygen being administered by nasal tubing. The oxygen tubing was dated 01/03/23.
According to the admission Record, Resident #14 was admitted to the facility with diagnoses which included, but were not limited to, Atherosclerotic Heart Disease (buildup of plaque in arteries causing reduced blood flow), muscle weakness, and reduced mobility.
A review of the physician orders in the Electronic Medical Record on 01/06/23 at 10:02 AM, did not include physician orders for oxygen administration. A review of the January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not include orders for oxygen administration.
A review of the documentation provided by the Director of Nursing (DON) on 01/11/23, reflected Resident #14's physician orders were updated on 01/06/23 at 10:27 AM to include O2 (oxygen) @ 2 liters per minute via nasal cannula as needed for dyspnea (shortness of breath) or Sp02 (amount of oxygen in the blood) < 92% maintain Sp02 >92% call MD if Sp02 <88% for further orders.
During an interview with the surveyor on 01/09/23 at 11:00 AM, Certified Nursing Assistant (CNA) #1 confirmed that the administration of oxygen required a physician order. CNA #1 also confirmed that the oxygen tubing should not be dated prior to the physician's order date.
During an interview with the surveyor on 01/09/23 at 12:03 PM, the assigned Licensed Practical Nurse (LPN) #1 reported that oxygen required a physician's order. Upon reviewing Resident #14's orders, LPN#1 confirmed that the order was placed on 01/06/23. LPN #1 verified that the oxygen tubing was dated 01/03/23. LPN#1 stated, It should be dated that day (the order date) and changed every 7 days.
During an interview with the surveyor on 01/09/23 at 12:55 PM, the DON identified that Resident #14's oxygen tubing should not be dated 01/03/23 unless that is the date the order is placed . Let me look if there was a previous one [order]. There is no order.
The surveyor reviewed an undated Facility Procedure titled, Medication and Treatment Administration Guidelines. Under the heading General, the procedure revealed Centers are to follow the Orders Management Matrix for initiation of non-medication or treatment orders. All orders are to be prescribed by a medical practitioner.
The surveyor reviewed the facility procedure titled, Oxygen Administration, long term care, with a revised date of 11/28/22. Under the heading Implementation, the procedure reflected to Verify the practitioner's order for oxygen therapy.
NJAC 8:39-11.2 (b); 29.2(d)
Based on observations, interviews, review of medical records and other facility documentation, it was determined the facility failed to consistently follow standards of professional clinical practice with regard to: a) accurately documenting medication administration for 1 of 1 residents (Resident #52) reviewed for antibiotic use, b) adhering to physician's orders for blood pressure medication parameters, clarification of physician's orders and adherence to the facility Medication Administration policy for 3 of 4 residents observed during medication administration pass (Residents #185, #186 and #187), and c. administering oxygen to a resident without physician orders for 1 of 3 residents (Resident # 14) reviewed for oxygen.
This deficient practice was identified as follows:
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 casefinding, 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 casefinding; 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.
The deficient practice is evidenced by the following:
1.) The surveyor reviewed the hybrid medical records of Resident #52 which revealed the following:
The admission Minimum Data Set (MDS) assessment, dated 12/7/22, which indicated the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 15 out of 15 which indicated that that the resident was cognitively intact. The MDS assessment also indicated the resident had active diagnoses of chronic frontal sinusitis and other local infections of the skin and subcutaneous tissue.
A review of the Order Summary Report and the electronic Medication Administration Record (eMAR) indicated Resident #52 had a physician order, dated 12/10/22, which read: Ertapenem [an antibiotic medication] Sodium Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for Sinus Infection until 01/11/2023.
The eMAR also had a physician order entry, discontinued date on 12/10/22 that read: Ertapenem [an antibiotic medication] Sodium Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for Sinus Infection until 01/11/2023.
A review of the December 2022 eMAR for Resident #52 revealed that on 12/9/22, the Ertapenem antibiotic medication scheduled for 2000 and on 12/21/22 the Ertapenem antibiotic medication scheduled for 0600, there were no nurse signatures for those entries.
On 1/12/23 at 10:46 AM, the Infection Preventionist (IP) was informed about concern that there were no nurse signatures documented for days identified on the Ertapenem entry in the December 2022 eMAR. The IP stated she would follow up and provide further information.
On 1/12/23 at 1:32 PM, the IP informed the surveyor that the Ertapenem medication entries identified were not signed and that the physician was notified. The IP further stated she contacted RN#1 who worked on 12/9/22 and RN#1 stated she would have to look at her notes when she came into work to see what happened. The IP stated the other nurse, who did not sign the eMAR no longer worked at the facility.
On 1/12/23 at 1:54 PM, the surveyor informed the Administrator, Quality Assurance Consultant #1 (QAC #1), QAC #2, and Regional Director of Operations of the above concerns for no nurses' signatures on the eMAR for Ertapenem medication on 12/9/22 and 12/21/22.
On 1/13/23 at 9:40 AM, the surveyor interviewed the IP on the above concerns. The IP stated if the nurses could not administer a medication, or a dose was missed that the physician would be made aware. The IP further stated the nurses were expected to review their eMAR assignment at the end of the shift to ensure all medications were administered and signed for.
On 1/13/23 at 10:24 AM, the surveyor interviewed RN #1 about missed signature for Ertapenem on the December 2022 eMAR. RN#1 stated she spoke with the IP yesterday (1/12/23), who asked her about the missing signatures for the Ertapenem. RN #1 stated she could not recall what happened since it was, so long ago. RN #1 stated she tried to check her documentation when she came into work last night but still wasn't sure what happened on 12/9/22. RN #1 acknowledged it would be expected for the physician to be notified if there were any changes with a resident's medication, such as a missed dose, delayed medication, or need to change the time for a medication.
On 1/13/23 at 10:44 AM, the surveyor met with the Administrator, Medical Director, QAC #1, and IP. QAC #1 stated an incident report was to be done and they would reach out to the nurses to provide re-education.
The surveyor reviewed the undated facility policy titled, Medication and Treatment Administration Guidelines, Long-Term Care. Under Documentation, it read: Medications and treatments administered are documented immediately following administration or per state specific standards, Medications not administered according to medical practitioner's orders are reported to the attending medical practitioner and documented on the clinical record including the name and dose of the medication and reason the medication was not administered, and The licensed nurse is responsible for validating documentation is completed for any medication administered during the shift.
NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to a.) evaluate and complete a wound assessment for one resident's wound in a timely manner, b.) complete weekly skin assessments for one resident and c.) discontinue a wound treatment when resolved. This deficient practice was identified for 1 of 1 resident (Resident #29) reviewed for pressure ulcers and was evidenced by the following:
On 01/03/23 at 10:05 AM, the surveyor observed Resident #29's legs were contracted, and the resident was lying supine in bed on an air mattress with the head of the bed elevated. The resident stated that he/she had a wound on the shin.
According to the admission Record Report, the resident was admitted with diagnoses which included, but were not limited to, contracture of muscle.
Review of the 10/14/22 Quarterly Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care, reflected that the resident was cognitively intact and required total care by staff for activities of daily living. The MDS further reflected that the resident had an active diagnosis of an unspecified open wound to the right lower leg.
Review of the ongoing Care Plan revealed a focus that Resident #29 had an actual right shin pressure ulcer with the goal to decrease/minimize skin breakdown risks times 90 days. The Care Plan reflected the interventions to observe skin condition with ADL care daily and report abnormalities, administer treatment per physician orders, and wound consult and treat.
Review of the Order Summary Report for Order Date Range: 10/01/22-01/11/23 reflected an order dated 10/27/22 to apply skin prep to the periwound (outside perimeter), then clean the right inner leg/shin wound with Skin Integrity Cleaner, apply Medihoney and silver alginate to the wound and cover with border gauze every day shift for wound care.
Further review of the January 2023 Treatment Administration Record (TAR) reflected that the 10/27/22 treatment order to the right inner leg/shin wound was discontinued on 01/06/23.
Review of the Skin & Wound Evaluation V5.0 dated 10/27/22 reflected that the resident had an unstageable (obscured full-thickness skin and tissue loss) wound to the right shin. The wound had a length of 3.0 cm and width of 1.6 cm.
The surveyor observed there were no Skin & Wound Evaluation V5.0 completed for the right inner leg/shin after 10/27/22 until after surveyor inquiry.
On 01/13/23 at 9:00 AM, the facility provided the Skin & Wound Evaluation V5.0 dated 11/03/22, completed by the Advanced Practice Wound Nurse (APWN) reflected that the wound to the right shin had resolved. This Skin & Wound Evaluation V5.0 dated 01/09/23 was not completed until after surveyor inquiry.
Review of the November 2022 TAR reflected that the nurses signed that the treatment to the right inner/leg shin was completed daily on 11/05/22, 11/06/22, 11/07/22, 11/08/22, 11/09/22, 11/10/22, 11/11/22, 11/13/22, 11/14/22, 11/15/22, 11/16/22, 11/17/22, 11/19/22, 11/20/22, 11/22/22, 11/23/22, 11/24/22, 11/25/22, 11/26/22, 11/28/22, 11/29/22, and 11/30/22.
Review of the December 2022 TAR reflected that the nurses signed that the treatment to the right inner/leg shin was completed daily on 12/01/22, 12/08/22, 12/12/22, 12/14/22, 12/15/22, 12/18/22, 12/20/22, 12/21/22, 12/22/22, 12/24/22, 12/25/22, 12/27/22, 12/28/22, 12/29/22 and 12/31/22.
Review of the January 2022 TAR reflected that the nurses signed that the treatment to the right inner/leg shin was completed daily on 01/01/23, 01/02/23, 01/04/23 and 01/05/23.
The surveyor further observed that Resident #29's Electronic Medical Record (EMR) revealed the following:
- the physician orders did not include an order for weekly skin assessments; and
- the nurses continued to sign the 10/27/22 treatment orders to the right inner leg/shin after the wound had resolved on 11/03/22.
On 01/11/23 at 11:10 PM, the surveyor, Director of Nursing (DON) and LPN #1 observed that Resident #29's right inner leg/shin wound was healed.
During an interview with the surveyor on 01/11/23 at 12:08 PM, the APWN stated that she was following the right inner leg/shin wound weekly and she believed it resolved in November 2022. The APWN further stated that her documentation of the wound would be found in the progress notes.
During an interview with the surveyor on 01/11/23 at 01:08 PM, the DON stated there were no Skin & Wound Evaluation V5.0 completed for the right inner leg/shin wound after 10/27/22 up to the date the wound treatment was discontinued on 01/06/23. The facility could not provide further documentation to indicate when the wound had resolved.
During a follow up interview with the surveyor on 01/11/23 at 2:03 PM, LPN #1 reviewed Resident #29's orders and confirmed there was no order for a skin assessment. LPN #1 stated that the physician puts in the order for the skin assessment and we follow that. On the second floor, we complete skin assessments on shower days. Surveyor inquired, if there was no skin assessment order, when are the skin assessments completed. LPN #1 stated that the skin assessments were usually documented in the EMR under Assessments. LPN #1 verified that the skin assessment was unavailable for him to complete for this resident under the Assessment tab in the EMR. LPN #1 further stated that we also had a paper assessment which could have been completed.
During an interview with the surveyor 01/12/23 at 11:46 AM, Quality Assurance Consultant (QAC) #1 and QAC #2 discussed Resident #29's right inner leg/shin wound. At that time, QAC #2 reviewed Resident #29's right inner leg/shin wound pictures. QAC #2 showed the surveyor a picture of the right inner leg/shin wound dated 11/03/22, which reflected that the wound was resolved. The surveyor further discussed with QAC #1 and QAC #2 the concern that the resident did not have an order for weekly skin assessments. QAC #1 stated that the skin assessments were usually completed on shower days and she he would get back to the surveyor. The surveyor further discussed with QAC #1 and #2 that the nurses continued to sign the TAR after the right shin healed. QAC #1 stated that the nurses should have notified the physician that the wound had healed for new orders.
During an interview with the surveyor on 01/12/23 at 12:01 PM, Certified Nursing Assistant (CNA) #2 stated that if she observed something different about a resident's skin, she would immediately alert the nurse to look at the resident's skin. CNA #2 stated that some examples would be a skin tear, skin opening, redness or anything different from their prior skin condition.
During a follow up interview with the surveyor on 01/12/23 at 12:13 PM, LPN #1 stated that he usually goes in on shower days to assess Resident #29's skin and he would document on the Body Audit in the EMR. For Resident #29, the CNA sees the skin during care and he observed the skin during dressing changes daily. LPN #1 further stated that if a resident's wound healed, he would tell the Advanced Practice Nurse, physician, or APWN and she would come and assess the wound and give me a direction to discontinue the treatment order.
During a follow up interview with the surveyor on 01/13/23 at 09:50 AM, the surveyor discussed with the APWN that the facility provided the right inner leg/shin Skin & Wound Evaluation V5.0 dated 11/03/22 which the APWN completed on 01/09/23. The APWN stated that the shin wound healed on 11/03/22 and she monitored the resident's wounds weekly. The APWN further stated that if a wound heals, she will discontinue the treatment. The surveyor inquired, why did the treatment continue. The APWN stated that there was a clarification by the nurse and she discontinued the treatment on 01/06/23, as it had healed. The APWN stated, It could be my mistake as a provider.
During a follow up interview with the surveyor on 01/13/23 at 10:10 AM, the QAC #1, in the presence of the Infection Preventionist, stated that she expected the wound nurse to complete weekly rounds, document in the progress notes, put orders in the medical record and discontinue orders when a wound healed. The APWN obviously knew that the wound had healed. The QAC #1 further stated that she expected the nurses, if a wound healed, to communicate with the physician and get an order to discontinue the treatment. The facility did not provide further information about the weekly skin assessments.
Review of the facility's Skin Management Guidelines, dated 03/2022, reflected that body audits were completed by the licensed nurse daily for patients with pressure injuries and documented in the TAR. The Guidelines further reflected that skin alterations and pressure injuries were evaluated and documented by the licensed nurse whenever there was a significant change in condition or clinically indicated.
Review of the facility's Skin Quick Reference document, dated 02/2022, reflected that the facility should document in the TAR daily body audit for patients, including but not limited to, with pressure injury, treatment completion, and weekly wound rounds.
NJAC 8:39-27.1(e)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure that a resident with limited range of motion of the right hand received appropriate services to prevent further decrease in range of motion. This deficient practice was identified for 1 of 1 residents (Resident #21) reviewed for positioning and mobility and was evidenced by the following:
During the initial tour of the facility on 01/03/23 at 10:03 AM, the surveyor observed Resident #21 with a contracture to the right hand. The surveyor observed a hand roll located on the resident's bedside table. Resident #21 stated that he/she can apply and remove the hand roll without assistance.
On 01/06/23 at 11:00 AM, the surveyor observed Resident #21 with a contracture to the right hand. The resident's hand roll was observed on the bedside table. When asked how often the resident used the hand roll, he/she responded, I wear it at night. I don't want it to get it dirty during the day.
On 01/09/23 at 11:17 AM, the surveyor observed resident #21 asleep in bed with the contracture to the right hand. The resident's hand roll was observed on the bedside table.
According to the admission Record, Resident #21 was admitted to the facility with diagnoses which included, but were not limited to, Atherosclerotic Heart Disease (buildup of plaque in arteries causing reduced blood flow), and muscle weakness.
Review of Resident #21's most recent Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/15/22, identified Resident #21 as cognitively intact with functional limitation in range of motion on one side of the upper and lower extremity. The MDS also revealed that Resident #21 required extensive assistance and was dependent on staff for most activities of daily living.
During the resident's Record Review on 01/06/23 at 10:02 AM, it was observed that Resident #21's ongoing Care Plan did not identify the right-hand contracture and hand roll intervention. A review of the January 2023 physician orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not address the resident's contracture or any interventions.
