Runnells Center for Rehabilitation & Healthcare
For profit - Corporation
300 Beds
THE ROSENBERG FAMILY
Data: November 2025
Trust Grade
63/100
#152 of 344 in NJ
Photo by Runnells Center for Rehabilitation and Healthcare
Photo by Runnells Center for Rehabilitation and Healthcare
Photo by Runnells Center for Rehabilitation and Healthcare
1 / 10 photos
Last Inspection: April 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Runnells Center for Rehabilitation & Healthcare has a Trust Grade of C+, indicating that it is slightly above average but not outstanding. It ranks #152 out of 344 facilities in New Jersey, placing it in the top half, and #11 out of 23 in Union County, suggesting that only a few local options are better. However, the facility’s trend is worsening, with issues increasing from 2 in 2023 to 3 in 2024. Staffing is rated 4 out of 5 stars, meaning it is generally strong, but with a turnover rate of 41%, which is average for the state. While the facility has an average fine of $5,160, it does have better RN coverage than many peers, which is a positive aspect as RNs can catch issues that CNAs might miss. However, there have been serious incidents, including two residents suffering physical abuse from other residents, resulting in facial injuries that required hospitalization. Additionally, the facility has faced concerns regarding delays in carrying out physician orders for necessary tests and failing to apply prescribed medical devices properly. Families should weigh these strengths and weaknesses when considering Runnells Center for their loved ones.
- Trust Score
- C+
- In New Jersey
- #152/344
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 41% turnover. Near New Jersey's 48% average. Typical for the industry.
- Penalties ✓ Good
- $5,160 in fines. Lower than most New Jersey facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for New Jersey. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
63/100
Top 44%
Needs review
2 → 3 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 2 issues
2024: 3 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (41%)
7 points below New Jersey average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 41%
Near New Jersey avg (46%)
Typical for the industry
Federal Fines: $5,160
Below median ($33,413)
Minor penalties assessed
Chain: THE ROSENBERG FAMILY
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 23 deficiencies on record
1 actual harm
Apr 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/3/23 at 12:30 PM, the surveyor requested for the reportable, incidents, and accidents for Resident #655 from the [NAME] ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/3/23 at 12:30 PM, the surveyor requested for the reportable, incidents, and accidents for Resident #655 from the [NAME] President of Clinical Services.
A review of the incident and accident report (Risk Management Assessment form (RMA; used to document, identify, and control risks) for Resident #655 included the following:
On 8/14/23 at 10:52 PM, the Resident was found sitting on the hallway by the Certified Nursing Assistant (CNA #1). The resident informed the CNA that he/she wanted to get ice water. The resident was educated to consistently request for assistance.
On 8/20/23 at 6:57 PM, the Resident informed CNA #2 that he/she fell on his/her right hip next to the bed and lifted himself/herself onto the bed. The resident was educated and redirected. The physician was informed, who then ordered another X-ray (to produce images of the internal tissue, bones, and organs). The X-ray showed good alignment and no injury was reflected on the result.
On 8/30/23 at 3:41 PM, an Unsampled Resident reported to the Licensed Practical Nurse (LPN) that while outside, he/she observed Resident #655 walk out of the electric sliding door and fall in the presence of the resident's sister. After returning to the facility, the family member did not report the resident's fall. The resident was assessed upon return, and the LPN documented that there were no apparent bruises. At that time, the sister was interviewed and stated that the resident barely fell, the resident's knee bent and did not touch the floor. The sister was educated to inform the facility of any incident.
On 9/4/23 at 7:24 AM, the resident was found on the floor by LPN#2. The resident informed LPN#2 that he/she went to the rest room, and while trying to get back onto the bed, he/she slid off the bed onto the floor. The Director of Nursing documented that the resident was receiving rehabilitative services and the resident continued to be non-compliant with assistive device.
The surveyor reviewed Resident #655's hybrid medical record.
A review of Resident #655's admission Record (AR) (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to unspecified intellectual disabilities (a condition that limits intelligence, and adaptive behavior), anxiety disorder, and major depressive disorder.
A review of Resident #655's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 11/7/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that Resident #655's cognition was intact.
Further review of section J.1800, Any falls since Admission/Entry or Re-entry or Prior Assessment, whichever is more recent reflected 0 which indicated No.
On 4/8/23 at 9:30 AM, during an interview with the surveyor, the MDSC stated that the quarterly MDS information was based of the nurses' progress notes (PN). The qMDS for 11/7/23, encompassed information from 8/12/23 to 11/7/23.
At that time, the surveyor asked the MDSC why the documented falls on the PN that occurred on 8/14/23, 8/20/23, 8/30/23 and 9/4/23, were not reflected on the qMDS dated [DATE].
At that time, the MDSC stated that she had signed the qMDS for 11/7/23, for completion however the MDS Nurse (MDSN) who completed and signed section for J.1800 for that qMDS should have included the data.
At that time, the MDSC informed the surveyor that MDSN was not in the facility that day but would reach out for more information as to why it was not included.
At that time, the MDSC stated that the accuracy of the MDS was important for care plan and other assessment for their residents.
A review of the resident's Care Plan reflected focus, goal and interventions for the falls that occurred on 8/14/23, 8/20/23, 8/30/23, and 9/4/23.
On 4/8/23 at 11:53 AM, the [NAME] President of Clinical confirmed with the surveyor that section J.1800 of the qMDS for 11/17/23, was missed, and informed the surveyor that the qMDS for 11/17/23, would be revised for correction after surveyor inquiry.
A review of the facility policy provided, Electronic Transmission of the MDS revised December 2010, included the following:
Policy Statement
All MDS assessments .will be completed electronically encoded into our facility's MDS information system and transmitted to CMS QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data.
Policy Interpretation and Implementation
6. The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking.
NJAC 8:39-11.1, 11.2(e)(1)
NJ #165993
Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 35 residents, Resident #200 and #655 reviewed for accuracy for MDS coding.
This deficient practice was evidenced by the following:
1. On 4/02/24 at 09:33 AM, the surveyor interviewed Resident #200 in their room. Resident #200 stated they take an antidepressant medication and have for a few years.
On 4/4/24 at 9:10 AM, the surveyor reviewed Resident #200's hybrid (paper and electronic) medical records.
The admission Record (AR) documented the resident had diagnoses that included but were not limited to, adjustment disorder with depressed mood, schizoaffective disorder depressive type, bipolar disorder, and generalized anxiety disorder.
A review of a Annual MDS assessment, dated 1/22/24, indicated in Section N-Medications, under N0415. High-risk Drug Classes: Use and Indication, Resident #200 was not coded for taking an antidepressant.
A review of the Order Summary Report included a physician's order dated 7/6/2022 which read, Sertraline HCL Tablet 100 milligrams (MG), Give 2 tablets by mouth one time a day for depression for a total dose of 200mg.
On 4/08/24 at 11:48 AM, the surveyor interviewed Registered Nurse/MDS Coordinator (MDSC), who stated all resident who are taking an antidepressant medication should have that coded in their MDS. The surveyor reviewed with MDSC the annual MDS assessment of Resident #200. MDS coordinator #1 stated the coding was a data entry error. MDSC stated the MDS assessment would be corrected.
According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023) on Chapter 3-page N7-9- N0415C1. Antidepressant: Check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or
reentry if less than 7 days). N0415C2. Antidepressant: Check if there is an indication noted for all antidepressant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days).
On 4/9/24 at 9:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyors with a facility policy titles, Electronic Transmission of MDS with a revision date of December 2010. The policy stated under the policy interpretation and implantation section, The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data.
On 4/9/24 at 11:30 AM, the survey team met with the LNHA and Director of Nursing (DON) to discuss the MDS coding error. The DON acknowledged the errors and stated they would fix errors that were discovered. No further comment made.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to ensure that the primary physician responsible for supervising the care of residents conducted face to face visits an...
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Based on interview and record review, it was determined that the facility failed to ensure that the primary physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 1 of 35 (Resident #658) reviewed for physician visits and was evidenced by the following:
On 4/4/24 at 12:40 PM, the surveyor reviewed the closed paper and electronic medical record for Resident #658.
The admission Record (a summary of important information about a resident) documented that Resident #658 had diagnoses that included but were not limited to, generalized anxiety disorder and major depressive disorder.
A review of physician progress notes revealed the following:
On 9/12/22, a medical visit note was completed by the resident's primary physician.
On 10/4/22, a medical visit note was completed by the Nurse Practitioner (NP).
On 11/1/22, a medical visit note was completed by the Nurse Practitioner (NP).
On 11/28/22, a medical visit note was completed by the Nurse Practitioner (NP).
On 12/6/22, a medical visit note was completed by the Nurse Practitioner (NP).
There was no documented evidence that the primary physician visited and examined Resident #658 at least every 60 days.
On 4/4/24 at 1:50 PM, the surveyor interviewed the VP of Clinical Services about the physician progress notes for Resident #658. The VP of Clinical Services acknowledged physicians were to conduct face-to-face visits at least every 30 days or at least every 60 days when alternating visits with an NP.
On 4/8/24 at 10:07 AM, the surveyor interviewed the Director of Nursing (DON) about the physician visits and documentation for Resident #658. The DON stated there should be documentation by the primary physician for the resident and would look to provide further information.
On 4/8/24 at 11:18 AM, the surveyor called to speak with the primary physician over the phone and left a message with the office for a call back.