During an interview with the surveyor on 01/09/23 at 11:00 AM, Certified Nursing Assistant (CNA) #1 confirmed that splinting/orthotic devices required physician orders and they are trained from the therapists on how to apply and remove the device.
During an interview with the surveyor on 01/09/23 at 12:03 PM, the assigned Licensed Practical Nurse (LPN) #1 reported that the unit manager was responsible for creating and updating care plans. LPN #1 further advised, There isn't one (a unit manager). If it something that needs to be added, I try to do it myself but I don't have time. When asked if splinting/devices are common care planning topics, LPN #1 responded, Yes. When asked to identify what would be documented, LPN #1 stated, The interventions to prevent worsening condition, how long for splinting, how often. The surveyor inquired if staff received any training as to donning and doffing the splint. LPN #1 explained, Therapy will come up and train. Everything [documentation] would be with them. Upon reviewing the resident's physician orders, LPN #1 confirmed, Well, that would be night shift; but no, I do not see any.
During an interview with the surveyor on 01/09/23 at 12:55 PM , the Assistant Director of Rehabilitation (ADDR) reported that upon discharge from rehabilitation, the nursing staff is trained on the application and removal of a device. The ADDR stated that nursing was responsible for ensuring that the resident wore the device, provided skin checks, and notified Rehabilitation of any changes, including the resident's refusal to wear the device or questions regarding the device.
Upon review of documentation provided by the ADDR on 01/09/23 at 1:04 PM, the Therapy Communication Form revealed, Under Splint Wear Section that the handroll was identified with the instruction checked off to apply roll to right (circled) upper extremity. Handwritten next to the entry identified as tolerated every day.
The surveyor also reviewed the Therapy Discharge Summary signed on 9/26/2022 at 12:42 PM revealed, Nursing range of motion (ROM) and activities of daily living (ADL) assistance as requested by patient. Therapy follow up established/trained. Restorative Splint and Brace Program Splint and Brace Program Established/Trained. Passive range of motion (PROM) and Gentle stretching right upper extremity (RUE) as tolerated followed by (f/b) right hand roll throughout the day/evening (as tolerated) and removed for hygiene and ROM. Physical Therapy (PT) educated and able to remove and apply splint on her own as well.
During an interview with the surveyor on 01/09/23 at 12:55 PM, the Director of Nursing (DON) identified that splinting/orthotics/palm guards require physician's orders. When asked by the surveyor if the Resident has any physician's orders the DON responded, No I don't see them. When asked if the Resident is Care Planned for the device the DON stated, I don't see it. It should be on there.
The surveyor reviewed the undated facility procedure titled, Facility Braces/Splints, Under Purpose revealed: To maintain function range of motion, decrease muscle contractures and provide support and alignment for weakened limbs through use of braces and/or splints. Under Procedure, it documented:
#1 Verify medical practitioner's order. Order should specify what type of brace/splint should be used as well as wearing schedule.
#9 Carefully inspect skin and appearance of body part during and between applications.
The surveyor reviewed an undated Facility Procedure titled, Medication and Treatment Administration Guidelines. Under General, it revealed Centers are to follow the Orders Management Matrix for initiation of non-medication or treatment orders. All orders are to prescribed by a medical practitioner.
NJAC 8:39-27.2(m)

Based on interview and review of facility documentation, it was determined that the facility failed to provide evidence that Certified Nursing Assistants (CNAs) received annual performance evaluations and 12 hours of mandatory in-service training as required.
This deficient practice was identified for 5 of 5 CNAs and was evidenced by the following:
On 1/4/23 at 11:40 AM the surveyor reviewed the facility's list of CNAs and requested the in-service training and performance evaluations for 5 randomly selected who had been hired on 4/1/2021.
On 1/5/23 at 10:00 AM, the Human Resources (HR) director provided the surveyor with a printout of a document titled, Transcript Report-Nurse Aide Completions with Training Hours.
A review of the Transcript Report-Nurse Aide Completions with Training Hours included CNA #5, #6, and #7, but did not include CNA #8 or #9. Additionally, there was no evidence on the transcript provided that ensured that CNAs #5, #6, and #7 received 12 hours of in-service training.
On 1/9/23 at 9:27 AM, the surveyor reviewed the transcript report with the HR director. The HR director confirmed that the transcript report did not include tracking of hours of education for the CNAs. When asked about the other two CNAs that were not on the transcript, the HR director stated that corporate had provided what was handed to the surveyor and she was unable to determine how many hours of education each CNA completed.
During an interview with the surveyor on 1/10/23 at 8:42 AM, the Director of Nursing (DON) stated that there were no performance evaluations completed for the CNAs.
During an interview with the Administrator, and HR director in the presence of the survey team on 01/13/23 at 10:43 AM, the HR director could not provide additional information. She stated she was responsible to monitor the CNA in-service hours to ensure each CNA receives twelve hours of training and also to ensure performance evaluations were done annually, but the DON did not have them completed.
A review of an undated facility policy titled, Employee Development included; Performance Appraisal .your job performance will be reviewed 90 days after hire, transfer or promotion and annually thereafter .In-service Training; Ongoing training is necessary to provide the highest level of quality care to our patients/residents. You will be responsible for participating in training related to your position. You will be paid for participating in mandatory training. Your supervisor and/or the HR designee will communicate those requirements to you.
NJAC 8:39-43.17(b)

Based on interview and record review, it was determined that the facility failed to a.) act on or respond to, recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 1 of 5 residents reviewed for medication regimen review (Resident #5) and was evidenced by the following:
The surveyor reviewed the progress notes (PN) from 06/01/22 through 01/12/23 and observed that the CP generated Medication Regimen Review (MMR) PNs dated 06/29/22, 08/01/22, 09/30/22, 10/31/22, 11/20/22 and 12/31/22 with his recommendations to be completed by the physician. The surveyor observed that the physician did not address the CP MMR Progress Notes.
During an interview with the surveyor on 01/10/23 at 10:36 AM, the surveyor asked the Director of Nursing (DON) for the physician's response to the CP recommendations for Resident #5. The DON stated that her date of hire was 12/14/22. The DON further stated that the CP reviewed each resident's medications monthly and generated a report which was emailed to the Medical Director and DON. The DON then printed out the recommendations, gave them to the physician to complete and the physician returned the completed CP recommendations to the DON within 30 days.
On 01/11/23 at 1:30 PM, the DON provided the following CP Medication Regimen Review (MMR) Progress Notes (PN) for Resident #5:
- MMR PN dated 06/29/22 reflected irregularities were noted. The CP recommended please evaluate the benefit/risk of use for Oxybutynin [a medication used to treat an overactive bladder] and to please evaluate the benefit/risk of use for Sliding Scale Insulin order (is it still needed)? The MMR PN further reflected a handwritten X for the Physician Response Accept the recommendation(s) above, please implement as written. The MMR PN further contained a handwritten signature of the APN. The surveyor observed that the signature was not dated.
- MMR PN dated 08/01/22 reflected irregularities were noted. The CP recommended please evaluate if a Clonazepam [a medication used to prevent and control seizures] dosage reduction could be attempted at this time. The MMR PN further reflected a handwritten X for the Physician Response Decline the recommendation(s) above and do not wish to implement any changes due to the reasons(s) below. The surveyor observed the Rationale portion of the MMR PN was blank. The MMR PN further contained a handwritten notation *See Psych [psychotherapy] note 8/10/22* and a signature of the APN. The surveyor observed that the signature was not dated.
- MMR PN dated 09/30/22 reflected No irregularities were noted. No action required. The surveyor observed the form was blank and did not contain a handwritten signature or date.
- MMR PN dated 10/31/22 reflected irregularities were noted. The CP recommended Is Esomeprazole [a medication used to treat heartburn] still needed? The MMR PN further reflected a handwritten X for the Physician Response Decline the recommendation(s) above and do not wish to implement any changes due to the reasons(s) below. The surveyor observed the Rationale portion of the MMR PN was blank. The MMR PN further contained a handwritten notation *See Diagnosis List* and a signature of the APN. The surveyor observed that the signature was not dated.
- MMR PN dated 11/30/22 which reflected irregularities were noted. The CP recommended please evaluate if a Clonazepam dosage reduction could be attempted at this time. The MMR PN further reflected a handwritten X for the Physician Response Decline the recommendation(s) above and do not wish to implement any changes due to the reasons(s) below. The surveyor observed the Rationale portion of the MMR PN was blank. The MMR PN further contained a handwritten notation *See CRNP (APN) note* 12/4/22 and a signature of the APN. The surveyor observed that the signature was not dated.
- MMR PN dated 12/31/22 which reflected No irregularities were noted. No action required. The surveyor observed the form was blank and did not contain a handwritten signature or date.
During an interview with the surveyor on 01/11/23 at 11:25 AM, the surveyor reviewed the MMR PNs with the APN and she acknowledged that she reviewed and signed the MMR PNs yesterday, 01/10/23. The APN stated that the CP came monthly, reviewed each resident's medications, and made recommendations. The CP provided the recommendations to the Director of Nursing (DON) and she provided these forms to the physician and the physician would address them. If the physician was not available, their APNs would complete the task. Once the recommendations were completed, they were returned to the DON.
At that time, the surveyor and APN reviewed each CP MMR PN as follows:
- For the 06/29/22 MMR PN, the APN reviewed the PN dated 07/04/22 which reflected that the resident had a chronic/labile (readily or frequently changing) overactive bladder. The APN further stated that the 07/04/22 PN further reflected that Resident #5 had a history of chronic/labile diabetes mellitus without complications with blood sugars between 113-283 for the last two days. The APN acknowledged that she did not fill in this rationale on the MMR PN.
- For the 08/01/22 MMR PN, the APN reviewed the 08/10/22 Psychotherapy PN and acknowledged she did not fill in the rationale on the MMR PN.
- For the 09/30/22 MMR PN, the APN confirmed that the form was incomplete.
- For the 10/31/22 MMR PN, the APN stated that Resident #5 had pain in the abdomen and confirmed that she did not fill in this rationale. The APN further reviewed the progress notes and confirmed that the CP recommendations were not addressed after 10/31/22.
- For the 11/30/22 MMR PN, the APN reviewed the 12/04/22 PN and confirmed that she did not fill in the rationale.
- For the 12/31/22 MMR PN, the APN confirmed that the form was incomplete.
At that time, the APN stated that the CP recommendations should be completed right away and voiced an understanding of completing the CP recommendations.
During an interview with the surveyor on 01/13/23 at 10:48 AM, the Quality Assurance Consultant #1 acknowledged that the MMR PNs were not completed in their entirety.
Review of the facility's Medication Regimen Review policy dated 08/2018 reflected the following:
- CPs perform MMR for patients and will generate recommendations with the overall goal of promoting positive outcomes and minimizing adverse consequences.
- The CP conducts review of the medical record. The findings and/or recommendations are entered in the electronic health record assessment.
- The CP generates three copies of the MRR recommendations with one copy provided to the DON and retained in the MRR binder as the master tracking system, one copy provided to the Medical Director and one copy provided to the attending physician or prescriber.
- The DON, or designee reviews the MRR and contacts the attending physician to review and obtain orders as warranted. The DON, or designee documents on the MRR and in the patient's clinical record, the physician order(s) and forwards the completed MRR to the DON within 30 days of the CP's review.
- The attending physician documents the review and any resulting actions or orders on the MRR.
- Once validated as complete, the paper copy of the MRR is filed in the patient's clinical record - Legal/Miscellaneous tab. The copy from the master tracking binder is removed and securely disposed of by placing in the secure document shred box.
NJAC 8:39 - 29.3 (a)(1)

Based on observation, interview, and record review, it was determined that the facility failed to a.) ensure that expired medications and supplies were removed from the medication rooms and unit emergency carts where other current in use items were stored, b.) ensure that each medication room refrigerator was maintained and locked, c.) ensure that each medication room refrigerator contained a secured/locked narcotics box and d.) consistently document medication room refrigerator temperatures. This deficient practice was identified for 2 of 2 units and was evidenced by the following:
On 01/10/23 at 10:46 AM, surveyor #1 inspected the medication room on the second floor with the Registered Nurse Supervisor (RNS) and observed the following:
1. The RNS and surveyor #1 reviewed the medications stored in the large refrigerator and the RNS confirmed the following items were expired: one Pneumovax 23 syringe expired 11/22/22, one Famotidine Injection 40 mg/4 ml expired 09/2022 and one IV Daptomycin 500 mg/100 mg expired 01/02/23.
2. Surveyor #1 reviewed the lower cabinet to the right of the sink, in the presence of the RNS, and the RNS confirmed, that the following items were expired: one bottle of Vitamin B-6 50 mg tablets expired 12/22 and four bottles of Aspirin 325 mg expired 12/22.
3. Surveyor #1 observed that the small black refrigerator did not have a lock affixed to the refrigerator.
4. Surveyor #1 observed that both refrigerators had a Medication/Vaccine Refrigerator Temperature Log (Temp Log) affixed to each refrigerator that was incomplete. Review of the Temp Log reflected the Month, Year and Location, an area checked to record the Refrigerator temperatures only, the Day, Time (AM and PM), Refrigerator (temperature), Freezer (temperature), and Initials.
Surveyor #1 reviewed the Temp Log affixed to the large refrigerator was dated January 2023. The Temp Log reflected the staff did not complete the refrigerator temperatures on 01/01/23 AM and PM, 01/02/23 AM, 01/03/23 PM, 01/04/23 AM and PM, 01/05/23 PM, 01/06/23 AM and PM, 01/07/23 AM, 01/08/23 AM, and 01/09/23 AM and PM.
Surveyor #1 reviewed the Temp Log affixed to the small refrigerator was dated January 2023. The Temp Log reflected the staff did not complete the refrigerator temperatures on 01/01/23 AM and PM, 01/02/23 AM, 01/03/23 PM, 01/04/23 PM, 01/05/23 PM, 01/06/23 AM and PM, 01/07/23 AM, 01/08/23 AM, and 01/09/23 AM and PM.
When interviewed at the time of the observations, the RNS stated that the refrigerators were reviewed for expired items when a resident was discharged from the facility and every two weeks. The RNS further stated that it was the nurses' responsibility and sometimes the Director of Nursing (DON) or the supervisors to review the refrigerators for expired items. The RNS confirmed there was no lock on the small refrigerator and that the large and small refrigerator Temp Logs were incomplete. The RNS stated that it was the responsibility of the day supervisor to check the refrigerator temperatures daily.
On 01/10/23 at 11:51 AM, two surveyors inspected the third floor medication room with the RNS and observed the following:
1. Surveyor #1 observed the small refrigerator was not locked and did not contain a secured, locked box inside of the refrigerator for narcotic medications. The small refrigerator contained the following items: three sealed boxes of one vial of Humalog, one sealed bottle of Latanoprost Ophthalmic 2.5 ml solution, three prefilled Basaglar insulin pens, two prefilled Humulin insulin pens, two prefilled Lantus insulin pens, and five prefilled Glargine pens. The surveyor #1 further observed that the ice compartment of the small refrigerator contained a thick layer of ice. At that time, the RNS confirmed the observations.
2. Surveyor #1 reviewed a storage cabinet to the right of the refrigerator and observed six 3 ml Syringe with hypodermic safety needles with an expiration date of 03/28/22. At that time, the RNS confirmed the observation.
3. Surveyor #2 reviewed the lower shelf of the bottom counter cabinet and observed the following expired medications: 19 individually wrapped Heparin Lock Flush Syringe expired 05/31/22, one sealed box of 50 individually wrapped Heparin Lock Flush Syringes expired 04/30/22 and one individually wrapped and sealed 0.9 Sodium Chloride Flush expired 09/30/22.
4. Surveyor #1 observed the Temp Log affixed to the small refrigerator was dated January 2023 and reflected the staff did not complete the refrigerator temperatures on 01/01/23 AM, 01/02/23 PM, 01/04/23 PM, 01/05/23 PM, 01/06/23 AM and PM, 01/07/23 AM and PM, 01/08/23 AM and PM, 01/09/23 AM and PM.
At that time, the RNS acknowledged that the Temp Logs were incomplete and stated that she was nurse supervisor and it was her responsibility to check the refrigerator temperatures daily on both floors.
The two surveyors reviewed the third floor crash cart, situated near the nurses' station, and observed the following expired items: Twenty-one 0.09 oz lubricating jelly expired 12/19, and six 0.09 oz lubricating jelly expired 01/20. The surveyors further observed to the right of the crash cart, affixed to the wall, was a container which housed two Biohazard Spill Kits with an expiration date of 10/31/22.
On 01/10/23 at 12:09 PM, the two surveyors reviewed the second floor crash cart, situated near the nurses' station, and observed the following expired items: nine packets of E-z lubricating Jelly expired 3/2021, eight packets of E-z lubricating Jelly expired 1/2020, two packets of Petroleum Jelly expired 02/21, one Non-Conductive Connecting Tubing expired 11/01/21, one Inner Cannula expired 06/30/21, and one Yankauer expired 11/28/21. The surveyors observed to the right of the crash cart, affixed to the wall, was a container which housed two Biohazard Spill Kits with an expiration date of 10/31/22.
During a follow up interview with surveyor #1 on 01/10/23 at 12:39 PM, the RNS stated, I believe the night supervisor checked the crash cart.
During a follow up interview with surveyor #1 on 01/10/23 at 1:06 PM, the RNS verified that there was no locked/secured narcotics box in the third floor refrigerator. She stated that if there was a new admission, who had a narcotic that needed to be refrigerated, that it would be stored in the second floor medication room.
During an interview with surveyor #1 on 01/11/23 at 11:10 AM, the DON stated that night shift was responsible to review the medications in the medication storage rooms and return the expired medications and discontinued medications of residents to the pharmacy. It was important to review the medications for expiration dates so that we don't give expired medications to the residents. The DON expected her nurses to keep the medication rooms clean, check for expired medications, and return expired/discontinued resident medications to the pharmacy.
At that time, the DON and surveyor #1 reviewed the crash cart on the second floor. The DON stated that there was a binder, which the night shift filled out to check the crash cart and the AED. The DON reviewed the crash cart and could not locate the binder. She stated that the binder was kept from survey to survey. The DON stated that she would have medical records locate the completed forms. She stated that it was important to review the crash cart for expired items because if there was a code, all items should be in date and available. The DON further stated that she expected night shift to maintain the binder, check the crash carts daily and complete the Basic Crash Cart Checklist daily. While at the crash cart, surveyor #1 and DON reviewed the Biohazard Spill Kit expiration dates. The DON confirmed the spill kits were expired and removed them from their basket on the wall. The DON was not sure if the spill kits were reviewed by the night nurse when she reviewed the crash cart and was uncertain if the spill kits were included on the Basic Crash Cart Checklist.
The DON reviewed the second floor medication room with surveyor #1. The DON confirmed there was a large and small refrigerator in the medication room and stated the small refrigerator did not require to be locked because it only housed flu vaccines. The DON stated that it was the responsibility of the Nursing Supervisors to monitor the refrigerator temperatures daily and she expected that the temperatures will be monitored daily so that the medications are kept at correct temperatures.
At that time, surveyor #1 and DON discussed that the third floor refrigerator did not contain a secured, locked narcotics box. The DON further stated that the narcotics could be stored in the second floor narcotics box unless the narcotic was resident specific.
During an interview with surveyor #1 on 01/13/23 at 10:48 AM, the Quality Assurance Consultant #1 stated that the facility could not locate the binders for the crash carts.
Review of the Basic Crash Cart Checklist did not include the Biohazard Spill Kits.
Review of the facility's undated Medication and Treatment Administration Guidelines, Long-Term Care reflected that medications and biologicals are securely stored in a locked cabinet, cart, or medication room. The guidelines further reflected that controlled substances are securely stored using a double-lock system (medication cart, medication room, refrigerator, controlled substance lock box, and/or separately keyed controlled substance drawer in medication cart). The guidelines further reflected that medications are stored in accordance with standards of practice.
Review of the facility's undated Emergency Management document reflected to use a crash cart check sheet and signature form daily to verify the contents of the crash cart. One sheet is used per cart per month. The document further reflected to check emergency care items and equipment stored in the crash cart against the crash cart checklist once a month and whenever the cart is opened to validate contents and expiration dates. The licensed nurse or designee: replaces items with expired dated, secures the cart with break-away lock and covers, signs and dates crash cart checklist. The document further reflected that checklists and signature logs are submitted to the Quality Assurance Performance Improvement committee for review and follow-up upon completion.
NJAC 8:39-29.4 (c)(e)(h), 29.7(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the initial tour on 01/03/23, the surveyor observed the small refrigerators in rooms [ROOM NUMBER]. Attached to each refrigerator was a Refrigerator/Freezer Temperature Log (Temp Log) dated October 2022. The Temp Log reflected columns for the Date, Time, Internal Temp, Other Temp, and Initials to record the temperatures of the refrigerators daily.
The Temp Logs further reflected that the forms were not completed for each day of the month as follows:
- The Temp Log from room [ROOM NUMBER] reflected the following dates were blank: 10/01/22, 10/02/22, 10/03/22, 10/04/22, 10/05/22, 10/06/22, 10/08/22, 10/09/22, 10/10/22, 10/11/22, 10/12/22, 10/13/22, 10/14/22, 10/15/22, 10/17/22, 10/18/22, 10/19/22, 10/20/22, 10/21/22, 10/22/22, 10/23/22, 10/24/22, 10/26/22, 10/27/22, 10/28/22, 10/29/22, 10/30/22, and 10/31/22.
- The Temp Log from room [ROOM NUMBER] reflected the following dates were blank: 10/01/22, 10/02/22, 10/03/22, 10/04/22, 10/05/22, 10/06/22, 10/08/22, 10/09/22, 10/10/22, 10/11/22, 10/12/22, 10/13/22, 10/14/22, 10/15/22, 10/17/22 reflected the Time of 11:, 10/18/22, 10/19/22, 10/20/22, 10/21/22, 10/22/22, 10/23/22, 10/24/22, 10/26/22, 10/27/22, 10/28/22, 10/29/22, 10/30/22, and 10/31/22.
- The Temp Log from room [ROOM NUMBER] reflected the following dates were blank: 10/01/22, 10/02/22, 10/03/22, 10/04/22, 10/05/22, 10/06/22, 10/08/22, 10/09/22, 10/14/22, 10/15/22, 10/16/22, 10/19/22, 10/20/22, 10/21/22, 10/22/22, 10/23/22, 10/25/22, 10/26/22, 10/27/22, 10/28/22, and 10/31/22.
During an interview with the surveyor on 01/05/22 at 1:25 PM, Resident #31 stated that the staff cleaned out the refrigerator yesterday.
During an interview with the surveyor on 01/11/23 at 10:49 AM, the Administrator stated that the in-room resident refrigerator logs are to be completed daily and I know they are not being done. The night shift was assigned to monitor the temperatures, and the Maintenance Department will place new temperature logs on each refrigerator monthly. The Certified Nursing Assistants (CNA) will check the temperatures daily on night shift. The Administrator stated, I am well aware that it is not happening and I talk about it all the time. I just hired a new Maintenance Director; and I hope it will be up and running soon. The Administrator stated that it was important to make sure that the food holds the correct temperature so that the residents do not get sick.
During an interview with the surveyor on 01/12/23 at 12:29 PM, CNA #3 stated that he worked on the 3-11 shift and that he was instructed to take the temperature of the refrigerators in resident rooms and make sure they are clean and nothing was spoiled. CNA #3 stated that the temperature should be recorded on the door of the refrigerator; and that normally, the 11-7 shift was assigned to do this task, but we help each other out.
During an interview with the surveyor on 01/13/23 at 10:26 AM, Registered Nurse (RN) #1 stated that she worked three days per week on night shift. She was instructed that the CNAs were to monitor the temperatures of the in-room refrigerators, to check the refrigerators for expired items and to make sure the refrigerators were clean. RN #1 stated that the temperature logs were maintained in a binder for a month or two months. RN #1 further stated, I don't see the CNAs doing it.
During an interview with the surveyor on 01/13/23 at 10:47 AM, Quality Assurance Consultant #1 stated that the in-room refrigerator logs were inconsistent. The surveyor requested to review the refrigerator log binder. The facility could not provide the binder.
Review of the facility's Food From Outside Sources and In-Room Refrigerators, with an Original Date of 11/2020, reflected:
If personal in-room refrigerators are used:
- A staff member designated by the administrator monitors the condition, temperature and maintenance with regard to food safety in the refrigerator.
- A temperature log is kept and responsibility for checking and recording temperatures is assigned by the administrator or director of nursing.
NJAC 8:39-17.2(g)
Based on observations, interviews, and record reviews, it was determined that the facility failed to a.) handle potentially hazardous foods, and maintain equipment and sanitation in a safe, consistent manner to prevent foodborne illness and b.) consistently document refrigeration temperatures for 3 out of 3 resident rooms.
This deficient practice was evidenced by the following:
On 01/03/23 from 9:52 AM to 10:36 AM, the surveyor observed the following in the kitchen in the presence of the Dining Services Director (DSD).
1. In a food preparation area, the surveyor observed that two of four five-pound packages of ground hamburger that were being thawed inside of a stock pot under running water within the sink, protruded halfway out of the stock pot and were not fully submerged beneath the water. The DSD stated that each package of ground beef was required to be submerged beneath the running water to ensure that they defrosted at the same time. She then proceeded to push the packages down into the stock put so that they were fully covered by the running water. [NAME] #1 returned to the food preparation area and acknowledged that the ground beef was not fully submerged beneath the running water as it was required to be to ensure a safe thawing process. [NAME] #1 further stated that he intended to defrost the meat to be utilized to make meat loaf to be served the next day.
2. In the walk-in refrigerator:
a) On the second shelf of a three-tiered wired rack, there was a clear, plastic bin which contained one cucumber that had multiple areas of a white plaque substance, a second cucumber that appeared to have been cut in half, was not covered, and had begun to decay. There was a head of cabbage with yellow and brown outer leaves. The DSD removed the items from the bin and placed them within a smaller bin. The DSD proceeded to remove the outer leaves from the cabbage, discarded them, and stated that the cabbage was still good. She then returned the cabbage to the storage bin. The DSD stated that the cucumbers should have been discarded and removed them from storage. The surveyor noted a received date of 12/21/22 on the produce bin which failed to contain a use by date. The DSD stated that she did not know why the use by date was not specified on the produce bin as required. She further stated that produce was normally used within a week of receipt.
b) On the bottom rack of a free-standing wired rack, there was an opened five-pound box of chicken thighs that were marked with a received by date of 12/29/22, the packing label failed to contain an opened date or use by date in the space provided. The DSD stated that there was another sticker on the box which contained a use by date, but it must have fallen off. When the surveyor asked the DSD why it was important to ensure that an opened date and a use by date were written on an opened package of chicken, a potentially hazardous food, she stated that the chicken would be cooked today and served tomorrow and failed to provide a rationale.
c) In a food preparation area:
The surveyor observed a can opener that was mounted on the front of the table in the food preparation area. The DSD removed the can opener from the holder upon request and the blade of the can opener was visibly soiled and had a dried, black substance on the anterior blade and a single strand of an orange substance was noted on the upper portion of the blade cover. The DSD stated that she personally cleaned the can opener in the dishwasher on Saturday, 12/31/22. The DSD stated that a soiled can opener could cause contamination. The DSD stated that the PM [NAME] should have cleaned it. The DSD stated that there was no cleaning schedule in place to ensure that the can opener was cleaned.
d) In the presence of the DSD and [NAME] #2 in the galley of the kitchen:
The surveyor observed that the cooking surface of a six-burner stove had a thick layer of a black, shiny substance encrusted on the interior and exterior surfaces of all six of the burners and there was also a moderate amount of a thick, yellow dried substance that was also noted on the burners. The DSD stated that the stove was last cleaned on 12/23/22 and was required to be cleaned every 15 days. The DSD further stated that the stove would be cleaned this Friday, 01/06/23.
The surveyor requested that the DSD open the oven door that was beneath the six-burner stove. The DSD stated that the oven was not utilized by the facility. When the DSD opened the oven door, a cloth rag was noted on the top rack of the oven, and a cleaning utensil (scraper) was noted on the bottom rack of the oven. Both the inside of the oven door and the floor of the oven were heavily soiled with dried white and yellow food particles. The DSD removed the cloth rag and stated that it posed a potential fire hazard. [NAME] #2 who was present at that time, stated that she cleaned the inside of the oven on 01/01/23, and the rag was not there at that time.
On 01/12/23 from 12:25 PM to 1:05 PM, during a follow-up visit to the kitchen, the surveyor observed the following in the presence of the DSD:
The surveyor observed Dietary Aide (DA) #1, who wore a hair net that only covered her ponytail and left the top and anterior portion of her hair uncovered as she approached the food service line that was in process. When interviewed, DA #1 stated that her hair was covered, but the hair net must have slipped off. The DSD who was present, stated that DA #1's hair should have been completely covered by the hair net to prevent contamination on the food service line.
During an interview with the surveyor on 01/13/23 at 9:46 AM, the Infection Preventionist (IP) stated that if DA #1's hair was not fully covered by the hair net, hair could end up in the food or an entire container of food could become contaminated.
During an interview with the surveyor on 01/13/23 at 11:17 AM, the Dining Services District Manager (DSDM) stated that the six-burner stove top should have been cleaned daily. The Administrator who was present at that time stated, It was dirty. The DSDM then agreed to furnish the surveyor with the kitchen cleaning schedule.
At 11:57 AM, in a later interview with the DSDM, he stated that, There was no process in place for a cleaning schedule in the kitchen previously, but there should have been.
Review of the facility policy titled, Food: Preparation (Revised 09/17) revealed the following: Procedures: .Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use .The Cook(s) thaws frozen items that requires defrosting prior to preparation using one of the following methods: .Completely submerging the item under cold water (at a temperature of 70 degrees F or below) that is running fast enough to agitate and float loose ice particles;
Review of the facility policy titled, Use By Dating Guidelines (Rev. 12/01/15) revealed the following: Ready to eat*, Time/Temperature Control for Safety Foods included but were not limited to: .Produce Date With: Use by date seven days after opening .Meats, eggs, and other frozen items that are placed in the refrigerator to thaw: Poultry Use by date 1-2 days .
Review of the facility policy titled, Equipment (Revised 09/17), revealed the following: Policy Statement: All foodservice equipment will be clean, sanitary, and in proper working order. Procedures: All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. All staff members will be properly trained in the cleaning and maintenance of all equipment. All food contact equipment will be cleaned and sanitized after every use. All non-food contact equipment will be clean and free of debris. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed .
Review of the facility policy titled, Staff Attire (Revised 09/17) revealed the following: All employees wear approved attire for the performance of their duties. Procedure: All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained .

Based on observation, interviews, medical record review and other pertinent facility documentation, it was determined that the facility's Administrator failed to ensure that the facility was in compliance with the following regulatory requirements, which affected the safety of all the residents in the facility. The Administrator failed to ensure: 1.) immediate action was taken to initiate contact tracing upon the identification of a COVID positive staff member, Registered Nurse #1 (RN #1), who was symptomatic and provided care to 9 residents on 1 of 2 units and tested positive for COVID-19 while at work on 12/24/22, 2) conduct contact tracing to identify residents and staff who had close contact with symptomatic COVID-19 positive residents (Resident #33 and #235), 3.) a process was in place to conduct immediate resident and staff testing upon identification of a COVID-19 positive staff and residents, 4.) COVID-19 surveillance and monitoring were completed for the residents, 5.) the facility followed the relevant Centers for Disease Control and Prevention (CDC), Federal, and State guidance for infection control, and 6.) the facility's Outbreak Plan and COVID-19 policies were followed to prevent exposure and mitigate the spread of COVID-19, a deadly highly transmissible infectious disease.