On 4/8/24 at 12:21 PM, the surveyor received a return telephone call from the NP who worked in collaboration with the resident's primary physician. The NP informed the surveyor that she visited the residents at least monthly. The NP stated when alternating with the physician, the physician would be required to visit quarterly, every three months.
On 4/9/24 at 11:50 AM, the survey team met with the Licensed Nursing Home Administrator, DON, IP, VP of Clinical Services, and regional staff. The surveyor informed the facility of the concern of the physician conducting face-to-face visits at least every 60 days when alternating with an NP. There was no additional information provided by the facility.
A review of the provided facility policy titled Physician Visits, under Policy Interpretation and Implementation read: After the first ninety (90) days, if the Attending Physician determines that a resident need not be seen by him/her every thirty (30) days, an alternate schedule for visits may be established, but not to exceed every sixty (60) days. A physician assistant or nurse practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulation .
NJAC 8:39 - 23.2 (d)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Complaint NJ #165993
Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to adequately monitor the targ...
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Complaint NJ #165993
Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to adequately monitor the target behaviors for the number of episodes, behavioral interventions, and its outcomes for the use of psychotropic medications (mood altering medications) in accordance with facility policy.
This deficient practice was identified for one (1) of six (6) residents (Resident #656) reviewed for abuse in a resident-to-resident interaction, and was evidenced by the following:
A review of the reportable event record/report (FRI; Facility Reported Incident) that was called in on 7/23/23 at 1:10 PM. The FRI occurred on 7/23/23, at approximately 11:22 AM, and was reported an incident of a resident-to-resident abuse. The event description included the following: At around 11:22 AM on 7/23/23, the Licensed Practical Nurse (LPN) was in the hallway by her medication cart when she witnessed Resident #656, and Resident #657 passed each other on opposite sides of the hallway. The LPN witnessed Resident #656 walked up to, then strike Resident #657 twice in the face. The LPN called out for help and immediately separated both residents .
A review of Resident #656's admission Record (AR) (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to unspecified dementia (impairment of memory loss and judgment), with other behavioral disturbance, and major depressive disorder.
A review of Resident #656's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 9/11/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated that Resident #656's cognition was severely impaired. Additionally, section E. Behavior revealed the resident was not delusional.
A review of the Order Summary Report contained Physician Orders that were active orders for June 2023 which included the following:
-Ativan 1 milligram (mg), give one (1) tablet by mouth every 8 hours for anxiety with a start date 2/20/23.
-Behavior Monitoring for medication: Lorazepam (antianxiety), target behavior of anxiousness with a start date of 2/20/23.
-Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium), give five (5) capsules by mouth every 12 hours for mood stabilizer with a start date of 5/26/23.
-Behavior Monitoring for medication: Depakote, target behavior of explosive aggressive behavior with a start date of 5/24/23.
A review of the Progress Notes from June 1, 2023, to June 30, 2023, revealed behaviors were observed, but did not indicate whether the behavior was for anxiousness or for explosive aggressive behavior for the following dates:
1)
6/1/23 at 9:54 PM
2)
6/7/23 at 12:48 PM
3)
6/7/23 at 12:49 PM
4)
6/8/23 at 12:35 AM
5)
6/8/23 at 12:35 AM
6)
6/12/23 at 12:29 AM
7)
6/12/23 at 12:29 AM
8)
6/13/23 at 12:28 AM
9) 6/13/23 at 12:28 AM
10)
6/14/23 at 1:54 PM
11)
6/14/23 at 1:54 PM
12)
6/16/23 at 12:38 PM
13)
6/16/23 at 12:39 PM
14)
6/18/23 at 12:26 PM (not reflected on the eMAR)
15)
6/19/23 at 2:57 PM (not reflected on the eMAR)
16)
6/19/23 at 2:57 PM (not reflected on the eMAR)
17)
6/25/23 at 12:11 PM
18)
6/25/23 at 12:11 PM
19)
6/26/23 at 2:50 PM
20)
6/30/23 at 12:07 AM
21)
6/30/23 at 12:07 AM
22)
6/30/23 at 7:00 PM
23)
6/30/23 at 7:00 PM
A review of the electronic Medication Administration Record (eMAR) for June 2023 included the following orders:
-Ativan 1 milligram (mg), give one (1) tablet by mouth every eight (8) hours for anxiety with a start date 2/20/23 and end date of 7/24/23.
-Behavior Monitoring for medication (BMFM): Lorazepam (antianxiety), target behavior of anxiousness with a start date of 2/20/23. The BMFM reflected that behaviors were documented without the number of episodes, without an intervention (non-pharmacological), and without the outcome of the intervention on the following dates:
1)
6/7/23, for the day shift (7:00 AM to 3:00 PM)
2)
6/7/23, for the night shift (11:00 PM to 7:00 AM)
3)
6/11/23, for the night shift
4)
6/12/23, for the night shift
5)
6/14/23, for the day shift
6)
6/18/23, for the day shift
7)
6/18/23 for the night shift
8)
6/29/23, for the night shift
-Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium), give five (5) capsules by mouth every 12 hours for mood stabilizer with a start date of 5/26/23.
-Behavior Monitoring for medication: Depakote, target behavior of explosive aggressive behavior with a start date of 5/24/23. The BMFM reflected that behaviors were documented without the number of episodes, without an intervention (non-pharmacological), and without the outcome of the intervention on the following dates:
1)
6/7/23 for the day shift (7:00 AM to 3:00 PM)
2)
6/7/23 for the night shift (11:00 PM to 7:00 AM)
3)
6/11/23 for the night shift
4)
6/12/23 for the night shift
5)
6/14/23 for the day shift
6)
6/18/23 for the night shift
7)
6/26/23 for the day shift
8)
6/29/23 for the night shift
A review of the Order Summary Report contained Physician Orders that were active orders for July 2023 which included the following:
-Ativan 1 milligram (mg), give one (1) tablet by mouth every 8 hours for anxiety with a start date 2/20/23.
-Behavior Monitoring for medication: Lorazepam (antianxiety), target behavior of anxiousness with a start date of 2/20/23.
-Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium), give six (6) capsules by mouth every 12 hours for mood stabilizer with a start date of 6/23/23.
-Behavior Monitoring for medication: Depakote, target behavior of explosive aggressive behavior with a start date of 5/24/23.
A review of the Progress Notes from July 1, 2023, to July 31, 2023, revealed behaviors were observed, but did not indicate whether the behavior was for anxiousness or for explosive aggressive behavior, on the following dates:
1)
7/5/23 at 1:41 PM
2)
7/5/23 at 1:42 PM
3)
7/8/23 at 9:52 PM
4) 7/8/23 at 9:52 PM
5) 7/15/23 at 2:07 PM
6)
7/15/23 at 2:07 PM
7) 7/17/23 at 12:52 PM
8)
7/17/23 at 12:53 PM
9)
7/20/23 at 11:40 PM
10)
7/20/23 at 11:44 PM
11)
7/23/23 at 11:42 PM
12)
7/23/23 at 11:43 PM
13)
7/24/23 at 12:43 PM
14)
7/24/23 at 12:43 PM
15)
7/28/23 at 12:19 AM
16)
7/28/23 at 12:20 AM
17)
7/29/23 at 12:10 AM
18)
7/29/23 at 12:10 AM
19)
7/30/23 at 6:36 PM
20)
7/30/23 at 6:36 PM
A review of the electronic Medication Administration Record (eMAR) for July 2023 included the following orders:
-Ativan 1 milligram (mg), give one (1) tablet by mouth every eight (8) hours for anxiety with a start date 2/20/23 and end date of 7/24/23.
-Behavior Monitoring for medication (BMFM): Lorazepam (antianxiety), target behavior of anxiousness with a start date of 2/20/23. The BMFM reflected that behaviors were documented without the number of episodes, without an intervention (non-pharmacological), and without the outcome of the intervention on the following dates:
1)
7/4/23, for the night shift
2)
7/8/23, for the evening shift
-Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium), give six (6) capsules by mouth every 12 hours for mood stabilizer with a start date of 6/23/23.
-Behavior Monitoring for medication: Depakote, target behavior of explosive aggressive behavior with a start date of 5/24/23. The BMFM reflected that behaviors were documented without the number of episodes, without an intervention (non-pharmacological), and without the outcome of the intervention on the following dates:
1)
7/4/23, for the night shift
2)
7/20/23, for the night shift
3)
7/23/23, for the night shift
4)
7/24/23, for the day shift
5)
7/27/23, for the night shift
6)
7/28/23, for the night shift
7)
7/31/23, for the night shift
A review of the Psychiatric Follow-Up Form dated 5/26/23 included the following: Patient presented with agitation/aggressive behavior. Patient was seen in peer's room. The peer was noted with bloody lips .start Depakote Sprinkle 750 mg every 12 hours and discontinue Depakote Sprinkle 500 mg every 12 hours. Notify Psych NP if patient becomes agitation/aggressive. Continue non drug interventions .
A review of the Psychiatric Follow-Up Form dated 6/14/23 included the following: No drug changes. Continue to monitor the patient's mood, behavior, and non-drug interventions .
On 4/8/24 at 10:43 AM, during an interview with the surveyor, the [NAME] President of Clinical Services could not explain why the behaviors under the progress note was not specific to the behavior, the number of episodes, interventions made were not specified, and the outcome of a non-pharmacological intervention(s) were not reflected on certain dates on June 2023 and July 2023 of the eMAR. The concerns were communicated with the VPCS.