The Administrator's failure to ensure facility wide infection control prevention standards, policies and procedures were implemented and immediately conduct contact tracing and testing upon the identification of COVID-19-positive staff and residents to prevent the spread of COVID-19, a contagious infectious and potentially deadly virus, posed a serious and immediate risk to the health and well-being of all staff and residents for contracting COVID-19. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 1/11/23. The removal plan was accepted and verified as implemented by the survey team during an onsite visit conducted on 1/12/23.
The IJ began on 11/15/22 when the former Director of Nursing (DON) who was primarily responsible for infection control left the facility without notice.
On 12/24/22 at 7:00 PM, RN #1 reported to work while sick with fever and cough, proceeded to provide care for 9 residents in 1 of 2 resident units, and tested positive for COVID-19 on 12/24/22 at 10:00 PM. The Infection Preventionist (IP) stated that the contact tracing policy was never initiated for the 9 residents on the RN's assignment. Three residents on the RN's assignment were immunocompromised and had a diagnosis of Human Immunodeficiency Virus (HIV) with prednisone (a glucocorticoid medication used to suppress the immune system and decrease inflammation) use, Sickle Cell Anemia (an inherited disease in which the red blood cells have an abnormal crescent shape, and block small blood vessels), Chronic Obstructive Pulmonary Disease (COPD, a condition involving constriction of the airways), 1 of the 3 immunocompromised residents was not vaccinated for COVID-19. Three additional residents were not vaccinated for COVID-19.
Additionally, two symptomatic residents tested positive in the facility on 1/1/23 and 1/2/23. There was no contact tracing or subsequent resident testing performed.
There were no consistent COVID-19 surveillance/assessments completed for the residents. The IP stated that she did not have a line list or notify the local health department of the positive cases. There was no screening or education provided to visitors entering the facility. The IP stated she was following the direction and guidance of the Administrator. The Administrator stated that she assumed that the IP was aware of her responsibilities and fulfilling her role as the IP.
Refer to F880L and F886L as it pertains to the facility's failure to ensure the implementation of infection control practices and precautions during an identified COVID-19 outbreak.
This deficient practice was evidenced by the following:
A review of the Administrator's job description provided by the facility revealed the following:
Manages all business related activity to achieve the organization's vision and supporting strategies and assures that the company image as an ethical and high quality provider of health services is maintained.
Communicates new Policy and Procedures and regulations to staff to ensure compliance.
Ensures that facility operations comply with local, state, and federal standards, laws, and licensing and certifying bodies.
Understands and uses company policies, procedures and compliance program to promote quality of care.
Develops all facility policies consistent with corporate guidelines.
During the entrance conference on 1/3/23 at 11:00 AM, the Infection Preventionist (IP), along with the DON, informed the surveyors there were two COVID-19-positive residents (Resident #33 and Resident #235) in the facility on the 2nd-floor unit. The IP stated she started in the facility in November and was responsible for staff development and infection control. The IP stated that the Administrator was currently on vacation.
On 1/4/23 at 9:18 AM, Surveyor #2 asked the DON for the facility line list (a table that contains key information about each case in an outbreak). The DON stated that there was no line list and that it had not been done since the prior DON had left. She stated she had started at the facility in December and was not aware there wasn't a line list until yesterday (1/3/23).
On 1/4/22 at 10:00 AM, Surveyor #1 reviewed the facility's COVID tracker (an internal tool that documents COVID-19 positive staff) titled COVID-19 Employee Detail, which revealed RN #1 was positive for COVID-19 on 12/24/22. An additional review revealed that the onset of symptoms was on 12/22/22 and the last day RN #1 worked was 12/24/22.
Surveyor #1 reviewed the COVID Tracker that included RN #1 with the DON and IP. The DON stated RN #1 tested positive for COVID-19 at work on 12/24/22 and had allergy symptoms that included sinus symptoms and headache, for a couple of days before. The DON stated RN #1 did not work on 12/22/22 and 12/23/22 and worked on 12/24/22 for the 7 pm to 7 am shift on the 2nd-floor unit. The DON further stated RN #1 should not have come in sick to work and should have tested before her shift. The DON stated she did not do contact tracing and would have to check the documentation for residents tested. The surveyor asked the IP about the line list for COVID-19 cases in the facility. The IP stated she was new, did not have access to everything, and was not sure of the line list. The IP confirmed the line list was not completed and was following up with the LHD about it. The IP stated the previous DON was completing the line list and was not sure of the date the previous DON had left.
During a telephone interview with Surveyor #1 On 1/4/23 at 11:57 AM, RN #1 stated she started feeling sick on 12/22/22 and called out sick to the Registered Nurse Supervisor (RNS) on 12/22/22 and 12/23/22. RN #1 stated she was running temperatures, had a cough, and reported to the RNS that she was not feeling well. She stated the RNS stated, ok and did not ask any further questions. RN #1 stated it was holiday time and if you call out before the holiday, you don't get time and a half.
RN #1 stated she went back to work on 12/24/22 and thought she was ok since she called her primary doctor who gave her antibiotics, and she also took Tylenol. RN #1 stated she still had a fever and cough symptoms when she went to work. RN #1 said she received report from the outgoing nurse, checked on her residents, and did her first medication administration pass before testing herself at 10:00 PM and tested positive for COVID-19. The surveyor asked if she had told anyone that she was not feeling well or about her symptoms on 12/24/22. RN #1 stated, Who was I gonna tell .there was no one . only nurses and she had called the DON at 10:00 PM after testing positive. RN#1 stated the DON told her that she had to go home and could not work as she tested positive for COVID-19. RN #1 said she gave report to the other nurse and went home. The surveyor asked RN #1 why she tested herself at 10:00 PM and not before that time. RN #1 replied that the outgoing nurses wanted to give report to go home, and she did not want to keep them waiting.
RN #1 stated that no one from the facility had called her to ask about contact tracing including residents she had contact with. RN #1 stated she had education about COVID-19 in 2020 and 2021 and acknowledged that the facility had stated if a staff member had symptoms or was COVID-19 positive that the staff member should not come to work.
On 1/4/23 at 11:54 AM, the IP provided the surveyor RN#1's timecard which revealed RN #1 worked on Saturday 12/24/22, clocked in at 7:00 PM, and clocked out at 10:45 PM.
On 1/4/23 at 12:38 pm, the IP provided the surveyor with the assignment of RN #1 on 12/24/22, which included 9 residents (Resident #236, #69, #239, #47, # 80, #63, #240, #238 and #52). The IP stated that the residents who were exposed were not tested and there was no documentation that the residents were tested. The IP stated she was new in training, but that she was responsible to ensure they were doing the correct thing and the residents should have been tested. Additionally, the IP stated that the contact tracing policy was not initiated.
A review of the medical records for the 9 residents that were assigned to RN #1 on 12/24/22, included three immunocompromised residents:
Resident #236 who had a diagnosis that included HIV, was receiving dialysis, and prednisone (a corticosteroid medication that suppresses the immune system and decreases inflammation) treatment;
Resident #240 who had a diagnosis that included Sickle Cell Anemia;
and Resident #238, who had a diagnosis that included COPD.
Four of the residents (Resident #236, #69, #239, and #47) were unvaccinated and 5 residents (Resident # 80, #63, #240, #238, and #52) were fully vaccinated according to the facility's resident COVID-19 vaccination matrix.
The COVID-19 Surveillance Assessment and progress notes relating to COVID-19 surveillance and monitoring for the 9 residents' electronic medical records were not consistent and were not completed every shift as per the facility's COVID-19 Clinical Monitoring and Measures Plan policy. The policy indicated a Screening UDA [User Defined Assessment] which included vital signs was to be completed every shift for residents in the affected unit (where a resident tested positive or positive employee worked).
On 1/4/23 at 12:53 PM, the IP provided to the surveyor a copy of the facility's Contact Tracing Worksheet, dated 10/05/2022, and COVID-19 Outbreak and Contact Tracing Tool, dated 10/19/22. The IP confirmed this was not initiated after positive staff and resident cases in the facility. The Contact Tracing Worksheet indicated the process for contract tracing when a positive COVID-19 case was identified, which included recording COVID-19 positive demographic and exposure data on the COVID-19 Outbreak and Contact Tracing Tool, identifying the first day of symptoms, determining where the symptomatic individual visited and others who were in close contact with the COVID-19 positive individual. The COVID-19 Outbreak and Contact Tracing tool was to be completed for staff and residents, included the COVID-19-positive individual's date of symptom onset, assignment for staff, room number for resident, potentially exposed individuals, if they were in close contact, for how long, and PPE (personal protective equipment, clothing or equipment worn to protect the person from infection) used during contacts.
On 1/4/23 at 1:05 PM, Surveyor #1 and Surveyor #2 interviewed the IP and the DON about the process of testing residents and staff, after a positive case. The IP stated testing should be twice a week, positive COVID results are logged in the computer's COVID tracker and there was a surveillance log in which results were written for staff testing. The IP stated there was no log for residents, positive results were found on the resident's medical record, and was not sure where negative results would be documented. The DON stated resident testing, whether positive or negative results, should be documented in the electronic medical record's progress notes. The surveyor requested from the DON and IP documentation of any resident testing conducted.
On 1/4/23 at 1:55 PM, Surveyor #1 interviewed the IP about the two COVID-19-positive residents in the facility. The IP stated the two residents were tested because they had symptoms. The IP stated she would check and provide information on contact tracing and resident testing.
A review of the progress notes provided by the IP revealed that Resident #235 had chills, muscle aches, cough, and tested positive for COVID-19 on 1/1/23, and Resident #33 had a sore throat with post-nasal drip and tested positive for COVID-19 on 1/2/23.
During a follow-up interview with Surveyor #2 on 1/5/23 at 10:58 AM and 12:03 PM, the IP stated there was no process in place to ensure resident testing was done. The IP stated contact tracing should have been done for COVID-19-positive residents and testing of residents in contact but was not done. The surveyor asked for the contact information of the LHD, and the IP handed an email address to the surveyor and stated that she did not have a phone number for the LHD and had not notified the LHD of any of the positive cases. She stated after the former DON left the facility, she was pulled into so many directions and was following the direction and guidance of the Administrator.
On 1/11/23 at 9:35 AM, the surveyor interviewed the DON who provided the infection control policy. The policies for isolation precautions, PPE, Infection Surveillance, outbreak investigations, and antibiotic stewardship had a review date of 7/2021. The DON stated she could not find the policy reviewed for the year 2022 and that the infection control policy was reviewed and approved in January 2023. The DON provided policies with an Annual Review page signed by the DON, Administrator, IP, and Medical Director, dated 1/9/2023.
During an interview with the surveyors on 1/11/23 at 10:05 AM, the Administrator stated that the former DON had left without notice in November and the IP had a solid week of training and spent a day with the Quality Assurance Consultant. She stated when the DON left, she had assigned the IP to be a Unit Manager on one of the units for oversight and she (the IP) should have been juggling everything. The Administrator stated she would let the IP know if something needed to be addressed and the IP was responsible for in-services, following up with tracking of covid positive residents, ensuring testing was being done, completing surveillance after a positive case, and checking the residents on the assignment after a positive staff case.
The Administrator stated she could not recall a positive staff case on 12/24/22. The surveyor informed the Administrator of RN #1, COVID-19 surveillance, and contact tracing concerns. The Administrator stated after a positive COVID-19 case, it was expected for the residents to be tested for COVID-19 and that staff was instructed not to come in to work when sick and to test before starting their shift. The Administrator further stated the LHD should have been notified after the first positive COVID-19 case and that the IP had a contact in the LHD but was not sure who. The Administrator acknowledged the facility's infection control policies and procedures should be reviewed annually and could not recall if the policy was reviewed in 2022. The Administrator stated the DON and herself were responsible for ensuring policies were reviewed.
The Administrator stated she was not aware that there was no line list and that there was no contact with the LHD. The Administrator stated she assumed the IP was doing what she was supposed to do and was not following up with her. She stated there was no team meeting held to discuss RN #1 testing positive on 12/24/22. The Administrator stated that she and the DON would be responsible for ensuring the IP was carrying out her responsibilities.
During an interview with Surveyor #1 on 1/13/23 at 8:45 AM, the Human Resource Director confirmed that the last day of the prior DON was on 11/15/22.
The surveyor reviewed the IP's competency checklist, a twelve page document, titled Infection Preventionist Orientation Plan and Skills Competency Checklist which was dated 11/4/22. Review of the checklist revealed 84 out of 92 tasks were not completed.
A review of the Job Description provided for the IP with a date of hire of 10/22/22 did not indicate her role and responsibilities as an IP.
A review of an undated facility's policy titled Outbreak Plan included the following: Under Testing, Refusal of Testing & Isolation/Cohorting, it read ProMedica Piscataway will continue to test healthcare personnel and residents for Covid-19 in accordance with CDC, CMS, and LHD guidelines.; Under Reporting Requirements, it read Any resident or staff suspected or diagnosed according to State-specific criteria shall be promptly reported to appropriate local and/or state health department officials, included but not limited to NHSN. The policies provided did not further address COVID-19 surveillance.
A review of the facility's policy titled COVID-19 Clinical Monitoring and Measures Plan, dated 10/10/22, indicated that when any employee tests positive or a resident (who was not previously being cared for in transmission based precautions [TBP]) tests positive for COVID-19, enhanced measures should be implemented. Enhanced measures included but were not limited to, a Screening UDA (User Defined Assessment) consisting of vital signs every shift for residents in the affected unit (where a resident tested positive or positive employee worked), identifying potential staff, visitor, and other resident prolonged exposure, notification to local department of health of any positive COVID-19 test results, and to refer to CDC Work Restrictions for HCP with SARS-CoV-2 Infection and Exposures to determine status of employee.
A review of the Centers for Medicare and Medicaid Services (CMS) directive QSO-20-38-NH, dated revised 09/23/22, included but was not limited to the definition of Close contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. Guidance - To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary. The testing summary included that for newly identified COVID-19 positive staff or resident in a facility that can identify close contacts, the facility should, regardless of vaccination status, test all staff that had a higher-risk exposure with a COVID-19 positive individual and test all residents who had a close contact with a COVID-19 positive individual. Testing during an outbreak revealed that upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. Documentation of testing revealed that upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested, the dates that staff and residents who tested negative are retested, and the results of all tests.
A review of CDC guidance Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, revised 9/23/22, indicated if healthcare-associated transmission is suspected or identified, facilities might consider expanded testing of HCP and patients as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. The guidance further indicated the following: A single new case of SARS-CoV-2 infection in any healthcare personnel (HCP) or resident should be evaluated to determine if others in the facility could have been exposed; The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission; Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status; Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5
NJAC 8:39- 19.1(a); 19.2(a)(c),8:39-27.1(a)

3) On 01/03/23 at 9:52 AM, during the initial tour of the kitchen, the surveyor observed the Dining Services Director (DSD) who touched the lid of a trash can with her bare hands as she attempted to open the lid after the foot pedal feature malfunctioned. The DSD then proceeded to wash her hands for 14 seconds before she began the tour of the kitchen.
During an interview with the surveyor on 01/04/23 at 8:40 AM, the DSD stated that when she washed her hands yesterday in the presence of the surveyor, she sang the happy birthday song once to ensure that she washed her hands for what she thought was the appropriate length of time of 20 seconds. The DSD further stated that if she did not wash her hands for at least 20 seconds prior to the tour of the kitchen there was a concern of contamination.
During an interview with the surveyor on 01/11/23 at 10:46 AM, the Administrator stated that if the DSD had not washed her hands for at least 20 seconds prior to the tour of the kitchen, She could have passed germs onto the food and all around the kitchen.
During an interview with the surveyor on 01/12/23 at 11:35 AM, the Infection Preventionist (IP) stated that the DSD should have washed her hands for 20 seconds prior to the tour of the kitchen to prevent the spread of infectious agents or bacteria.
On 01/12/23 at 12:25 PM, during a follow-up visit to the kitchen, the surveyor observed Dietary Aide (DA #1) who washed her hands for 32 seconds at the handwashing sink, left the water running in the sink, dried her hands on a paper towel, removed her hair net, and replaced it with a larger one that provided full coverage, as the one she wore only covered her ponytail, and not the front or top of her head. DA #1 then proceeded to turn off the faucet with her bare hands. When interviewed at that time, DA #1 stated that she knew that she should have used a paper towel to turn off the faucet, but she had forgotten to. The DSD who was present stated that there was a potential for contamination since DA #1 touched her hair, then touched the faucet with her bare hands. The DSD stated that DA #1's responsibilities included plating food on the food service line, which was in process during the time of the observation.
During an interview with the surveyor on 01/13/23 at 9:46 AM, the IP stated that DA #1 should have used a paper towel to turn off the faucet after she washed her hands because she re-contaminated her hands and that could have transferred to the faucet which had a potential for the spread of infection.
4) On 01/03/23 at 12:10 PM, the surveyor observed that a Dietary Aid (DA) delivered the food truck to Hall A of the Second Floor Nursing Station and proceeded to leave the unit.
At 12:11 PM, the surveyor observed Certified Nursing Assistant (CNA #4) as she approached the food truck and removed the first meal tray without first performing hand hygiene before she delivered the tray to Unsampled Resident #1. The resident requested a plastic cup. CNA #4 returned to the food truck, obtained a plastic cup, and provided it to the resident as requested. CNA #4 then exited the resident's room without first performing hand hygiene.
At 12:12 PM, the surveyor observed CNA #4 as she approached the food truck and reviewed Unsampled Resident #2's meal ticket before she poured coffee from a carafe into a coffee cup and placed it on the resident's tray. CNA #4 then proceeded to deliver the meal tray to the resident without first performing hand hygiene. The surveyor observed that CNA #4 did not offer to assist the resident with hand hygiene prior to the meal service. CNA #4 then exited the resident's room without first performing hand hygiene.
At 12:13 PM, the surveyor observed CNA #4 who removed Unsampled Resident #3's tray from the food truck without first performing hand hygiene. The resident was asleep when she entered the room and she attempted to wake the resident by calling the resident's name without success. CNA #4 left the tray at the bedside and exited the resident's room without first performing hand hygiene.
At 12:15 PM, the surveyor observed CNA #4 who removed Unsampled Resident #4's tray from the food truck without first performing hand hygiene and delivered it to the resident. CNA #4 offered the resident assistance and opened items on the tray. CNA #4 failed to offer the resident assistance to perform hand hygiene. CNA #4 exited the resident's room without first performing hand hygiene.
At 12:15 PM, CNA #4 removed Unsampled Resident #5's tray from the food truck without first performing hand hygiene. CNA #4 delivered the tray to the resident's room and placed the meal tray on the resident's counter. CNA #4 then informed the resident that she would return to offer meal assistance. CNA #4 exited the resident's room without first performing hand hygiene.
At 12:17 PM, the surveyor observed CNA #4 as she entered the nurse's station and phoned the kitchen to report a missing meal tray.
At 12:18 PM, the surveyor interviewed Unsampled Resident #1 who stated that he/she was not helped with hand hygiene prior to meal service. The resident further stated that he/she used their own personal hand sanitizer prior to the meal.
At 12:23 PM, the surveyor interviewed Unsampled Resident #2 who stated that he/she washed up in the morning but was not helped with hand hygiene prior to meal service. The surveyor did not see hand wipes or hand sanitizer on the resident's tray or within the resident's reach within the room.
At 12:27 PM, the surveyor interviewed CNA #4, who stated that she did not offer the residents assistance with hand hygiene prior to the meal because the residents had their own wipes. CNA #4 further stated that she did not perform hand hygiene prior to meal delivery or upon exiting the resident's rooms because there was no hand sanitizer in the halls or within the resident's rooms. CNA #4 stated that she would have to wash her hands in the resident's room and acknowledged that she did not do that today. CNA #4 stated that she washed her hands after she called the kitchen and before she went down to the kitchen to pick up a missing meal tray. CNA #4 stated that she worked at the facility for a couple of months and did not know that she was required to perform hand hygiene between residents during the meal pass. CNA #4 further explained that she did not offer Unsampled Resident #2 assistance with hand hygiene prior to meal service because the resident did not ask for assistance.
During an interview with the surveyor on 01/11/23 at 10:56 AM, the Administrator stated that CNA #4 should have provided the residents with hand sanitizer to clean their hands prior to meal service. She further stated that CNA #4 should have also sanitized her hands between residents or, she could have passed bugs to different people all day long. The Administrator explained that the residents could get sick if there was something on their hands while they ate. The Administrator stated that while there may not be hand sanitizer dispensers in the hallway, there were hand sanitizer dispensers in every resident room.
During an interview with the surveyor on 01/11/23 at 12:25 PM, the surveyor interviewed Registered Nurse (RN #2) who stated that she worked at the facility for a couple of months and confirmed that there were hand sanitizer dispensers in every resident room on the unit. RN #2 stated that CNA #4 was required to wash her hands prior to the meal service to prevent the spread of infection. RN #2 stated that CNA #4 should have also assisted the residents into the bathroom to wash their hands or offered them assistance to use the hand sanitizer dispensers that were positioned on the wall within the resident rooms. RN #2 stated that in order to prevent infection residents should have performed hand hygiene prior to meals.
During an interview with the surveyor on 01/11/23 at 12:31 PM, CNA #4 clarified that while there was no hand sanitizer in the hallways, there was hand sanitizer mounted on the wall within the resident rooms. CNA #4 stated, I told you before, I normally washed my hands every couple of rooms.
During an interview with the surveyor on 01/13/23 at 9:39 AM, the Infection Preventionist (IP) stated that CNA #4 should have washed her hands prior to meal service and sanitized her hands prior to exiting the resident's room. The IP stated that there was a possibility of the spread of infection between residents if hand hygiene was not performed. The IP stated that the residents should have been offered hand wipes or assisted into the bathroom to do hand hygiene before meal service. The IP further stated, Anything on the resident's hands could be put into their system and there was a potential for infection.
5) On 01/05/23 at 08:22 AM, the surveyor observed that there was a medication cart positioned outside of an Unsampled Resident's room on the Second Floor B Hall Nursing Unit. The surveyor observed Licensed Practical Nurse (LPN #2) who walked down the hallway from the direction of the nurse's station and presented to the medication cart. LPN #2 stated that she was an Agency Nurse and had only worked at the facility a couple of times prior on the eleven to seven shift. The surveyor observed that LPN #2 had not performed hand hygiene prior to accessing the computer keyboard, computer mouse, and medication cart as she reviewed the resident's medications and attempted to locate them. LPN #2 opened the top drawer of the cart, and the second and third drawers of the medication cart as she attempted to locate the resident's medications. LPN #2 poured three oral medications into a medication cup before she proceeded to open a new bottle of Polysaccharide Iron (mineral, used to treat iron deficiency) 150 mg, she removed the lid, and used a plastic utensil to remove the pill from the bottle and placed it into a medication cup. LPN #2 wrote the date on the bottle with a marker and returned the bottle to the top drawer of the medication cart. LPN #2 poured five additional oral medications before she opened a new bottle of Polyethylene glycol (used to treat constipation) 17 grams, and she used her fingers to remove the foil that covered the opening of the sealed bottle of medication. LPN #2 proceeded to measure one scoop of the medication into the cap of the medication, dated the bottle with a marker, and mixed the medication into a plastic cup that contained water. LPN #2 obtained a straw and placed it into the cup.
The surveyor observed that LPN #2 did not perform hand hygiene before she picked up the medications, knocked on the resident's door, awoke the resident, and adjusted the bed control to raise the head of the resident's bed prior to medication administration.
At 9:04 AM, LPN #2 returned to the medication cart and used hand sanitizer to perform hand hygiene with the hand sanitizer that was present on top of the medication cart.
At 9:16 AM, in a later interview with LPN #2, she stated that she had washed her hands after she administered medications to the last resident prior to the medication observation. LPN #2 stated that she then went to the medication room to look for a medication that she was not able to find. LPN #2 alleged that she used hand sanitizer to perform hand hygiene immediately prior to the medication pass with the hand sanitizer that was on top of the medication cart which was not observed by the surveyor. LPN #2 stated that there was a chance of contamination if hand hygiene was not performed before the medication pass after she touched the medication cart, computer keyboard, and computer mouse, and before she opened new bottles of medications. LPN #2 stated that she cleaned her cart and computer components prior to the start of her shift with bleach wipes which was not observed by the surveyor.
During an interview with the surveyor on 01/06/23 at 10:53 AM, the Licensed Practical Nurse/Charge Nurse (LPN/CN) #1 stated that hand hygiene should be performed prior to accessing the medication cart and prior to going to see the resident. LPN/CN #1 stated, You should sanitize your hands after you have touched something because you do not know what is on your hands, and that is why handwashing is so important.
During an interview with the surveyor on 01/11/23 at 11:00 AM, the Administrator stated that LPN #2 should have first sanitized her hands prior to medication preparation. The Administrator stated that she could have potentially made somebody sick by touching things, then touching medications. The Administrator stated that there could have been germs on the new bottles of medications that were opened. The Administrator stated that LPN #2 picked up germs from the bed controls which could have been transferred to the resident when the medications were administered. The Administrator further stated that the first thing LPN #2 should have done was to have prepared the resident, washed her hands, and then administered the medications in a sanitary manner.
During an interview with the surveyor on 01/12/23 at 11:38 AM, the Infection Preventionist (IP) stated that LPN #2 should have used hand sanitizer before she poured the medications and washed her hands before she entered the resident's room after she touched any surface in the resident's room, and before she exited the resident's room. The IP stated that there was a potential to spread an infectious agent and cross-contamination.
A review of the facility policy titled, Hand Hygiene (Reviewed 8/19/22), revealed the following: The hands are conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient, and from a staff member to a patient. Therefore, hand hygiene is the single most important procedure in preventing infection. To protect a patient from health care-associated infection, hand hygiene must be performed routinely and thoroughly .Washing with soap and water is appropriate when hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens (such as Clostridioides difficile (C-diff, results from disruption of normal healthy bacteria in the colon, often from antibiotics, and spreads from person to person by spores and can be fatal) .is strongly suspected or proven, and after using the restroom. Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; .after contact with a patient, (if the hands aren't visibly soiled); after removing gloves; and after contact with inanimate objects in the patient's environment. The CDC (Centers for Disease Control) recommends performing hand hygiene with soap and water before eating, and the WHO (World Health Organization) recommends using either an alcohol-based hand rub or soap and water before preparing food and handling medication. Handwashing: With your arms angled down under the faucet, adjust the water temperature until it's comfortably warm but not hot. Wet your hands and wrists with warm water and apply soap from dispenser .Hold your hands below elbow level to prevent water from running up your arms and back down, thus contaminating clean areas. Work up a generous lather by vigorously rubbing your hands together for at least 20 seconds .Pay special attention to the areas under your fingernails and around your cuticles and your thumbs, knuckles, and sides of your fingers and hands, because microorganisms thrive in these protected or overlooked areas .Avoid touching the sink and faucet because they're considered contaminated. Rinse your hands and wrists well, because running water flushes away suds, soiled and microorganisms. Pat your hands and wrists dry with a paper towel. Avoid rubbing, which can cause abrasion and chapping .Turn of the faucets with a paper towel to avoid recontaminating your hands. Hand sanitizing: Apply alcohol-based hand rub to the palm of one hand and then rub your hands together, covering all surfaces of your hands. Continue rubbing your hands together until all of the product has dried (usually about 30 seconds) .
Review of facility policy titled, Medication Administration: Medication Pass (06/21) revealed the following: Procedure: Perform hand hygiene .prepare medications for administration .
NJAC 8:39-19.1, 19.2 (a)(c), 19.4 (a)(g)
Based on observation, interview, and record review, it was determined that the facility failed to ensure: 1.) immediate action was taken to initiate contact tracing upon the identification of a COVID positive staff member, Registered Nurse #1 (RN #1), who was symptomatic and provided care to 9 residents on 1 of 2 units and tested positive for COVID-19 while at work on 12/24/22 2. 2) conduct contact tracing to identify residents and staff who had close contact with symptomatic COVID-19 positive residents (Resident #33 and #235) 3.) COVID-19 surveillance and monitoring were completed for the residents, 4.) the facility followed the relevant Centers for Disease Control and Prevention (CDC), Federal, and State guidance for infection control, and 5.) the facility's Outbreak Plan and COVID-19 policies were followed to prevent exposure and mitigate the spread of COVID-19, a deadly highly transmissible infectious disease.
The facility's system-wide failure to immediately conduct contact tracing upon the identification of COVID-19-positive staff and residents to prevent the spread of COVID-19, a contagious infectious and potentially deadly virus, posed a serious and immediate risk to the health and well-being of all staff and residents for contracting COVID-19. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 1/5/23 at 3:35 PM. The removal plan was accepted and verified as implemented by the survey team during an onsite visit conducted on 1/6/23.
The IJ situation began on 12/24/22 at 7:00 PM, when RN #1 reported to work while sick with fever and cough, proceeded to provide care for 9 residents in 1 of 2 resident units, and tested positive for COVID-19 on 12/24/22 at 10:00 PM. The Infection Preventionist (IP) stated that the contact tracing policy was never initiated for the 9 residents on the RN's assignment. Three residents on the RN's assignment were immunocompromised and had a diagnosis of Human Immunodeficiency Virus (HIV) with prednisone (a glucocorticoid medication used to suppress the immune system and decrease inflammation) use, Sickle Cell Anemia (an inherited disease in which the red blood cells have an abnormal crescent shape, and block small blood vessels), Chronic Obstructive Pulmonary Disease (COPD, a condition involving constriction of the airways). 1 of the 3 immunocompromised residents was not vaccinated for COVID-19. Three additional residents were not vaccinated for COVID-19.
Additionally, two symptomatic residents tested positive in the facility on 1/1/23 and 1/2/23. There was no contact tracing or subsequent resident testing performed.
There were no consistent COVID-19 surveillance/assessments completed for the residents. The IP stated that she did not have a line list or notify the local health department of the positive cases. There was no screening or education provided to visitors entering the facility. The IP stated she was following the direction and guidance of the Administrator.
This deficient practice was evidenced by the following:
Refer to F 886L
Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, revised 9/23/22, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements.
Reference: Centers for Disease Control and Prevention (CDC) guidance, Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, revised 9/23/22.
During the entrance conference on 1/3/23 at 11:00 AM, the Infection Preventionist (IP), along with the Director of Nursing (DON), informed the surveyors there were two COVID-19-positive residents (Resident #33 and Resident #235) in the facility on the 2nd-floor unit. The IP stated she started working in the facility in November and was responsible for staff development and infection control. The IP stated that the Administrator was currently on vacation.
On 1/4/23 at 9:18 AM, Surveyor #2 asked the DON for the facility line list. The DON stated that there was no line list and that it had not been done since the prior DON had left. She stated she had started at the facility in December and was not aware there was not a line list until yesterday (1/3/23).
On 1/4/23 at 10:00 AM, Surveyor #1 reviewed the facility's COVID tracker (an internal tool that documents COVID-19 positive staff) titled COVID-19 Employee Detail, which revealed RN #1 was positive for COVID-19 on 12/24/22. An additional review revealed that the onset of symptoms was on 12/22/22 and the last day RN #1 worked was 12/24/22.