On 4/8/23 at 12:37 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that she had reviewed the eMAR for the discussed concerns with the VPCS and interviewed four (4) nurses who had indicated Yes for behavior on the eMAR without documentation of the number of episodes, interventions made, and the non-pharmacological intervention outcome.
At that time, the DON informed the surveyor that the nurses who had marked yes, on the eMAR meant that they had administered the medication to the resident and did not understand how to properly use the BMFM. The DON acknowledged that the order was for behavior monitoring, not administration of the medication and the documentation on the BMFM was incorrect.
At that time, the DON stated that a facility wide in-service/education for behavior monitoring documentation would be conducted to increase the nurses' understanding.
A review of the undated facility provided policy, Behavioral Assessment and Monitoring included the following:
Policy Statement
Problematic behaviors will be identified and managed appropriately with minimal complications using non-pharmacological and/or pharmacological approaches as appropriate.
Monitoring
1. Exception charting will be used to document the occurrence of any problematic behaviors, interventions implemented, and the resident response to interventions when these behaviors occur.
N.J.A.C. 8:39-27.1 (a)
Jul 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review, the facility failed to protect the right of two (Resident (R) 11 an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review, the facility failed to protect the right of two (Resident (R) 11 and R7) of four residents reviewed for abuse to be free from physical abuse by another facility resident. R11 experienced physical abuse by R24 resulting in facial injury requiring hospitalization and R7 experienced physical abuse by R23 resulting in facial injury requiring hospitalization and surgical intervention. The failure resulted in harm to R11 and R7.
Findings include:
1. A. Review of R24's Profile tab in the electronic medical record (EMR) revealed he was admitted to the facility's secure unit on 03/06/23 with diagnoses, according to the Medical Diagnoses tab of the EMR, of metabolic encephalopathy with altered mental status, muscle weakness and difficulty walking, and heart failure. R24 was discharged from the facility on 03/18/23.
Review of R24's 03/06/23 hospital Discharge Summary, located in the Miscellaneous tab of the EMR, revealed the resident was brought to the emergency room for increased confusion and disorientation. He was diagnosed with metabolic encephalopathy (brain dysfunction). R24's documented behaviors included wandering and trying to stand though he was at risk of falling. There were no aggressive behaviors documented.
Review of R24's five-day Minimum Data Set (MDS), assessment, with an assessment reference date (ARD) of 03/13/23, revealed he scored zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R24 required extensive assistance with transfers and locomotion, and he was ambulatory but unsteady on his feet.
Review of R24's 03/10/23 Care Plan, located in the Care Plan tab of the EMR, revealed, [R24] has metabolic encephalopathy/dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] cognitive deficits. The interventions included: All staff to converse with [R24] while providing care . [R24] needs assistance/escort to activity functions . [R24's] preferred activities are looking [at] magazines, books, and walking around . Encourage ongoing family involvement. Invite [R24's] family to attend special events, activities, meals . [and] Introduce [R24] to residents with similar background, interests, and encourage/facilitate interaction.
Review of R24's 03/06/23 to 03/17/23 Notes, located in the Notes tab of the EMR, revealed the resident had one incident of attempting to hit staff during care on 03/07/23. No additional aggressive behaviors were documented.
Review of R24's 03/19/2023 1:38 AM Occurrence [sic] Note, located in the Notes tab of the EMR, revealed, Around 10 PM, resident physically abuse [sic] his roommate [R11] with his chair and his fist. His roommate sustained severe injuries to his face, all parties were notified. Order obtained to send him to [emergency room]. Resident was picked [up] by 911 at 10:45 PM.
B. Review of R11's Profile tab in the EMR revealed the resident was admitted the facility on 02/23/23 with diagnoses, according the Medical Diagnoses tab of the EMR, of Alzheimer's disease with behavioral disturbance, muscle weakness, and difficulty walking. R11 was discharged from the facility on 03/27/23.
Review of R11's five-day MDS assessment, with an ARD of 03/08/23 and located in the MDS tab of the EMR, revealed R11 scored five out of 15 on the BIMS, indicating severely impaired cognition. R11 required limited assistance with bed mobility, transfers, and locomotion and was able to ambulate. R11 occasionally exhibited physical behaviors directed towards others and wandering.
Review of R11's Care Plan, located in the Care Plan tab of the EMR and dated 02/24/23, revealed, [R11] is physically aggressive (Hitting staff) r/t [related to ] anger, dementia, [and] poor impulse control. The interventions included: The resident's triggers for physical aggression are (hitting staff). The resident's behaviors is [sic] de-escalated by redirecting . Analyze times of day, places, circumstances, triggers, and what deescalates behavior and document . Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain, etc. [and] When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. The Care Plan also documented, [R11] is an elopement risk/wanderer r/t disoriented to place, impaired safety awareness. The approaches included: identify pattern of wandering: is wandering purposeful, aimless, or escapist? is resident looking for something? does it indicate the need for more exercise? intervene as appropriate . Monitor location every 15 min. Document wandering behavior and attempted diversional interventions in log . [and] Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes.
Review of R11's 03/19/23 Occurrence [sic] Note, located in the Notes tab of the EMR, revealed, Resident physically abuse [sic] by his roommate with a chair and his fist as a result resident sustained severe injuries to his nose and face around 10 PM [on 03/18/23]. I was trying to take the chair from him; he chased me trying to hit me too. I called for help, all the CNA [certified nurse aides] came and helped. All parties involve [sic] were notified, order obtained to send resident to [Emergency Room]. Resident picked up by 911 at 10:30 PM.
Review of R11's 03/19/23, 6:18 AM Orders - General Note from eRecord, located in the Notes tab of the EMR, revealed, [R11] arriver [sic] at the facility at around 2:20 AM via emergency transportation, he was brought to the unit at 2:30 AM in a stretcher by two emergency personnel . very agitated, will not stay still in the stretcher, he was dropped off at the TV and will not sit still, chair was offered to him but he would not sit down, walking around the hall, had to be monitored 1:1 [one-to-one].
Review of R11's 03/18/23 Care Plan, located in the Care Plan tab of the EMR, revealed, [R11] was a receiver of physical aggression. Punched by another resident in the face. The approaches included: Separate the two residents. Call 911, police, and transfer to ER [emergency room] for evaluation. Apply ice pack to the nose bridge until transferred out to ER. Provide emotional support . Upon readmission: monitor any injuries to [the] facial area and follow any treatment orders if applicable. Provide with psychology services to allow him ability to vent any concerns he may have related to incident. Encourage his wife to visit as often as possible for support. Social services to visit weekly as well to assist with adjustment period.
C. Review of the facility's 03/20/23 Reportable Event Record/Report, provided on paper, revealed on 03/18/23 at 9:30 PM, a resident-to-resident abuse incident occurred, and was reported to the state agency on 03/18/23 at 10:00 PM. The narrative documented, On 3-18-2023 at approximately 9:30 PM, both residents were sitting talking with each other in the dayroom witnessed by staff as they were also roommates. Suddenly [R24] picked up a chair and before staff could get to him, he proceeded to hit [R11] with the chair and punched him in his face 2-3 times with his closed fist. Causing [R11] injuries to his face in 3 different areas as well as a bloody nose. As staff where [sic] attempting to grab [R11] away, [R24] started swinging and throwing chairs at the staff as well. Supervisor spent some time calming down [R24] enough for him to sit and relax, while the other staff were tending to the injuries of [R11] and calling 911. Police arrived with paramedics and transferred both residents separately to [the hospital.] [R24] was sent for a psych evaluation and [R11] was sent to be evaluated for his injuries. [R11] was later sent back to the facility, stable with no facial fractures, no pain, and didn't understand what happened. [R24] is currently inpatient involuntary psych commitment and will be placed in a facility better suited for his needs. The police, Ombudsman, both residents' physicians, and both residents' responsible parties were notified. The facility conducted an investigation which included interviews with multiple staff members. The investigation revealed R24 had no history of aggressive behaviors and staff could not determine why he became aggressive with R11.
In an interview on 07/06/23 at 3:37 PM, Licensed Practical Nurse (LPN) 4 stated on the evening of 03/18/23, she witnessed R11 and R24, who were roommates, sitting and talking with each other in the day room. She stated, All of a sudden, [R24] grabbed a chair and kept hitting [R11]. I called for help . We separated the residents. LPN4 stated she did not witness an argument or any behavior preceding the event that would cause R24 to hit R11. She stated R24 admitted to her that he hit R11 but did not state a reason to her. LPN4 stated, R11 suffered facial lacerations and a bloody nose that required emergency medical transport to the emergency room for evaluation. She stated, It was horrific, there was blood everywhere.
In an interview on 07/06/23 at 3:52 PM, the Director of Nursing (DON) stated in the event of resident-to-resident abuse resulting in serious injury, the incident should be reported to the state agency and police department within two hours. She stated this incident of resident-to-resident physical abuse resulted in serious injury for R11. She stated the incident was reported on 03/18/23 within a half hour of the occurrence.
2. A. According to R23's Profile tab of the EMR, the resident was admitted to the facility on [DATE] with diagnoses, per the Medical Diagnoses tab of the EMR, of schizoaffective disorder and anxiety.
Review of R23's 08/10/22 Pre-admission Screening and Resident Review (PASRR) Level I Screen, located in the Miscellaneous tab of the EMR, revealed R23 was in a psychiatric hospital and had a diagnosis of schizophrenia, which significantly impaired his functioning. A primary dementia exclusion was requested.
Review of R23's 08/10/22 PASRR Level II Psychiatric Evaluation, located in the Miscellaneous tab of the EMR, revealed dementia/major neurocognitive disorder was confirmed by the psychiatrist; however, R23 did not meet the conditions for a primary dementia exclusion. The psychiatrist documented, Pt [patient] became noncompliant w/ [with] treatment at his residence. Pt was noted to be internally preoccupied. Paranoid. Poor ADLs [activities of daily living], talking to self, w/ neurocognitive deficits. Pt kept asking if he could fight people while off meds [medications], this behavior has stopped. Nursing home placement was recommended and the rationale was, Pt. needs supervision taking medications [and] with most needs - when compliant with assistance he is psychologically stable . [he] needs assistance with meals [and] showering. The evaluation documented R23 did not have an active psychosis, had a serious mental illness and treatment needs that could be met in a nursing facility, and did not need specialized services.
Review of R23's 10/06/22 Care Plan, located in the Care Plan tab of the EMR, revealed, [R23] has Level II PASRR determination with mental health treatment needs related to Mental Illness. On 10/07/22, the Care Plan documented, The resident is (dependent on staff) for meeting emotional, intellectual, physical, and social needs r/t [related to] intellectual deficits. The approaches included: All staff to converse with resident while providing care . [and] establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary . The resident uses psychotropic medications (antipsychotics) r/t disease process (schizophrenia) . Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness [every shift].
Review or R23's Notes, under the Notes tab of the EMR, did not reveal any documented behaviors since admission until an incident on 10/09/22.
Review of R23's 10/09/22 Occurance [sic] Note, located in the Notes tab of the EMR, revealed, [R23] is observed leaving [R7's] room with bloodied hands and blood stains on both of his cheeks. [R23] showed no aggression prior and after the incident. Supervisor . was made aware . [physician] is informed and ordered may use restraints. A cut was noticed on the back of his right hand around the ring finger. Resident denies any pain. When asked what happened, [R23] states, I punched him in the face. When asked again 30 minutes later in the presence of . [police officer], [R23] reiterated, I punched him in the face! Resident was immediately removed from [R7's] room and redirected inside his room . 911 is called. Officers . arrived around 4:30 PM and interviewed both [residents] separately. [R23] is asked to wash his hands. A cut/laceration was noted on the back of his right ring finger. Resident denies any pain. Bacitracin is applied after being cleansed with normal saline and patted dry. Approximately after 5 PM [sic], [R23] is escorted out via stretcher by two EMS [emergency medical service] personnel and sent to [hospital].
B. Review of R7's Profile tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses, according to the Medical Diagnoses tab of the EMR, of shoulder fracture, seizures, weakness, schizophrenia, bipolar disorder, depression, and anxiety. R7 was discharged from the facility on 10/09/22.
Review of R7's admission MDS assessment, with an ARD of 09/19/22 and located in the MDS tab of the EMR, revealed he scored five out of 15 on the BIMS, indicating severely impaired cognition. R7 experienced hallucinations but no additional behavioral symptoms. He required extensive assistance with bed mobility, transfers, and locomotion.
Review of R7's 09/27/22 Care Plan, located in the Care Plan tab of the EMR, revealed, The resident uses psychotropic medications (lithium and haloperidol) r/t [related to] behavior management. The approaches included, Monitor/record occurrence of for target behavior symptoms (SPECIFY: hallucination and agitation) and document per facility protocol.
Review of R7's 10/09/22 Occurance [sic] Note, located under the Notes tab in the EMR, revealed, At approximately 4:15 PM while giving medications to one of my patient [sic], the nursing assistant while standing in front of the patient's room, called for my attention. As I raced into [R7's] room, [R23] was seen walking away from inside the room with blood on his hands and blood splattered on his face. [R7] was found bleeding from both nostrils and a lateral cut (2.5 cm [centimeters]) on the bridge of his nose with both eyes bleeding and right cheek swollen. When asked what happened, [R7] states the guy (pointing at [R23]) hit me! At approximately 4:20 PM, 911 was immediately called. Treatment was provided. Wounds were cleansed with normal saline, patted dry. Pressure applied to the nose to prevent further bleeding. [R7] is advised and educated not to blow his nose. Supervisor . is notified. Officers . arrived at around 4:30 PM and interviewed both residents. [Physician] and POA [Power of Attorney] were made aware. Approximately 5:15 PM, resident is taken to [Hospital] via stretcher escorted by two EMS [emergency medical service] personnel.
Review of R7's 10/10/22 No Type Specified note, located in the Notes tab of the EMR, revealed, Called [Hospital] . informed writer that [R7] is in stable condition, awaiting transfer to an eye specialist [surgeon] in University Hospital in [NAME].
C. Review of the 10/12/22 Reportable Event Record/Report revealed an incident of resident-to-resident abuse occurred on 10/09/22 at 4:45 PM, and the incident was called in to the state agency on 10/09/22 at 5:44 PM. The narrative documented, On 10/9/22 at approximately 4:45 PM, a nursing aide observed [R23] in the room of another resident, [R7]. [R23] had, what appeared to be, blood on his hands and proceeded to walk out of [R7's] room, heading towards his own room. The nursing aide entered [R7's] room and observed [R7] sitting on the couch with lacerations to his face and a bloody nose. The nursing aide called for the nurse and another aide called for the nursing supervisor. [R23] was placed on 1:1 [one-to-one] monitoring in his room and [R7] was assessed by the nurse and his injuries treated. 911 was called at 4:48 PM. Two officers from the [NAME] Heights Police Department arrived at approximately 4: 55 PM. An ambulance arrived at 5:15 PM and [R7] was transported to [the hospital] for evaluation of his injuries. Another ambulance arrived at 5:25 PM and [R23] was transported to [the hospital] for crisis [evaluation]. The police, Ombudsman, both residents' physicians, and both residents' responsible parties were notified. The facility conducted an investigation which documented, A nursing aide on the unit had observed [R7] lying in bed at approximately 4:00 PM. This same aide also observed [R23] ambulating on a different hall of the unit at that same time. Another nursing aide, who was assigned to [R7], saw the resident in bed at 4:30 PM and provided him with water. When she exited [R7's] room, she observed [R23] down the hall at the nursing station. At approximately 4:45 PM, this same nursing aide observed [R23] in the room of [R7] with blood on his hands and injuries to [R7's] face. Upon questioning, [R23] repeated several times, l hit him but could not elaborate any further. When [R7] was questioned about the incident, he answered, He hit me!' He, also, was unable to provide any further information. No other staff member on the unit heard any noises indicative of a physical altercation taking place . It appears that a resident-to-resident altercation occurred between [R7] and [R23], facility is unable to substantiate abuse as there is no evidence as to what may have caused the altercation or which resident was responsible for initiating the altercation; it is unclear if the resident acted willfully or in self-defense.
In an interview on 07/05/23 at 4:10 PM with LPN3, she stated she did not witness an altercation between R7 and R23; she was called to the room by the nurse [Registered Nurse (RN) 1] and recalled seeing a trail of blood on the floor to R23's room and R23 with blood on his hands, and found R7 with a bloody nose. LPN3 stated when she spoke with R23 after the incident, R23 reported R7 had called him the N-word and he had reacted by hitting R7.
In an interview on 07/06/23 at 12:33 PM, CNA3 stated she had just seen both residents about 15 minutes prior to the incident and had not witnessed any aggression or fighting. She stated she found R23 leaving R7's room with blood on his hands, and R7 with blood on his face.
In an interview on 07/06/23 at 2:35 PM, RN1 stated he did not witness the incident between R7 and R23; he was called to R7's room by the CNA. RN1 stated R23 stated he had hit R7, but he could not recall if he stated anything had happened to cause the aggression.
In an interview on 07/06/23 at 3:52 PM, the DON stated in the event of resident-to-resident abuse resulting in serious injury, the incident would be reported to the state agency and police department within two hours. She stated this incident of resident-to-resident physical abuse resulted in serious injury for R7 and was reported to the state agency within an hour of incident on 10/08/22.
Review of the facility's Prohibition of Resident Abuse & Neglect policy, dated 02/28/23 and provided on paper, revealed, Our facility practices ZERO tolerance of resident abuse, neglect, mistreatment, exploitation or misappropriation of property by anyone including staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, vendors, or any other visitors or individuals . Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish . Instances of abuse of all residents, irrespective of mental or physical condition, cause physical harm, pain, or mental anguish . Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
NJAC 8:39-4.1 (a) 5
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C# 160500
Based on interviews, record review, and review of other pertinent documents on 1/13/23, it was determined that the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C# 160500
Based on interviews, record review, and review of other pertinent documents on 1/13/23, it was determined that the facility failed to ensure that residents were consistently provided quarterly statements of their Personal Needs Account (PNA) for 3 of 3 residents (Residents #3, #4 and #5) reviewed for PNA records. This deficient practice is evidenced by the following:
1. According to the admission Record (AR), Resident #3 was admitted to the facility on [DATE].
The Minimum Data Set (MDS), an assessment tool, dated 12/6/22, revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated that the Resident's cognitive status was moderately impaired.
During an interview with surveyor on 1/13/23 at 9:25 AM, Resident #3 stated that he/she did not receive quarterly PNA statements for 2022.
2. According to AR, Resident #4 was admitted to the facility on [DATE].
The MDS dated [DATE], revealed a BIMS score of 13 which indicated that the Resident's cognitive status was intact.
During an interview with surveyor on 1/13/23 at 12:15 PM, Resident #4 stated that he/she did not receive PNA statements every quarter for 2022.