During an interview with Surveyor #1 and Surveyor #2 on 1/4/23 at 11:05 AM, the IP, in the presence of the DON, stated the facility's infection control practice was based on the infection control manual and facility policies based on corporate, CDC guidelines and guidance from the Local Health Department (LHD). The IP stated COVID-19 testing was conducted twice a week and in between that time if someone was symptomatic. The IP stated the residents and staff were tested twice a week on Mondays and Thursdays.
Surveyor #1 reviewed the COVID Tracker that included RN #1 with the DON and IP. The DON stated RN #1 tested positive for COVID-19 at work on 12/24/22 and had allergy symptoms that included sinus symptoms and headache, for a couple of days before. The DON stated RN #1 did not work on 12/22/22 and 12/23/22 and worked on 12/24/22 for the 7 pm to 7 am shift on the 2nd-floor unit. The DON further stated RN #1 should not have come in sick to work and should have tested before her shift. The DON stated she did not do contact tracing and would have to check the documentation for residents tested. The surveyor asked the IP about the line list (a table that contains key information about each case in an outbreak) for COVID-19 cases in the facility. The IP stated she was new, and did not have access to everything, and was not sure of the line list. The IP confirmed the line list was not completed and was following up with the LHD about it. The IP stated the previous DON was completing the line list and was not sure of the date the previous DON had left.
Surveyor #2 requested the contact information for RN #1, timecards, and residents assigned to RN #1 on 12/24/22.
During a telephone interview with Surveyor #1 On 1/4/23 at 11:57 AM, RN #1 stated she started feeling sick on 12/22/22 and called out sick to the Registered Nurse Supervisor (RNS) on 12/22/22 and 12/23/22. RN #1 stated she was running temperatures, had a cough, and reported to the RNS that she was not feeling well. She stated the RNS stated, ok and did not ask any further questions. RN #1 stated it was holiday time and if you call out before the holiday, you don't get time and a half.
RN #1 stated she went back to work on 12/24/22 and thought she was ok since she called her primary doctor who gave her antibiotics, and she also took Tylenol. RN #1 stated she still had a fever and cough symptoms when she went to work. RN #1 said she received report from the outgoing nurse, checked on her residents, and did her first medication administration pass before testing herself at 10:00 PM and tested positive for COVID-19. The surveyor asked if she had told anyone that she was not feeling well or about her symptoms on 12/24/22. RN #1 stated, Who was I gonna tell .there was no one .only nurses and she had called the DON at 10:00 PM after testing positive. RN#1 stated the DON told her that she had to go home and could not work as she tested positive for COVID-19. RN #1 said she gave report to the other nurse and went home. The surveyor asked RN #1 why she tested herself at 10:00 PM and not before that time. RN #1 replied that the outgoing nurses wanted to give report to go home, and she did not want to keep them waiting.
RN #1 stated that no one from the facility had called her to ask about contact tracing including residents she had contact with. RN #1 stated she had education about COVID-19 in 2020 and 2021 and acknowledged that the facility had stated if a staff member had symptoms or was COVID-19 positive that the staff member should not come to work.
On 1/4/23 at 11:54 AM, the IP provided the surveyor RN#1's timecard which revealed RN #1 worked on Saturday 12/24/22, clocked in at 7:00 PM, and clocked out at 10:45 PM.
On 1/4/23 at 12:38 PM, the IP provided Surveyor #2 with the assignment of RN #1 on 12/24/22, which included 9 residents (Resident #236, #69, #239, #47, # 80, #63, #240, #238 and #52). The IP stated that the residents who were exposed were not tested and there was no documentation that the residents were tested. The IP stated she was new in training, but that she was responsible to ensure they were doing the correct thing and the residents should have been tested. Additionally, the IP stated that the contact tracing policy was not initiated.
A review of the medical records for the 9 residents that were assigned to RN #1 on 12/24/22, included three immunocompromised residents:
Resident #236 who had a diagnosis that included HIV, was receiving dialysis, and prednisone treatment;
Resident #240 who had a diagnosis that included Sickle Cell Anemia;
and Resident #238, who had a diagnosis that included COPD.
Four of the residents (Resident #236, #69, #239, and #47) were unvaccinated and 5 residents (Resident # 80, #63, #240, #238, and #52) were fully vaccinated according to the facility's resident COVID-19 vaccination matrix.
The COVID-19 Surveillance Assessment and progress notes relating to COVID-19 surveillance and monitoring for the 9 residents' electronic medical records were not consistent and were not completed every shift as per the facility's COVID-19 Clinical Monitoring and Measures Plan policy. The policy indicated a Screening UDA [User Defined Assessment] which included vital signs was to be completed every shift for residents in the affected unit (where a resident tested positive or positive employee worked).
On 1/4/23 at 12:53 PM, the IP provided Surveyor #2 a copy of the facility's Contact Tracing Worksheet, dated 10/05/2022, and COVID-19 Outbreak and Contact Tracing Tool, dated 10/19/22. The IP confirmed this was not initiated after positive staff and resident cases in the facility. The Contact Tracing Worksheet indicated the process for contract tracing when a positive COVID-19 case was identified, which included recording COVID-19 positive demographic and exposure data on the COVID-19 Outbreak and Contact Tracing Tool, identifying the first day of symptoms, determining where the symptomatic individual visited and others who were in close contact with the COVID-19 positive individual. The COVID-19 Outbreak and Contact Tracing tool was to be completed for staff and residents, included the COVID-19-positive individual's date of symptom onset, assignment for staff, room number for resident, potentially exposed individuals, if they were in close contact, for how long, and PPE used during contacts.
On 1/4/23 at 1:05 PM, Surveyor #1 and Surveyor #2 interviewed the IP and the DON about the process of testing residents and staff, after a positive case. The IP stated testing should be twice a week, positive COVID results are logged in the computer's COVID tracker and there was a surveillance log in which results were written for staff testing. The IP stated there was no log for residents, positive results were found on the resident's medical record, and was not sure where negative results would be documented. The DON stated resident testing, whether positive or negative results, should be documented in the electronic medical record's progress notes. Surveyor #1 requested from the DON and IP documentation of any resident testing conducted.
On 1/4/23 at 1:55 PM, Surveyor #1 interviewed the IP about the two COVID-19-positive residents in the facility. The IP stated the two residents were tested because they had symptoms. The IP stated she would check and provide information on contact tracing and resident testing.
A review of the progress notes provided by the IP revealed that Resident #235 had chills, muscle aches, cough, and tested positive for COVID-19 on 1/1/23, and Resident #33 had a sore throat with post-nasal drip and tested positive for COVID-19 on 1/2/23.
During an interview with Surveyor #1 on 1/5/23 at 10:42 AM, the RNS stated if someone said they were calling out sick or not feeling well, she would ask about their symptoms, how long, and when they last worked. The RNS could not recall if she received any callouts when working on 12/22/22 and 12/23/22. The surveyor asked the RNS if she was aware of a positive COVID-19 staff case on 12/24/22. The RNS stated she knew they had a case but does not know who it was. The RNS stated there was a schedule logbook where callouts are written.
During a follow-up interview with Surveyor #2 on 1/5/23 at 10:58 AM and 12:03 PM, the IP stated there was no process in place to ensure resident testing was done. The IP stated contact tracing should have been done for COVID-19-positive residents and testing of residents in close contact but was not done. The surveyor asked for the contact information of the LHD, and the IP handed an email address to the surveyor and stated that she did not have a phone number for the LHD and had not notified the LHD of any of the positive cases. She stated after the former DON left the facility, she was pulled into so many directions and was following the direction and guidance of the Administrator.
On 1/5/23 at 1:30 PM, the DON provided Surveyor #1 with the call-out log for December 2022. The call-out log was in calendar format, which included the employee's name written on the day the employee called out. RN #1's name was documented on the December 2022 call-out log for 12/22/22 and 12/23/22. There was no further information documented on the call-out log.
During an interview with the surveyors on 1/11/23 at 10:05 AM, the Administrator stated that the former DON had left without notice in November and the IP had a solid week of training and spent a day with the Quality Assurance Consultant. She stated when the DON left, she had assigned the IP to be a Unit Manager on one of the units for oversight and she (the IP) should have been juggling everything. The Administrator stated she would let the IP know if something needed to be addressed and the IP was responsible for in-services, following up with tracking of covid positive residents, ensuring testing was being done, completing surveillance after a positive case, and checking the residents on the assignment after a positive staff case.
The Administrator stated she could not recall a positive staff case on 12/24/22. The surveyor informed the Administrator of RN #1, COVID-19 surveillance, and contact tracing concerns. The Administrator stated after a positive COVID-19 case, it was expected for the residents to be tested for COVID-19 and that staff was instructed not to come in to work when sick and to test before starting their shift. The Administrator further stated the LHD should have been notified after the first positive COVID-19 case and that the IP had a contact in the LHD but was not sure who.
The Administrator stated she was not aware that there was no line list and that there was no contact with the LHD. The Administrator stated she assumed the IP was doing what she was supposed to do and was not following up with her. She stated there was no team meeting held to discuss RN #1 testing positive on

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review of facility documentation, it was determined that the facility failed to implement their protocol to monitor and track resident antibiotic use for the month of December 2022. This deficient practice was identified for 1 of 1 resident (Resident #52) reviewed for antibiotics and was evidenced by the following:
On 1/9/23 at 9:10 AM, the surveyor asked the DON and IP to provide information on Antibiotic Stewardship tracking and surveillance.
On 1/10/23 at 9:25 AM, the DON provided the surveyor with the facility's Antibiotic Stewardship Report (an automated report generated from the information entered about initial resident infection trends). A review of the provided Antibiotic Stewardship Report, dated 1/9/23, indicated the monthly data for antibiotic use and infections from 12/1/22 to 12/31/22. The report did not detail any further information regarding specific residents, type of organisms, diagnostic tests, treatments, or durations of antibiotics. The surveyor asked the DON to provide further information regarding their Antibiotic and Infection tracking.
The surveyor reviewed the hybrid medical records of Resident #52 who was being reviewed for antibiotic medication use, which revealed the following:
The admission Minimum Data Set (MDS) assessment, dated 12/7/22, which indicated the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). The resident scored a 15 out of 15 which indicated that that the resident was cognitively intact. The MDS assessment also indicated the resident had active diagnoses of chronic frontal sinusitis and other local infections of the skin and subcutaneous tissue.
A review of the Order Summary Report and the electronic Medication Administration Record (eMAR) indicated Resident #52 had a physician order, dated 12/10/22, which read: Ertapenem [an antibiotic medication] Sodium Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for Sinus Infection until 01/11/2023.
The eMAR also had a physician order entry, discontinued date on 12/10/22 that read: Ertapenem [an antibiotic medication] Sodium Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for Sinus Infection until 01/11/2023.
On 1/10/23 at 9:45 AM, the DON provided the surveyor with the facility's Infection Detail Report for Excel (a report that provides comprehensive information on residents with infections), which was dated 1/9/23. A review of the Infection Detail Report listed residents with infections from 12/1/22 to 12/31/22, which included documentation of their symptoms, diagnostic tests (if any completed), antibiotic medications and other treatments administered, and duration of the prescribed treatment. Resident #52, who was being reviewed for antibiotic medication use, was not listed on the report.
On 1/10/23 at 10:33 AM, the surveyor interviewed the DON about antibiotic stewardship and that Resident #52 was not listed on the report. The DON stated the IP was educated yesterday about the Antibiotic Stewardship tracking and the Infection Detail Report for December 2022 was completed yesterday.
On 1/10/23 at 1:08 PM, the surveyor interviewed the IP about Antibiotic Stewardship. The surveyor asked the IP about antibiotic surveillance and tracking process. The IP stated during morning interdisciplinary meetings new admissions and residents with changes in conditions are reviewed to determine residents with infections or antibiotic treatment. The IP acknowledged the [DATE] Antibiotic Stewardship reports were completed yesterday (1/9/23). The IP stated the December 2022 tracking report was updated to include Resident #52 and the report for January 2023 was currently in progress. The IP stated she was aware it had to be done and that it was her responsibility as IP. The IP further stated that she did not finish her orientation and was not aware how to complete it until she was trained yesterday by the Interim DON.
On 1/12/23 at 1:54 PM, the surveyor informed the Administrator, Quality Assurance Consultant (QAC) #1, QAC #2, and Regional Director of Operations of the concerns for the Antibiotic Stewardship tracking for December 2022 not being completed. The facility provided no additional information.
A review of the facility's Infection Control Manual policy, dated 07/10/2021 included the following: Under Surveillance, Section 2: Monthly Surveillance, Monthly Infection Surveillance Tracking and Trending read, Information about infections is gathered, monitored and tracked throughout the month .The data entered generates surveillance reports which are reviewed by the Infection Preventionist for trend identification including trends that may require initiating outbreak investigations .The Infection Preventionist monitors types of infections, symptoms, location, onset date, cultures, swabs and X-rays taken including dates and results, the type of precautions, treatment interventions initiated and the date the infection is resolved. Any patient/resident placed on antibiotics for reasons other than prophylactic i.e., pre-surgical, pre-dental procedures or non-transmissible disease conditions, should be counted on Surveillance Tracking.
A review of the facility titled, Antibiotic Stewardship, dated 07/2021, indicated under Leadership Commitment, QMS trend reports submitted by Infection Preventionist to Antibiotic Stewardship Committee and/or QAPI/Infection Control Committees for review and consideration include: Antibiotic Stewardship Report, Infection Rate Report, Infection Detail Report, Question Response Drill Down Report and Monthly Infection Control Analysis Report.
NJAC 8:39-19.4(d)(g)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure resident representatives were informed of a newly confirmed COVID-19 diagnosis of a staff member in the facility by 5 PM the next calendar day. This deficient practice was identified for 1 of 1 staff who tested positive for COVID-19 (Registered Nurse #1) and was evidenced by the following:
During the entrance conference on 1/3/23 at 11:00 AM, the surveyor requested the process of notification of confirmed and suspected COVID-19 cases to residents and resident representatives.
On 1/4/22 at 10 AM, Surveyor #1 reviewed the facility's COVID tracker (an internal tool that documents COVID-19 positive staff) titled COVID-19 Employee Detail, which revealed RN #1 was positive for COVID-19 on 12/24/22.
On 1/5/23 at 10:01 AM, the DON informed Surveyor #2 that COVID-19 positive results for staff and residents were entered into the facility's COVID tracker and would trigger automated (robo) calls to resident representatives. The DON further stated they started making flyers to notify the residents in the facility.
On 1/9/23 at 12:30 PM, the IP provided the surveyor a report of automated calls made to resident representatives about the COVID case on 12/24/22.
A review of the untitled report of automated calls for the notification of resident representatives regarding the 12/24/22 COVID-19 positive case revealed the automated calls were dated as assigned on 12/27/22. The report included the resident's name their resident representative and indicated if a call was answered.
On 1/11/23 9:35 AM, the surveyor interviewed the DON about the automated call report that was dated 12/27/22 for notification to residents' representatives about the COVID-19 case on 12/24/22. The DON was unable to provide any additional documentation that resident representatives were notified by 12/25/22 at 5 PM when the new COVID-19 positive case was confirmed on 12/24/22. The DON stated the most recent report for automated calls was on 12/27/22. The DON further stated it was the holiday and the automated calls go out once results were submitted to the facility's COVID tracker.
During an interview with the surveyor on 1/11/23 at 10:05 AM, the Administrator stated resident representatives would be notified of COVID-19 cases in the facility by automated calls. The Administrator stated it was expected for resident representatives to be notified by the next day. The surveyor informed the Administrator of the concern that the report of the automated calls indicated that resident representatives were notified on 12/27/22 about the COVID-19 case on 12/24/22. The Administrator acknowledged notification was delayed and stated it was because of the holiday.