3. According to AR, Resident #5 was admitted to the facility on [DATE].
The MDS dated [DATE], revealed a BIMS score of 15 which indicated that the Resident's cognitive status was intact.
During an interview with the surveyor on 1/13/23 at 12:35 PM, Resident #5 stated that the facility used to provide PNA statements every quarter but not this year. The Resident explained that he/she received a quarterly PNA statement once in 2022 but could not confirm which quarter.
The surveyor conducted a telephone interview with the Director of Social Services (DSS) on 1/13/23 at 3:07 PM, who stated that the business office handles resident's PNA accounts and statement distribution.
During an interview with the surveyor on 1/13/23 at 11:28 AM, the Business Office/HR Manager (BO/HRM) stated that the facility receives quarterly PNA statements from a contracted company that manages residents' accounts, but she was unsure how the statements are distributed to residents. She explained that she is responsible for recording the resident's cash-out receipts and reconciling them with the contracted company. However, she could not confirm if she is responsible for the timely distribution of quarterly PNA statements to the residents.
During the exit conference with the Director of Nursing (DON) and Regional VP of Nursing (RVPN) on 1/13/23 at 4:24 PM, they stated that every quarter the administrator and social worker would distribute and review the PNA statements with the residents, then the residents would sign an area on the statement to acknowledge receipt, and a copy of the signed statement is retained afterwards. The DON and RVPN stated that residents should have received their PNA statements every quarter for 2022 but they were unable to provide documented evidence to the surveyor during the survey.
During a telephone interview with the Assistant Administrator (AA) on 1/17/23 at 2:43 PM, he stated that the BO/HRM is now responsible for distributing quarterly PNA statements to residents. He explained that residents should have received their PNA statements every quarter for 2022 because the former administrator and administrator in training distributed the PNA statements, however, the AA was unable to provide documented evidence to the surveyor. Additionally, the AA was unable to provide a policy for PNA accounts and stated that the facility refers to the regulation.
A review of the job description titled Director of Human Resources/Business Office Manager, undated, under Responsibilities/Duties, indicated monitors, categorizes and distributes all correspondence regarding resident finances, including but not limited to PNA .distributes quarterly PNA statements jointly with Social Services Department.
NJAC 8:39-4.1 (a) 9
Jan 2022
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based off observation, interview, and record review it was determined that the facility failed to maintain respect and dignity for a resident prior to providing incontinence care. This deficient pract...
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Based off observation, interview, and record review it was determined that the facility failed to maintain respect and dignity for a resident prior to providing incontinence care. This deficient practice was identified for one of three residents, (Resident #43) reviewed for respect and dignity and was evidenced by the following:
On 01/10/22 at 10:17 AM, the surveyor walked by Resident #43's room and observed the resident's Certified Nursing Aide (CNA) in the room with the resident. Resident #43's bed was closest to the door in the room. The surveyor observed that the door to the resident's room was open, the resident's privacy curtain was drawn open, and the resident's genital area was exposed. The surveyor observed a white sheet placed just below the resident's genitals. At that time, the surveyor made the CNA aware that incontinence care was going to be observed. The CNA walked out of the room to gather supplies. The resident remained uncovered with his/her genitals exposed. The CNA did not close the door to the resident's room or pull the privacy curtain before exiting the resident's room. The surveyor stood between the resident and the hallway to obstruct the view of the resident's genitals.
At 10:21 AM, the CNA entered the resident's room and walked over to the resident. At that time, the surveyor interviewed the CNA who stated that privacy was maintained by closing the door to the resident's room and the privacy curtain. The CNA acknowledged that she had walked out of the room and left the resident's genital area exposed.
At 10:55 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the resident was alert and oriented and had expressive aphasia (decline or loss in the ability to express speech). The LPN further stated that the resident could make his/her needs known by speaking very slowly but could not speak clearly.
At 11:03 AM, the LPN further stated that privacy should be maintained for all resident's while providing incontinence care. The LPN stated that staff should close the door to the resident's room and pull the privacy curtain closed for the resident when the resident was naked or being changed.
At 11:27 AM, the surveyor interviewed the resident's Registered Nurse/Unit Manager (RN/UM) who stated that privacy was maintained by closing the privacy curtain, shutting the door, and covering up exposed genitals.
At 11:47 AM, the surveyor interviewed the Director of Nursing (DON) who stated that privacy was maintained by pulling the privacy curtain and closing the bedroom door. The DON further stated that the resident should have been covered by the staff member before she walked out of the resident's room. The DON stated that the purpose for maintaining privacy was to maintain dignity for the resident.
The surveyor reviewed the medical record for Resident #43.
A review of the resident's admission Record (an admission Summary) reflected that the resident had resided at the facility for several years and had diagnoses which included but were not limited to metabolic encephalopathy (a chemical imbalance in the brain), personal history of traumatic brain injury, flaccid hemiplegia (inability to move one side of the body), muscle spasm, and major depressive disorder.
A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/5/21 indicated that the resident had unclear speech and was usually able to be understood when expressing himself/herself. A further review of the resident's MDS indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of Section H0300 further indicated that the resident was occasionally incontinent of urine.
A review of the facility's In-Service Record/Meetings Form dated 01/10/22 indicated that the CNA was in-serviced on, Dignity- Providing privacy while giving care.
A review of the facility's undated Quality of Life - Dignity Policy and Procedure indicated, Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
NJAC 8:39-4.1 (a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) maintain a resident's motorized wheelchair in a clean and sanitary ma...
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Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) maintain a resident's motorized wheelchair in a clean and sanitary manner and, b.) maintain a resident's tube feeding pole in a clean and sanitary manner. This deficient practice was identified on 1 of 5 nursing units, 3 West, for 1 of 35 residents reviewed, (Resident # 42) for cleanliness of wheelchairs, and for 1 of 5 residents reviewed, (Resident #15) who were receiving artificial nutrition via a tube feeding.
The deficient practice was evidenced by the following:
1. On 01/04/22 at 10:02 AM, the surveyor observed Resident #43 glide up to the front of the nursing station while seated in his/her motorized wheelchair. The surveyor observed that the residents motorized wheelchairs was covered in yellow, brown, and white caked on dust and debris. The resident spoke very softly and was able to tell the surveyor his/her name.
On 01/05/22 at 12:21 PM, the surveyor observed the resident laying in bed in his/her room. The surveyor exited the resident's room and observed the residents motorized wheelchair in the hallway, in the same condition as the day prior. Caked on yellow, white, and brown debris covered the legs, parts of the seat, and the bottom base of the wheelchair.
On 01/06/22 at 10:51 AM, the surveyor observed the residents motorized wheelchair in the hallway outside of the resident's room. The surveyor observed that the residents motorized wheelchairs was covered in yellow, brown, and white caked on dust and debris.
At 11:50 AM, the surveyor interviewed the daytime Housekeeper (HK) for 3 [NAME] who stated that she was not responsible for cleaning the resident's wheelchairs.
At 11:56 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that if observed a resident's wheelchair was soiled, she would clean it. The CNA further stated that she believed each CNA made rounds throughout their shift to make sure the resident's rooms and their wheelchairs were clean. The CNA did not speak to the cleanliness of Resident #43's wheelchair.
At 12:00 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that she honestly did not know if there was a schedule in place for cleaning the resident's wheelchairs. The LPN further stated that if the wheelchair was visibly soiled, the staff would clean the wheelchair for the resident.
At 12:03 PM, the LPN observed the residents motorized wheelchair in the presence of the surveyor and stated that the residents motorized wheelchair needed to be cleaned. The LPN further stated that the bottom portion of the residents motorized wheelchair was dusty and layered in a brownish colored debris.
At 1:16 PM, the surveyor interviewed the Housekeeping Director (HKD) who stated that there was a cleaning schedule in place for cleaning the resident's wheelchairs and the facility staff tried to clean the resident's wheelchairs at least once a month.
On 01/11/22 at 11:11 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the residents motorized wheelchair was cleaned on 01/6/22. The DON further stated that the resident's wheelchairs were cleaned monthly by the nighttime HK and porter and as needed by either the housekeeping or nursing staff.
On 01/11/22 at 11:12 AM, the surveyor interviewed the Administrator who stated that the wheelchairs were power washed monthly and there was no Supervisor on the 3:00 PM to 11:00 PM shift who checked to see if the wheelchairs were cleaned. The Administrator further stated that the facility did not have a Policy and Procedure in place for cleaning the wheelchairs.
A review of the facility's Wheelchair Cleaning Logs dated October 2021, November 2021, December 2021 indicated that the wheelchairs on 3 [NAME] had been cleaned. A further review of the facility's Wheelchair Cleaning Logs for the months of October 2021, November 2021, and December 2021 did not indicate a specific numerical date in which the wheelchairs were cleaned. The surveyor was not provided with a Wheelchair Cleaning Log for the month of January 2022.
2. On 01/04/22 at 10:21 AM, the surveyor Observed Resident #15 laying in bed with his/her eyes closed. The surveyor observed a tube feeding pole in the resident's room. The bottom of the tube feeding pole was observed to have crusted layers on brownish, tan colored splatter throughout.
On 01/05/22 at 12:23 PM, the surveyor observed the tube feeding pole in the resident's room in the same condition as the day prior. The bottom of the tube feeding pole was observed to have crusted layers on brownish, tan colored splatter throughout.
On 01/06/22 at 10:57 AM, the surveyor observed that the bottom portion of the resident's tube feeding pole had crusted layers of brownish, tan colored spillage throughout.
At 11:50 AM, the surveyor interviewed the HK for 3 [NAME] who stated that she cleaned all the resident's rooms on the unit. The HK stated that it was her responsibility to clean the resident's tables, dressers, bathrooms, and floors. The HK further stated that she was responsible for cleaning the tube feeding poles in the resident's rooms.
At 11:56 AM, the surveyor interviewed the resident's CNA who stated that her responsibility for cleaning a resident's room was she would sweep the floors, remove soiled linen, and take out the trash when full. The CNA further stated that she believed each CNA during their shift would make rounds to make sure the resident's rooms were clean. The CNA stated that she thought it was the nurse's responsibility to clean the tube feeding poles in the resident's room because the nurses were responsible for administering the tube feeding formula.
At 12:00 PM, the surveyor interviewed the resident's LPN who stated that the housekeeping staff were responsible for cleaning the tube feeding poles in the resident's rooms.
At 12:04 PM, the surveyor entered Resident #15's room with the residents LPN. The LPN looked at the tube feeding pole and stated that the bottom of the pole had beige colored spillage on it that was from the resident's tube feeding formula.
At 1:16 PM, the surveyor interviewed the facility's HKD who stated that the housekeeping staff were responsible for cleaning the trash, mopping, and disinfecting the resident's rooms and bathrooms, cleaning high touch areas such as door handles, and doorknobs. The HKD further stated that the housekeepers were responsible for cleaning the toilets in the resident's bathrooms, sweeping the floors, and replenishing the supplies on the unit. The HKD stated that the housekeeping staff were responsible for cleaning spillage on the tube feeding poles in the resident's rooms. The HKD stated that he follows up with his staff and checks three to five resident rooms daily to make sure that the rooms were cleaned. The HKD explained to the surveyor that when he checked the resident's rooms, he looks for overall cleanliness and checking that the tube feeding poles were clean would be something he would look for.
On 01/11/22 at 11:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #15's tube feeding pole was cleaned yesterday and she observed that there was tube feeding formula throughout the tube feeding pole.
On 01/11/22 at 11:37 AM, the surveyor interviewed the Administrator who stated that it was housekeeping's responsibility to clean the tube feeding poles in the resident's rooms. The Administrator further stated that the facility had no Policy and Procedure for cleaning the tube feeding poles.
NJAC 8:38-4.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to follow physician's orders by administering as needed narcotic pain medications based on pain scale parameters for the prescribed tramadol and oxycodone in accordance with professional standards of practice. This deficient practice was identified for 1 of 2 residents (Resident #154) reviewed for pain.
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 evidence was as follows:
On 1/3/22 at 12:46 PM, the surveyor observed Resident #154's door closed. The resident was on transmission-based precautions for COVID-19 and had not responded to surveyor knocking.
The surveyor reviewed the medical record for Resident #154.
A review of the admission Record face sheet (admission summary) reflected that the resident was re-admitted to the facility in October 2021, with diagnoses which included generalized muscle weakness, Parkinson's disease, and pain disorders with related psychological factors.
A review of the active Order Summary Report (OSR) reflected a physician's order (PO) dated 11/20/21, for oxycodone HCL 5 milligram (mg) tablet, a narcotic pain medication; to give one tablet by mouth every six hours as needed for severe pain. A further review revealed PO dated 11/20/21, for tramadol HCL 50 mg tablet, a narcotic pain medication; to give two tablets by every six hours as needed for moderate pain. A PO dated 10/16/21, indicated to evaluate pain using the [NAME] 0-10 pain scale: 0 = no pain; 1-3 = mild pain; 4-6 = moderate pain; 7-9 = severe pain; and 10 = worst pain.
A review of the corresponding electronic Medication Administration Record (eMAR) for December 2021, reflected that the resident was administered oxycodone out of the prescribed parameters (7-10) on the following dates and time:
Pain Level 0: 12/31/21 at 9:27 AM.
Pain Level 4: 12/20/21 at 4:48 PM.
Pain Level 5: 12/26/21 at 6:01 PM; 12/27/21 at 6:33 PM.
Pain Level 6: 12/6/21 at 8:54 PM; 12/13/21 at 12:00 PM; 12/13/21 at 7:29 PM; 12/14/21 at 5:36 PM; 12/18/21 at 10:37 AM; 12/18/21 at 7:31 PM; 12/19/21 at 10:00 AM.
A review of the corresponding eMAR for December 2021, reflected that the resident was administered tramadol out of the prescribed parameters (4-6) on the following dates and time:
Pain Level 7: 12/8/21 at 12:50 PM; 12/15/21 at 2:08 PM; 12/26/21 at 10:13 AM.
Pain Level: 8: 12/9/21 at 7:45 PM; 12/19/21 at 1:05 AM; 12/21/21 at 8:48 PM; 12/24/21 at 10:00 PM.
Pain Level 9: 12/12/21 11:13 PM; 12/15/21 at 9:20 PM; 12/25/21 at 9:36 AM.
Pain Level 10: 12/5/21 at 5:29 PM.
A review of the corresponding eMAR for January 2022, reflected that the resident was administered oxycodone out of the prescribed parameters on the following dates and time:
Pain Level 6: 1/4/22 at 1:01 AM; 1/4/22 at 6:59 PM; 1/5/22 at 8:44 PM; 1/9/22 9:02 PM.
On 1/10/22 at 10:03 PM, the surveyor observed Resident #154 lying in bed. The resident stated that he/she had frequent pain and received oxycodone and another medication that he/she could not recall the name. The resident stated that he/she could take the medication every six hours as needed.
On 1/10/22 at 11:00 AM, the surveyor interviewed the resident's medication nurse for the day who was the Registered Nurse/Unit Manager (RN/UM) who stated that she just administered the resident an oxycodone for a pain level of a six. The RN/UM stated that the resident also received tramadol as needed and had routine gabapentin (nerve pain medication) for neuropathy (weakness, numbness, and pain from nerve damage). The RN/UM stated that she administered the oxycodone instead of the tramadol because the oxycodone relieved the resident's pain better.
On 1/10/22 at 11:39 AM, the surveyor interviewed the Director of Nursing (DON) who stated that pain medication was administered according to the pain level and the PO. If the resident was asking for a pain medication that did not correlate with the pain level, the nurse would need to communicate that to the Physician. The DON stated that you would expect to see documentation from the nurse regarding this in the Progress Notes.
On 1/10/22 at 12:08 PM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), [NAME] President Clinical, and survey team acknowledged that Resident #154 was receiving oxycodone and tramadol outside of the ordered parameters. The DON confirmed that medications should only be administered in accordance with the PO.
NJAC 8:39- 11.2(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to obtain the appropriate physician orders for the care of a ...
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Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to obtain the appropriate physician orders for the care of a resident with a tracheostomy (an opening surgically created through the neck into the trachea). This deficient practice was identified for 1 of 1 residents (Resident # 210) reviewed for respiratory care.
This deficient practice was evidenced by the following:
On 1/3/22 at 1:00 PM, the surveyor observed Resident # 210 inside his/her room. The resident was observed with a tracheostomy. The resident was able to speak. The tracheostomy dressing was clean and intact.
On 1/4/22 at 10:45 AM, the surveyor observed the resident in his/her room. The resident did not wish to speak with the surveyor.
The surveyor reviewed the medical record for Resident #210.
A review of the resident's admission Record reflected that the resident had diagnoses which included but were not limited to malignant neoplasm of check mucosa, cellulitis of face, malignant neoplasm of accessory sinus, unspecified, squamous cell carcinoma of skin of scalp and neck, and tracheostomy status.
A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/14/21, reflected that the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15 which indicated the resident was cognitively intact. Further review of the resident's MDS, section O-Special Treatments, Procedures, and Programs indicated the resident received tracheostomy care.
A review of the resident's electronic January 2022 Order Summary Report (OSR) reflected the following discontinued physician's order dated 2/25/21:
- to change inner # 4 Shiley cuffless daily and as needed everyday shift for change inner #4.
- suction every shift and as needed for suction.
- Trach care every shift.
Further review of the electronic January 2022 OSR did not reflect physician orders for the care of the resident's tracheostomy.
Review of the December 2021 and January 2022 electronic Medication Administration Record (eMAR) and Treatment Administration Record (eTAR) reflected there was no documented evidence to ensure the daily care of the resident's tracheostomy care was completed.
A review of the resident's individualized comprehensive care plan date initiated 7/14/21, reflected a focus area that the resident has a tracheostomy related to cancer of the neck, face, and throat. The goal of the resident's care plan was that the resident will have no abnormal drainage around trach site through the review date and will have no complications resulting from trach through the review date. The interventions for the resident's care plan indicated to ensure that trach ties are secured at all times; monitor/document for restlessness, agitation, confusion, increased heart rate (tachycardia), and bradycardia; monitor/document level of consciousness, mental status, and lethargy as needed; oxygen settings: O2 via (specify: nasal prongs/ mask); provide good oral care daily and as needed; provide means of communication and procedural information. Reassure that help is available immediately; provide paper and pencil if needed. Work with resident to develop communication system that will work in an emergency; Reassure resident to decrease anxiety; Suction as necessary; Tube out procedures: keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate head of bed 45 degrees and stay with resident. Obtain medical help immediately; use universal precautions as appropriate.
On 1/10/22 at 11:21 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) for the 3 [NAME] unit. The ADON stated that the resident has a trach and a feeding tube due to mouth cancer and recent surgery for the cancer. She further stated that the nurses do the trach care for the resident.