During an interview with the surveyor on 1/12/23 at 10:46 AM, IP stated once COVID-19 cases were entered into the COVID tracker, it triggered automated calls for notification. The IP stated she was responsible for entering COVID-19 positive cases into the COVID tracker. The IP confirmed the COVID-19 case was entered into the COVID tracker on 12/27/22, after the holiday weekend when she returned to work.
On 1/12/23 at 1:54 PM, the surveyor informed the Administrator, Quality Assurance Consultant (QAC) #1, QAC #2, and Regional Director of Operations about the concern of timely notification of COVID-19 cases in the facility and notification for COVID-19 case on 12/24/22 was on 12/27/22. No further information was presented to the surveyor.
The surveyor reviewed the facility policy titled, Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff, dated 1/27/2021. Under Procedure, 3. Positive COVID test results must be entered into the COVID Tracker as soon as received, seven days a week, to meet the requirement of calls being made by 5 pm the next calendar day following the occurrence.
NJAC 8:39-5.1 (a)

Based on interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure: 1.) a symptomatic Registered Nurse #1 (RN #1) notified the supervisor, prior to the start of her shift on 12/24/22 that she was ill, 2.) a process was in place to conduct immediate resident and staff testing upon identification of a COVID-19 positive staff member (RN #1) who provided care to 9 residents on 1 of 2 units while working on 12/24/22, and for two residents who tested positive for COVID-19 (Residents #33 and #235) 3.) the facility followed the relevant Centers for Disease Control and Prevention (CDC), Federal, and State guidance for infection control, and 4.) the facility's Outbreak Plan and COVID-19 policies were followed to prevent exposure and mitigate the spread of COVID-19, a deadly, highly transmissible infectious disease.
The facility's system-wide failure to immediately conduct COVID-19 testing upon the identification of COVID-19-positive staff and residents to prevent the spread of COVID-19, a contagious infectious and potentially deadly virus, posed a serious and immediate risk to the health and well-being of all staff and residents for contracting COVID-19. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 1/5/23 at 3:35 PM. The removal plan was accepted and verified as implemented by the survey team during an onsite visit conducted on 1/6/23.
The IJ situation began on 12/24/22 at 7:00 PM, when RN #1 reported to work while sick with fever and cough, proceeded to provide care for 9 residents in 1 of 2 resident units, and tested positive for COVID-19 on 12/24/22 at 10:00 PM. The Infection Preventionist (IP) stated there was no process in place to test the residents and staff. There was no evidence that the facility tested the 9 residents the RN had on her assignment. Three residents on the RN's assignment were immunocompromised and had a diagnosis of Human Immunodeficiency Virus (HIV) with prednisone use, Sickle Cell Anemia, and Chronic Obstructive Pulmonary Disease (COPD). 1 of the 3 immunocompromised residents was not vaccinated for COVID-19. Three additional residents were not vaccinated for COVID-19.
Additionally, two symptomatic residents tested positive in the facility on 1/1/23 and 1/2/23. There was no subsequent resident testing performed.
This deficient practice was evidenced by the following:
Refer to 880L
Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, revised 9/23/22, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements
During the entrance conference on 1/3/23 at 11:00 AM, the IP, along with the Director of Nursing (DON), informed the surveyors that there were two COVID-19-positive residents (Resident #33 and Resident #235) in the facility on the 2nd-floor unit. The IP stated she started in the facility in November and was responsible for staff development and infection control. The IP stated that the Administrator was currently on vacation.
On 1/4/22 at 10:00 AM, Surveyor #1 reviewed the facility's COVID tracker (an internal tool that documents COVID-19 positive staff), titled COVID-19 Employee Detail which revealed RN #1 was positive for COVID-19 on 12/24/22. An additional review revealed that the onset of symptoms was on 12/22/22 and the last day the RN #1 worked was 12/24/22.
During an interview with Surveyor #1 and Surveyor #2 on 1/4/23 at 11:05 AM, the IP, in the presence of the DON, stated the facility's infection control practice was based on the infection control manual and facility policies based on corporate, CDC guidelines and guidance from the Local Health Department (LHD). The IP stated COVID-19 testing was conducted twice a week and in between that time if someone was symptomatic. The IP stated the residents and staff were tested twice a week on Mondays and Thursdays.
Surveyor #1 reviewed the COVID Tracker which included RN #1 with the DON and IP. The DON stated RN #1 tested positive for COVID-19 at work on 12/24/22 and had allergy symptoms that included sinus symptoms and headache, for a couple of days before. The DON stated RN #1 did not work on 12/22/22 and 12/23/22 and worked on 12/24/22 for the 7 pm to 7 am shift on the 2nd-floor unit. The DON further stated RN #1 should not have come in sick to work and should have tested before her shift. The DON stated she did not do contact tracing and would have to check the documentation for residents who were tested.
During a telephone interview with Surveyor #1 On 1/4/23 at 11:57 AM, RN #1 stated she started feeling sick on 12/22/22 and called out sick to the Registered Nurse Supervisor (RNS) on 12/22/22 and 12/23/22. RN #1 stated she was running temperatures, had a cough, and reported to the RNS that she was not feeling well. She stated the RNS stated, ok and did not ask any further questions. RN #1 stated it was holiday time and if you call out before the holiday, you don't get time and a half.
RN #1 stated she went back to work on 12/24/22 and thought she was ok since she called her primary doctor who gave her antibiotics, and she also took Tylenol. RN #1 stated she still had a fever and cough symptoms when she went to work. RN #1 stated she received report from the outgoing nurse, checked on her residents, did her first medication administration pass before testing herself at 10:00 PM, and tested positive for COVID-19. The surveyor asked if she had told anyone that she was not feeling well or about her symptoms on 12/24/22. RN #1 stated, Who was I gonna tell .there was no one .only nurses and she had called the DON at 10:00 PM after testing positive. RN#1 stated the DON told her that she had to go home and could not work as she tested positive for COVID-19. RN #1 said she gave report to the other nurse and went home. The surveyor asked RN #1 why she tested herself at 10:00 PM and not before that time. RN #1 replied that the outgoing nurses wanted to give report to go home, and she did not want to keep them waiting.
RN #1 stated that no one from the facility had called her to ask about contact tracing including residents she had contact with. RN #1 stated she had education about COVID-19 in 2020 and 2021 and acknowledged that the facility had stated if a staff member had symptoms or was COVID-19 positive that the staff member should not come to work.
On 1/4/23 at 11:54 AM, the IP provided the surveyor RN #1's timecard which revealed RN #1 worked on Saturday 12/24/22, clocked in at 7:00 PM, and clocked out at 10:45 PM.
On 1/4/23 at 12:38 PM, the IP provided the surveyor with the assignment of RN #1 on 12/24/22, which included 9 residents (Resident #236, #69, #239, #47, # 80, #63, #240, #238 and #52). The IP stated that the residents who were exposed were not tested and that there was no documentation that the residents were tested. The IP stated she was new in training, but that she was responsible to ensure they were doing the correct thing and the residents should have been tested.
A review of the medical records for the 9 residents that were assigned to RN #1 on 12/24/22, included three immunocompromised residents:
Resident #236 who had a diagnosis that included HIV, was receiving dialysis, and prednisone (a corticosteroid medication that suppresses the immune system and decreases inflammation) treatment;
Resident #240 who had a diagnosis that included Sickle Cell Anemia;
and Resident #238, who had a diagnosis that included COPD.
Four of the residents (Resident #236, #69, #239, and #47) were unvaccinated and 5 residents (Resident # 80, #63, #240, #238, and #52) were fully vaccinated according to the facility's resident COVID-19 vaccination matrix.
On 1/4/23 at 1:05 PM, Surveyor #1 and Surveyor #2 interviewed the IP and the DON about the process of testing residents and staff, after a positive case. The IP stated testing should be twice a week, positive staff COVID results are logged in the computer's COVID tracker and there was a surveillance log in which results were written for staff testing. The IP stated there was no log for residents, positive results were found on the resident's medical record, and she was not sure where negative results would be documented. The DON stated resident testing, whether positive or negative results, should be documented in the electronic medical record's progress notes. The surveyor requested from the DON and IP documentation of any resident testing conducted.
On 1/4/23 at 1:55 PM, Surveyor #1 interviewed the IP about the two COVID-19-positive residents in the facility. The IP stated the two residents were tested because they had symptoms. The IP stated she would check and provide information on contact tracing and resident testing.
A review of the progress notes provided by the IP revealed that Resident #235 had chills, muscle aches, and cough, and tested positive for COVID-19 on 1/1/23, and Resident #33 had a sore throat with post-nasal drip and tested positive for COVID-19 on 1/2/23.
During an interview with Surveyor #1 on 1/5/23 at 10:42 AM, the RNS stated if someone said they were calling out sick or not feeling well, she would ask about their symptoms, how long, and when they last worked. The RNS could not recall if she received any callouts when working on 12/22/22 and 12/23/22.
During a follow-up interview with Surveyor #2 on 1/5/23 at 10:58 AM and 12:03 PM, the IP stated there was no process in place to ensure resident testing was done. The IP stated contact tracing should have been done for the COVID-19-positive residents and testing of residents in contact but was not completed. She stated after the former DON left the facility, she was pulled into so many directions and was following the direction and guidance of the Administrator.
During an interview with the surveyors on 1/11/23 at 10:05 AM, the Administrator stated that the former DON had left without notice in November and the IP had a solid week of training and spent a day with the Quality Assurance Consultant. She stated when the DON left, she had assigned the IP to be a Unit Manager on one of the units for oversight and she (the IP) should have been juggling everything. The Administrator stated she would let the IP know if something needed to be addressed and the IP was responsible for in-services, following up with tracking of covid positive residents, ensuring testing was being done, completing surveillance after a positive case, and checking the residents on the assignment after a positive staff case.
The Administrator stated she could not recall a positive COVID-19 staff case on 12/24/22. The surveyor informed the Administrator of RN #1, COVID-19 surveillance, and contact tracing concerns. The Administrator stated after a positive COVID-19 case, it was expected for the residents to be tested for COVID-19 and that staff was instructed not to come in to work when sick and to test before starting their shift.
The Administrator stated she assumed the IP was doing what she was supposed to do and was not following up with her. She stated there was no team meeting held to discuss RN #1 testing positive on 12/24/22. The Administrator stated that she and the DON would have been responsible for ensuring the IP was carrying out her responsibilities.
During an interview with Surveyor #1 and Surveyor #2 on 1/13/23 at 9:13 AM, the Medical Director stated he was made aware of the COVID-19 tracking and testing concerns. The Medical Director stated that the facility followed CDC and CMS guidelines for policies and was unaware they were not being followed. The Medical Director stated he was always made aware of positive COVID-19 cases in the facility and testing of residents should be based on contact tracing.
The surveyor reviewed the IP's competency checklist, a twelve page document, titled Infection Preventionist Orientation Plan and Skills Competency Checklist which was dated 11/4/22. Review of the checklist revealed 84 out of 92 tasks were not completed.
A review of the Job Description provided for the IP with the date of hire of 10/22/22, did not indicate her role and responsibilities as an IP.
A review of the Centers for Medicare and Medicaid Services (CMS) directive QSO-20-38-NH, dated revised 09/23/22, included but was not limited to the definition of Close contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. Guidance - To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary. The testing summary included that for newly identified COVID-19 positive staff or resident in a facility that can identify close contacts, the facility should, regardless of vaccination status, test all staff that had a higher-risk exposure with a COVID-19 positive individual and test all residents who had a close contact with a COVID-19 positive individual. Testing during an outbreak revealed that upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. Documentation of testing revealed that upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested, the dates that staff and residents who tested negative are retested, and the results of all tests.
A review of an undated facility's policy titled Outbreak Plan included the following: Under Evidence-Based Outbreak Response Measures, it revealed, if a new/reemergence of an infectious disease is detected, ProMedica Piscataway will follow its Infection Control policies and the measures and procedures set forth by the CDC, CMS, and LHD for guidelines and directives. Under Testing, Refusal of Testing & Isolation/Cohorting, it read ProMedica Piscataway will continue to test healthcare personnel and residents for Covid-19 in accordance with CDC, CMS, and LHD guidelines.; Under Reporting Requirements, it read Any resident or staff suspected or diagnosed according to State-specific criteria shall be promptly reported to appropriate local and/or state health department officials, included but not limited to NHSN. The policies provided did not further address COVID-19 surveillance.
A review of the facility's policy titled COVID-19 Clinical Monitoring and Measures Plan, dated 10/10/22, indicated that when any employee tests positive or a resident (who was not previously being cared for in transmission based precautions [TBP]) tests positive for COVID-19, enhanced measures should be implemented. Enhanced measures included but were not limited to, a Screening UDA [User Defined Assessment] consisting of vital signs every shift for residents in the affected unit (where a resident tested positive or positive employee worked), identifying potential staff, visitor, and other resident prolonged exposure, notification to local department of health of any positive COVID-19 test results, and to refer to CDC Work Restrictions for HCP with SARS-CoV-2 Infection and Exposures to determine status of employee.
A review of the facility's policy titled Testing Criteria Summary, dated 10/05/22, for newly identified COVID-19 positive staff or resident (not in TBP) in a facility/community that can identify close contacts included: For newly identified COVID-19 positive staff or resident in a facility that can identify close contacts, the facility should, regardless of vaccination status, test all staff that had a higher-risk exposure with a COVID-19 positive individual and test all residents who had a close contact with a COVID-19 positive individual and testing frequency should be performed Day 1, 3, and 5 unless a positive result is obtained.
NJAC 8:39- 19.1(a); 19.2(a)(c)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that staff wear the appropriate personal protective equipment (PPE) for residents on contact plus airborne isolation, to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice.
This deficient practice was identied for 3 of 3 residents (Residents #18, #22, and #27) reviewed for infection control practices and was evidenced by the following:
On 10/08/2020 at 8:10 AM, as Surveyor #1 entered the facility's conference room, a notice was left from the Administrator that the facility had a positive employee who worked on the second floor, and that after consultation with the local health department, the facility was on outbreak status with full house precautions for both floors in the facility.
During an interview with Surveyor #1 on 10/08/2020 at 8:30 AM, the Administrator stated that the staff were to wear N95 masks, face shields and gowns when entering resident rooms on both floors.
On 10/08/2020 at 9:40 AM, on the 3rd floor, Surveyor #2 observed a Certified Nursing Assistant (CNA) #1 delivering breakfast trays to the residents. CNA #1 entered Resident #18's room with a breakfast tray, wearing a N95 mask, gloves and face shield. There was a yellow sign on door. The yellow sign read Patient-Specific Contact Plus Airborne Precautions, wear a N95/approved KN95 Respirator, Gown, Face Shield and gloves upon entering this room. CNA #1 then entered Resident #27's room with a breakfast tray, wearing a N95 mask, gloves and face shield. There was a yellow sign on the door. The yellow sign read Patient-Specific Contact Plus Airborne Precautions, wear a N95/approved KN95 Respirator, Gown, Face Shield and gloves upon entering this room. CNA #1 then entered Resident #22's room with a breakfast tray, wearing a N95 mask, face shield, and gloves. There was a yellow sign on door. The yellow sign read Patient-Specific Contact Plus Airborne Precautions, wear a N95/approved KN95 Respirator, Gown, Face Shield and gloves upon entering this room.
On 10/08/2020 at 9:46 AM, as CNA #1 was exiting Resident # 22's room, Surveyor #2 asked CNA #1 what the yellow sign on the door meant. She stated that the yellow sign meant you must wear a gown, gloves, mask, and face shield when you are giving care. CNA #1 stated she was only passing trays and was told by her supervisor that she did not need to wear a gown while passing trays.
During an interview with Surveyor #2 on 10/08/2020 at 9:47 AM, the Clinical Supervisor (CS) stated that the yellow signs meant that upon entering the room, full Personal Protective Equipment (PPE), a face shield, a N95 mask, gloves, and gown should be worn to protect yourself and the resident from spreading the infection.
On 10/08/2020 at 9:48 AM, the CS stopped CNA #1 from entering another room and told her that she needed to wear a gown upon entering the room, even if she was just passing trays.
During an interview with the surveyors on 10/13/2020 at 1:11 PM, the Infection Control Nurse (ICN) stated that all staff were aware they must follow the directions on the yellow sign. This would include donning (putting on) full PPE: a mask, a face shield, gown, and gloves, from the moment the room was entered. The ICN stated while delivering trays, full PPE must be worn to prevent the spread of an infection.
Review of the facility's Infection Control Policies and Procedures IC405 COVD-19 policy, revised 10/01/2020, revealed that Airborne Precautions was defined as wearing an N95/approved KN95 respirator upon entry into the patient's room to prevent the development and transmission of COVID-19.
Review of the facility's Infection Control Policies and Procedures, IC304 Infectious Disease and Transmission Based Precautions policy, reviewed 11/15/2019, revealed that the appropriate types and duration of Transmission Based Precaution would be followed based on patient's condition, Center for Disease Control and Prevention (CDC) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in HealthCare Settings. Purpose: To prevent the spread of infection/infectious disease.
Review of the facility's Infection Control Policies and Procedures, IC400 Infectious Disease Management policy, revised 11/15/2019, revealed that Emerging/Novel Organisms/Infections: Manage care according to Centers for Disease Prevention and Control (CDC) and state/local health department recommendations to prevent the transmission of infectious diseases.
NJAC 8:39-19.4(a)(1-2)(c)

Based on observation, interview, and review of facility documentation provided, it was determined that the facility failed to maintain proper kitchen sanitation practices, store dry foods in a safe and sanitary environment to prevent the development of food borne illness, and maintain 2 of 3 ice machines used for residents in a sanitary manner.
The deficient practice was observed and was evidenced by the following:
On 10/06/2020 at 9:25 AM, during the initial tour of the kitchen in the presence of the Food Service Director (FSD), the surveyor observed the following:
1. On the drying rack, there were 20 multiple sized serving trays/pans nestled on top of each other. The surveyor asked the FSD to separate the trays/pans and observed moisture between them. The FSD stated the pans should be separated to allow for proper drying to prevent bacteria growth.
2. On the drying rack, there were multiple different colored cutting boards drying. The surveyor asked the FSD to pull out the cutting boards. There were three white cutting boards that had multiple gouges and contained a black substance. The FSD stated that they should not be used because they could contain bacteria and get someone sick. The FSD threw the three white cutting boards in the trash.
3. In the dry storage room, there were paper coffee filters on the top shelf of a storage rack, open to air. The FSD stated that they should not be open to air because dust could contaminate them.
4. In the dry storage room, there was an opened container of pink peppercorns with a handwritten date of 04/18/2019 and an opened container of coriander with a handwritten date of 10/12/2018. The FSD stated that the facilities use by policy was that the spices were good for 6 months after the date they were opened.
5. In the dry storage room, there was a Styrofoam cup inside the sugar storage bin which directly touched the sugar. The FSD stated that it should not be there because the surface could be contaminated. The FSD stated that staff should get a clean scoop to get what they need out of the bin and then the scoop should be removed and washed. It should not be stored in the bin.
On 10/08/2020 at 8:52 AM, during a tour of the kitchen with the FSD, the surveyor observed the following:
1. The ceiling vents over the drying rack and over the pot sink had dust build up on the vents. The FSD stated the vents should be kept clean because dust could contaminate the clean dishware on the drying rack.
2. On the drying rack, there were 3 cambro containers nested on top of each other. The FSD separated the containers and there was water between them. The FSD stated that water should not be there because bacteria could grow. The containers should be separated to allow proper drying.
On 10/08/2020 at 10:04 AM, upon examination of the residents' ice machine, located on the 2nd floor Power Bar, the surveyor observed a white and brown substance around the dispensing portion of the ice machine, a white substance around the back portion of the machine, and a brown moist substance in the base of the machine.
During an interview with the surveyor on 10/08/2020 at 10:15 AM, the maintenance employee stated that housekeeping was responsible for the daily cleaning of the ice machines, but they should notify maintenance if they cannot get the machine clean.
Review of the Ice Machine Quarterly Check log, located on the side of the ice machine, revealed documentation that the ice machine was last checked 07/01/2020.
On 10/08/2020 at 10:20 AM, the surveyor and maintenance employee inspected the residents' ice machine located on the 3rd floor Power Bar. The surveyor observed a white, pink and brown substance around the dispensing portion of the ice machine, a white substance around the back portion of the machine, and a brown moist substance in the base of the machine.
Review of the Ice Machine Quarterly Check log, located on the side of the ice machine, revealed the ice machine was last checked 04/05/2020. The maintenance employee stated that he changed the filters in July but did not sign the log. He stated that the ice machine should be kept clean because bacteria could grow and make the residents sick.
On 10/08/2020 at 10:35 AM, during an interview with the surveyor, the 3rd floor Housekeeper (HK) stated that housekeeping was supposed to wipe down the countertop, the ice maker, cabinets, and microwave in the Power Bar Area. The HK stated that he did not clean the Power Bar area yet today. He stated that the ice machine was not clean and did not look like it was cleaned recently. The HK stated the he would wipe down, clean, and sanitize the ice machine, but if he could not get it cleaned, he would unplug it and report it to his supervisor because people could get sick if the ice machine was dirty.
During an interview with the surveyor on 10/08/2020 at 10:38 AM on the 3rd floor, the Environmental Services Director (ESD) stated that he was the director for maintenance and housekeeping. The ESD stated that housekeeping cleans the ice machines daily and that maintenance should inspect the ice machines monthly to make sure they were clean and working properly. The ESD stated he did daily checks to make sure that the maintenance and housekeeping staff were doing what they were supposed to do. He stated that he noticed that the ice machines on the 2nd and 3rd floor did not look clean the day before and that he needed CLR to clean them, but the facility was out of it.
Review of the facility's Food and Nutrition Services Use By Dating Guidelines policy, revised on 12/01/2015, revealed liquids/flavorings: Use by date six months after opening and properly closed.
Review of the facility's Food Storage: Dry Goods policy, revised date 09/2017, revealed: Policy Statement: All dry goods will be appropriately stored in accordance with the FDA Food Code. Procedures: 5. All packaged and canned food items will be kept clean, dry and properly sealed, 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate.
Review of the facility's Warewashing policy, revised 09/2017, revealed Procedures: 1. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine and proper handling of sanitized dishware, 4. All dishware will be air dried and properly stored.
Review of the facility's Manual Warewashing policy, revised 09/2017, revealed Procedures: 3. All serviceware and cookware will be air dried prior to storage.
Review of the facility's undated policy for check filters (if present), clean coils, sanitize interior, delime as necessary included, Recurrence: Monthly, Category: Ice Machines. Sanitize Interior: 1. Sanitize interior of ice machine per manufacturer's instructions; Clean Exterior: 1. Clean and wipe down exterior.
NJAC 8:39-17.1(a);17.2(g)

Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to address recommendations made by the Consultant Pharmacist in a timely manner for 1 of 16 residents (Resident #6) reviewed for drug regimen.
This deficient practice was evidenced by the following:
On 10/07/2020 at 11:44 AM, the surveyor observed Resident #6 in bed eating breakfast. The resident stated when he/she received Tylenol for pain it was effective for pain management.
According to the admission Record, Resident #6 was admitted to the facility on 07/2020 with diagnoses that included, but were not limited to: Cerebral infarction (stroke), left sided hemiplegia (paralysis), and hypertension (elevated blood pressure).
Review of Resident #6's Order Summary Report (OSR) reflected an active order dated 08/10/2020 for Tylenol Extra Strength 1000 mg (milligram) every eight hours for bilateral knee pain. Further review revealed an active order dated 08/04/2020 for Tylenol 325 mg two tablets every six hours as needed for left shoulder pain.
Review of Resident #6's Medication Administration Record (MAR) for August and September 2020 included the aforementioned orders.
Review of the Consultant Pharmacist Progress Notes, dated 08/19/2020, revealed the Consultant Pharmacist (CP) recommended to discontinue the as needed Tylenol order.
Review of additional Consultant Pharmacist Progress Notes, dated 09/08/2020, revealed the same CP recommendation to discontinue the as needed Tylenol order.
Review of the August Monthly Consultant Pharmacist Report, dated 08/01/2020-08/31/2020, revealed a recommendation to discontinue the as needed Tylenol order. Included in the recommendations, were areas indicating the response date and a nurse's signature. These areas were blank.
Review of the September Monthly Consultant Report, dated 09/06/2020-09/11/2020 revealed the same recommendation to discontinue the as needed Tylenol. Further review of the report revealed the recommendation was addressed on 10/13/2020.
During an interview with the surveyor on 10/13/2020 at 9:45 AM, the Registered Nurse Clinical Director (RN/CD) stated each shift was responsible to review the monthly pharmacy recommendations. The surveyor and the RN/CD reviewed Resident #6's Electronic Physician Orders. The review revealed the resident could receive a total of 5600 mg of Tylenol in a 24-hour period. The RN/CD stated the maximum amount of Tylenol in a 24-hour period would be 4000 mg and the resident could receive more than the manufacturer's recommended amount of Tylenol.
During an interview with the surveyor on 10/13/2020 at 10:47 AM, the DON stated the September Consultant Pharmacist Report recommended to discontinue the as needed Tylenol orders since the resident was receiving 3 grams (3000 mg) daily. The DON stated the recommendation were not followed at the time of the review.
During an interview with the surveyor on 10/13/2020 at 11:11 AM, the CP stated he recommended to discontinue the as needed Tylenol order for Resident #6 in August and September. The CP stated the resident had a routine Tylenol order for 1000 mg to be given every 8 hours and if the resident also received Tylenol 650 mg every 6 hours when needed, the amount could exceed the recommended daily dose of 4000 mg which could cause liver toxicity. The CP stated that he would expect after writing the monthly recommendations, that the nursing staff would have addressed the recommendations. He stated if the second recommendations were not being addressed, he would speak to the DON.
During a follow up interview on 10/14/2020 at 9:22 AM, the DON stated the Consultant Pharmacist Reports were given to the supervisors to follow up with the recommendations or given directly to the nurse practitioner to be addressed. The DON stated she would receive the report back when they were finished. The DON confirmed that the CP recommendations for Resident #6 were overlooked for August and September and were not addressed until 10/13/2020.
Review of the facility's Medication Regimen Review Policy, with an effective date of 12/01/2007 and 11/28/2016, indicated the attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visits to the facility to assess the resident. The facility should encourage physician/prescriber or other responsible parties receiving the Medication Regimen Review (MRR) and the Director of Nursing (DON) to act upon the recommendations contained in the MRR. The facility should encourage the physician/prescriber to either accept or reject all or some of the recommendations contained in the MRR with an explanation as to why the recommendations were rejected.
NJAC 8:39-29.3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to a.) label intravenous (IV) hydration and b.) label and store tube feedings in accordance with the facility policy for 1 of 1 residents (Resident #52) reviewed for IV and tube feedings.
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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
1. According to the admission Record, Resident #52 was admitted to the facility in 09/2020 with diagnoses that included, but were not limited to: Chronic Respiratory Failure, Cerebral Infarction (Stroke), and Dysphagia (Difficulty Swallowing).
Review of Resident #52's admission Minimum Data Set (MDS), an assessment tool dated 9/23/2020, revealed that the resident's cognition was severely impaired.
Review of Resident #52's Care Plan (CP), dated 9/29/2020, revealed the resident was at risk for dehydration and included an intervention to administer intravenous (IV) fluids as ordered dated 10/07/2020.
Review of Resident #52's Order Summary Report (OSR) included a physician's order for Sodium Chloride Solution 0.9% at 80 milliliter (mL) per hour intravenously every shift for hydration, dated 10/06/2020 to 10/07/2020.
On 10/07/2020 at 11:20 AM, the surveyor observed that Resident #52 was receiving IV fluids (Sodium Chloride Solution 0.9%). The bag of IV fluids had a label that was torn off the bag and did not indicate the resident's name, date, or time the IV fluids were hung. The IV tubing was also missing a label with the date and time it was used.
When interviewed at that time, the Registered Nurse (RN) taking care of the resident stated the IV bag and tubing should be labeled with the resident's name, date, and time.
During an interview on 10/13/2020 at 11:15 AM, the Licensed Practical Nurse (LPN) stated the IV fluid bag and tubing should be labeled with the date and time it was hung so that the oncoming nurse knows when to discard the supplies.
During an interview with the surveyor on 10/13/2020 at 11:45 AM, the Unit Manager (UM) stated the IV bag should have been labeled with the resident's name, IV solution, the rate of the IV solution, date, time, and the nurse's initials when the IV bag was hung. The IV tubing should also be labeled with the date and time it was used. The UM further stated that labeling the IV supplies was important because the nurse must verify the resident was receiving the correct IV fluids and to know when to change the bag and tubing per protocol.
During an interview with the surveyor on 10/13/2020 at 11:55 AM, the Director of Nursing (DON) stated that IV bags should be labeled with the resident's name, IV fluid, and date, and the IV tubing should be labeled with the date the tubing was used. The DON further stated it was important to label the IV supplies so that the nurse on duty can verify the resident was receiving the correct IV fluids.
Review of the facility's Labeling of Infusions policy, revised 05/01/2016, included All infusions must be appropriately labeled, and the licensed nurse administering non-admixed solution for infusion from a sealed manufacturer's package will label the bag with: patient's name, route and rate, ancillary precautions, date and time the solution was hung, nurse's initials.
2. Review of Resident #52's admission MDS, dated [DATE], included the resident received a tube feeding (nutrition taken through a tube that goes directly into the stomach).
Review of Resident #52's CP, dated 09/17/2020, revealed the resident had an enteral feeding tube to meet nutritional needs.
Further review of the OSR included a physician's order for Enteral Feed Order Osmolite 1.5 CAL, administer bolus via gravity 240 mL five times per day dated 9/28/2020.
On 10/07/2020 at 12:00 PM, the surveyor observed two open 1000 mL bottles of Osmolyte 1.5 CAL on Resident #52's dresser that were approximately half empty. One bottle was labeled with the date 10/6 and the other bottle was not labeled. Review of the bottle's printed instructions included to hang the bottle for no longer than 24 hours and to protect contents from light. The bottle also included a label indicating the enteral feed contained milk.
When interviewed at that time, the RN taking care of the resident stated the bottles were already in the room at the start of her shift, but she did not use them since she did not know how long the bottles were sitting out at room temperature. The RN further stated she would throw away the two bottles since they are no longer usable.
During an interview with the surveyor on 10/08/2020 at 11:55 AM, the Dietician stated an open enteral feeding bottle may be stored in the refrigerator for 24-48 hours.
During an interview with the surveyor on 10/13/2020 at 11:15 AM, the LPN stated an open enteral feeding bottle may be stored in the refrigerator for up to 36 hours. The LPN further stated the enteral feed must be refrigerated between use because it contained dairy and could go bad.
During an interview with the surveyor on 10/13/2020 at 11:45 AM, the UM stated an open enteral feeding bottle can be stored in the refrigerator for up to 36 hours. The UM further stated that the enteral feed bottle should be labeled so that the oncoming nurse knew if the feeding was still good. If the bottle was not labeled or was past the 36 hours, it should be thrown out to prevent illness.
During an interview with the surveyor on 10/13/2020 at 11:55 AM, the DON stated an open enteral feeding bottle can be stored in the refrigerator for up to 36 hours. The DON further stated that if the bottle was not refrigerated, it should be thrown away because it could be spoiled.
Review of the facility's Enteral Feeding: Administration by Syringe Bolus policy, revised 11/01/19, included Label (with patient's name and date) and cover any unused tube feeding formula. Place in refrigerator. Discard unused, covered formula after 24 hours.
NJAC 8:39-27.1(a)