On that same date and time, the surveyor together with the ADON reviewed the electronic January 2022 OSR which indicated that the physician orders for the care for the resident's tracheostomy were discontinued on 2/25/21 and there were no active physician orders for the care of the tracheostomy. The ADON stated she would have to look into why the resident did not have active physician orders for care of the tracheostomy.
On 1/10/22 at 12:49 PM, the ADON stated that the resident likes to do his/her trach care him/herself, the nurses sometimes do it. But yes, he/she should have physician orders for tracheostomy care.
On 1/10/22 at 1:11 PM, the surveyor met with the administrative team and discussed the above concerns.
On 1/11/22 at 11:04 AM, the Director of Nursing (DON) stated that the resident was readmitted to the facility in October 2021 and the trach orders were not put into the electronic medical record. The DON stated the resident should have had physician orders for the care of the tracheostomy and that the nurses ensured the resident's trach care by visible inspection and by talking with him/her. She further stated that the resident was seen monthly by an outside respiratory company. The DON stated that the respiratory care notes were not in the resident's medical record we are getting that now. I can't speak to anything until I see the documentation. He/she was last seen on 12/31/21. He/she is seen monthly.
There was no additional information provided.
A review of the facility's Tracheostomy Care policy revised on 11/12/21, indicated that Tracheostomy care and suctioning shall be performed as necessary to maintain a clear airway and to prevent infection. Tracheostomy care and suctioning shall be performed by a Registered Nurse or a Licensed Practical Nurse.
NJAC 8:39-11.2 (b); 27.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**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 ensure that all medications we...
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**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 ensure that all medications were administered without error of 5% or more. During the medication observation on 1/6/22 and 1/10/22, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 33 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 6.06 %. This deficient practice was identified for 1 of 4 residents (Resident #47), that were administered medications by 1 of 2 nurses and was evidenced by the following:
1. On 1/6/22 at 11:03 AM, the surveyor conducted a medication pass observation in the presence of a second surveyor. The surveyor observed the Licensed Practical Nurse (LPN) preparing to administer ten (10) medications to Resident #47 which included polyethylene glycol 3350 powder (Clearlax; a laxative medication to relieve constipation) 17 grams (GM). The LPN stated that Clearlax was an over the counter (OTC) medication and was obtained by the facility as a house stock product and stored in the original container in the medication cart. The LPN also stated that according to the electronic Medication Administration Record (eMAR) for Resident #47, Clearlax was the OTC medication ordered by the physician. The LPN poured the Clearlax powder into the cap of the manufacturer's bottle and then put the powder into a clear plastic cup. The surveyors had not observed the LPN measure the amount of powder in the cap. The LPN stated that the resident did not like cold water so she would use tap water in the resident's room to dilute the powder.
On 1/6/22 at 11:22 AM, the LPN confirmed that she was going to administer the ten (10) medications to Resident #47. The surveyor in the presence of another surveyor, stopped the LPN and asked her to review the medications she was about to administer. The surveyor asked the LPN how she measured the 17 GM of Clearlax powder. The LPN replied that she thought there should have been a measuring device to accompany the Clearlax. Then the LPN poured the powder from the clear plastic cup back into the Clearlax manufacturer's cap and the surveyors were able to visualize that the powder did not reach the indicated measuring line. The LPN proceeded to pour the powder into a teaspoon which yielded a teaspoonful of Clearlax powder. The surveyor asked the LPN to review the directions for use on the Clearlax manufacturer's bottle which revealed: the bottle top is a measuring cap marked to contain 17 grams of powder when filled to the indicated line (white section on cap). The LPN had to read the instructions on the manufacturers' bottle because she did not understand the indicated measuring line and the surveyor had to point out where the measuring line was indicating on the cap for 17 GM to be measured. (ERROR#1)
The LPN further stated if she gave the full amount of 17 GM, Resident #47 would refuse to take the full amount of Clearlax powder because of the taste. The LPN then measured again the Clearlax to the indicated 17 GM line.
On 1/6/22 at 11:45 AM, the surveyor in the presence of another surveyor observed the LNP add four ounces of tap water to the Clearlax 17 GM powder and administered the Clearlax to Resident #47. The resident took his/her medications by drinking the entire amount of liquid that contained the Clearlax.
On 1/6/22 at 11:46 AM, the surveyor interviewed Resident #47 who stated that he/she took the pills the nurses brought by drinking the water with the laxative in it. The resident added that he/she was not bothered by the taste of the water with the laxative.
On 1/6/2021 at 12:01 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that Clearlax must be administered as instructed on the eMAR and physician order (PO). The RN/UM also stated that he/she would follow the measurement instructions on the manufacturer's bottle. The RN/UM stated that medications should always be offered regardless of previous refusals and any refusals or if the resident did not take the medication in full, there would be documentation on the eMAR and electronic Progress Notes (ePN). In addition, the RN/UM stated that the physician would need to be notified of the refusals.
The surveyor reviewed the medical record for Resident #47.
A review of the resident's admission Record (an admission summary) reflected that the resident was admitted to the facility in July of 2020 with diagnoses which included disc degeneration, lumbar region, and other chronic pain.
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/12/21, reflected that 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 January 2022 eMAR had not reflected any refusals of Clearlax.
On 1/10/22 at 11:00 AM, the surveyor interviewed Assistant Director of Nursing/Registered Nurse (ADON) who stated that she was the facility educator. The ADON/RN stated that the nurses were to document any refusals of medications and contact the physician. The ADON further stated that if a nurse was unsure how to administer a medication or measure a medication, then the nurse can ask the UM, the other ADON, or her. In addition, the ADON stated that the nurses were to administer the medications according to the physician's order. The ADON also stated that new nurses were observed for medication administration after shadowing an experienced nurse and each nurse was observed at least once a year.
On 1/10/22 at 2:30 PM, the surveyor interviewed the consultant pharmacist (CP) via telephone who stated that he thought the nurses would know how to measure Clearlax powder in the cap.
On 1/11/22 at 12:16 PM, the Director of Nursing (DON) acknowledged that the nurses should administer a medication as prescribed by the physician.
A review of the facility's Medication Administration Policy dated revised 12/20/21, included prior to administering the first dose of a new medication, the nurse will verify the order was correctly transcribed by comparing with the physician's order .check the transcribed order on MAR for the dose, time and route of administration .compare medication order on the MAR three (3) times with label on medication (taking out of the drawer, before opening and compare label again).
A review of the manufacturer specifications for Clearlax powder included to follow the directions for use to the bottle top is a measuring cap marked to contain 17 grams of powder when filled to the indicated line (white section on cap).
2. On 1/6/22 at 11:03 AM, the surveyor conducted a medication pass observation in the presence of a second surveyor. The surveyor observed the LPN preparing to administer ten (10) medications to Resident #47. The surveyor observed the LPN read the eMAR for a PO for Lidocaine 5% ointment (a topical medication used to relieve pain by numbing the area). The LPN removed a Bengay 5% patch (menthol 5% patch; a topical medication used to relieve pain by cooling and desensitizing the area) from the medication cart and stated that the Bengay 5% patch (menthol) was an OTC medication and was obtained by the facility as a house stock product. The LPN added that the BenGay patch was the medication to be administered.
On 1/6/22 at 11:22 AM, the LPN confirmed that she was going to administer the ten (10) medications to Resident #47. The surveyor in the presence of another surveyor stopped the LPN and asked her to review the medications she was about to administer. The surveyors with the LPN reviewed the eMAR which revealed a PO for Lidocaine 5% ointment; apply to the lower back topically in the morning for pain management. The LPN stated that the RN/UM had advised her in the past to substitute Bengay 5% patch (menthol 5% patch) when the Lidocaine 5% patch was not in stock. The LPN confirmed Bengay 5% patch (menthol 5% patch) was not the correct medication; it was not the same as Lidocaine 5% ointment. The LPN stated that she would speak with the RN/UM to obtain the Lidocaine 5% ointment. The LPN had not administered the BenGay Patch after surveyor inquiry. (ERROR#2)
On 1/6/22 at 11:47 AM, the surveyor interviewed Resident #47 who stated that he/she took pills for pain which helped relieve the pain in his/her back. The resident added that the nurses also put something on his/her back for pain. The resident stated that he/she thought the medication on the back was a patch but was unsure and thought it could also have been an ointment or cream. The resident added that today the nurse had not done that yet.
On 1/6/2021 at 12:01 PM, the surveyor interviewed the RN/UM who stated that medications can be ordered from central supply. The RN/UM added that for house stock medications, the nurses can check other medication carts for availability. The RN/UM further stated that the physician can be contacted, and a request made for an alternative medication if a medication was not available.
The surveyor reviewed the medical record for Resident #47.
A review of the resident's admission Record reflected that the resident was admitted to the facility in July of 2020 with diagnoses which included disc degeneration, lumbar region, and other chronic pain.
A review of the most recent quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 14 out of 15, indicating that the resident had an intact cognition.
On 1/10/22 at 11:00 AM, the surveyor interviewed the ADON who stated that medications were to administered according to PO and must match the eMAR. The ADON also stated that if a house stock medication was not available in the cart, then central supply can be called to restock the missing house stock/OTC medication. The ADON/RN further stated that the physician can also be contacted for a substitution.
A record review of the house stock item list provided by the and Licensed Nursing Home Administrator (LNHA) revealed that Lidocaine 5% patch was on the list and Lidocaine 5% ointment was not on the list.
On 1/10/22 at 2:30 PM, the surveyor interviewed the CP via telephone who stated that he was not aware of any substitutions for OTC medications. The CP further stated that Lidocaine 5% ointment cannot be substituted for a Bengay 5% patch (menthol 5% patch) because it is not the same medication.
On 1/11/21 at 10:00 AM, the surveyor interviewed a Pharmacy Representative (PR) from the facility's provider pharmacy who provides the medications to the facility via telephone. The PR stated that a physician's order for Lidocaine 5% ointment for Resident #47 had an order date of 11/10/2020 and was filled for a 35.44 GM tube with refill dates of 12/25/2020, 1/10/21, 1/14/21, 5/21/21, and 6/6/21. The PR further stated there were no issues with availability for Lidocaine 5% ointment.
On 1/11/22 at 12:16 PM, the DON acknowledged that the nurses should administer a medication as prescribed by the physician.
On 1/11/22 at 1:52 PM, the surveyor in the presence of the survey team asked the LNHA, the DON, and [NAME] President Clinical (VPC) asked what the process receiving and administering medications. The VPC responded that when the nurses received a medication from the pharmacy, they were to make sure that the medication matched what was ordered by the physician. The DON further stated that if there was a discrepancy, then the physician should be called to clarify the physician order.
A review of the manufacturer's specifications for Lidocaine 5% ointment reflected that the medication is a prescription medication.
A review of the manufacturer's specifications for BenGay patch reflected that the medication was an OTC medication containing menthol as the main ingredient.
NJAC 8:39-11.2(b), 29.2(d)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) identify and remove expired medications from an ...
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Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) identify and remove expired medications from an active medication cart and b.) maintain a completed temperature log for a medication storage refrigerator. This deficient practice was identified for 1 of 5 observed medication carts (2 East) and 1 of 3 observed medication storage rooms (3 West) and was evidenced by the following:
1. On 1/10/22 at 9:53 AM, the surveyor interviewed the Licenced Practical Nurse/Unit Manager (LPN/UM) regarding the process for checking medication storage. The LPN/UM stated that the nurses and her were responsible for checking medication storage to ensure there were no expired medications or items. The LPN/UM further stated that expired medications and items were given back to central supply to discard.
On 1/10/22 at 10:01 AM, the surveyor in the presence of a second surveyor and LPN #1 inspected medication cart two (2) on 2 East. The cart contained the following expired medications:
geri-tussin 11/21 house stock
docu liquid 10/21 house stock
On 1/10/22 at 10:09 AM, LPN #1 confirmed geri-tussin and docu liquid medications were expired. The LPN stated that all nurses on all shifts were supposed to check the expiration date prior to administering the medications.
On 1/10/22 at 2:30 PM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who confirmed that he conducted unit inspections at the facility which included indentifying expired medications.
On 1/11/22 at 11:07AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA), [NAME] President Clinical (VPC), and survey team acknowledged that there should not have been expired medications on the medication cart. The DON further stated that the facility utilized a Unit Inspection Audit tool once a week.
A review of the facility provided Storage of Medications policy dated revised 12/10/21 included the facility shall not use discontinued, outdated or deteriorated drugs or biological's. All such drugs shall be returned to the dispensing pharmacy or destroyed.
2. On 1/10/22 at 10:56 AM, the surveyor in the presence of LPN #2 inspected the 3 [NAME] medication storage room. The surveyor observed the Med Room Temp Log for the unit's medication refrigerator was not completed since 1/6/22. The surveyor observed at this time, that resident medications were being stored inside of it. At this time, the surveyor interviewed the LPN who stated that she could not speak to why the temperatures were not recorded since 1/6/22 or who was responsible for taking the temperature of the medication storage refrigerator.
On 1/10/22 at 11:09 AM, the surveyor interviewed the DON who stated that the Unit Manager (UM) on each unit was responsible for checking the medication storage refrigerator, as well as the CP. The temperature log was completed by the UM in the mornings, Monday through Friday. The DON could not speak to who was responsible for completing the medication refrigerator temperature logs on the weekends.
On 1/10/22 at 11:18 AM, during a follow-up interview with the DON, she informed the surveyor that the 11-7 shift nursing staff was responsible for recording the medication storage refrigerator temperatures in the medication storage room. In addition, the DON stated that the UM was responsible for verifying that it was done by the 11-7 shift nursing staff Monday through Friday, and that the Nursing Supervisor was responsible for making sure it was done on the weekends. The DON further stated, The UM and the Nursing Supervisor did spot checks on different areas on the units; but did not necessarily check the medication storage refrigerator temperature logs each day.
On 1/10/22 at 11:30 AM, the surveyor interviewed the 3 [NAME] Registered Nurse/UM (RN/UM) who stated that the 11-7 shift nursing staff were responsible for checking and documenting temperatures for the medication storage refrigerator in the medication storage room. The RN/UM confirmed that she was responsible Monday through Friday for ensuring the temperatures for the medication storage refrigerator were completed. The RN/UM could not speak to who was responsible for checking the temperatures on the weekends. The RN/UM stated, I do check the temperatures in the morning, but I'm on the cart today and didn't get to do most of the stuff I was supposed to do. The RN/UM stated if the Med Temp Log was not signed, then she would think the nursing staff forgot to do it and would question why it was not done.
At this time, the surveyor showed the RN/UM the Med Temp Log for her unit that had not been completed since 1/6/22. The RN/UM confirmed that the temperature log was incomplete and that the temperatures should be taken daily. The surveyor asked the UM if the temperatures were not done, how did she know the temperatures were maintained for the days the temperature log was not completed? The RN/UM replied, I would check the thermometer myself. Then I would look at the medications to see if they were still good; for example, insulin, if it was cloudy, then it would be no good. When questioned, the RN/UM could not speak to the acceptable temperature ranges for the medication storage refrigerator.
On 1/10/22 at 1:04 PM, the surveyor asked the LNHA what the medication storage refrigerator temperature range should be, and she responded, It should be below 40 degrees.
On 1/10/22 at 2:30 PM, the surveyor interviewed the CP via telephone who stated that he completed monthly unit inspections and looked for expired medications and proper medication storage. The CP would also check the medication refrigerators on the units for the same issues. The CP stated that all refrigerated medications should be stored between 36 to 46 degrees Fahrenheit (F), and the CP thought it was noted on the log that the nurses checked daily. The CP was unaware of any problems with medication storage refrigerator temperature logs at the facility. The CP stated the medication refrigerator temperature logs should be completed daily to ensure the temperatures were correct. The CP stated he was at the facility last week to do the checks.
On 1/11/22 at 11:09 AM, DON in the presence of the LNHA, VPC, and survey team stated that 3 [NAME] nursing unit was using the wrong temperature log recording sheet. The DON provided a new recording sheet labeled Med Room Temp Log which included on the sheet temperature ranges 36-46 Degrees F, Check Refrigerator every day. If out of range, NOTIFY YOUR SUPERVISOR. The DON stated that she had called the 11-7 LPN, who stated that she had checked the medication storage refrigerator temperatures each night, but she did not document on the temperature log.
A review of the facility provided Storage of Medications policy dated 12/10/21 included in #2 The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.
NJAC: 8-39 - 29.4(g)(h)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/3/22 at 12:32 PM, the surveyor interviewed Resident #27 in his/her room. The resident stated that their call bell was no...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/3/22 at 12:32 PM, the surveyor interviewed Resident #27 in his/her room. The resident stated that their call bell was not working, and they had informed maintenance, but it still was not repaired.
The surveyor reviewed the medical record for Resident #27.
A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in September of 2020 with diagnoses which included Parkinson's disease, spinal stenosis (narrowing of the spinal canal), paranoid schizophrenia, and low blood pressure.
A review of the most recent quarterly MDS dated [DATE], reflected that the resident had a BIMS score was 15 out of 15, which indicated a fully intact cognition.
On 1/10/22 at 10:26 AM, the surveyor was unable to speak with the resident because the CNA #2 was rendering care, however the resident called out from behind the curtain that the call bell was still not working.
At this time, CNA #2 confirmed that the resident's call bell was not working, and that the facility had provided the resident a tap bell to ring if needed. When the surveyor asked if CNA #2 was aware if maintenance had come to look at the call bell, the CNA replied she was unsure. The surveyor then asked CNA #2 to press the call bell and the CNA confirmed that she had. The surveyor did not observe the light illuminated outside the resident's door as expected.
On 1/10/22 at 10:32 AM, the surveyor interviewed RN/UM #2 who stated that the process for when something was broken or not working, was to call the front desk and they would call maintenance. The nurse or whoever called the front desk would not document the call. RN/UM #2 stated that she was aware Resident #27's call bell was not working since last week. Maintenance had come to check it and they were unable to fix it, so they had given the resident a tap bell temporarily.
On 1/10/22 at 11:04 AM, the surveyor interviewed the MD who stated that he was responsible for everything related to maintenance, electric, sheetrock, and plumbing. The MD stated that the facility procedure for a work order was for staff to call the front desk and the Receptionist would write down the request on a log; then he would obtain the log and assign the work to his staff. The MD confirmed that everything should be documented on the log, both the request and that the work had been completed. The MD further stated a call bell repair would be considered an emergency. The MD stated extra supplies of call bells were kept on hand in the key room.
On 1/10/22 at 11:18 AM, the MD and the surveyor toured the key room which contained numerous replacement call bells.
On 1/10/22 at 11:21 AM, the surveyor interviewed the facility's front desk Receptionist who confirmed that she kept a log of the maintenance requests. At that time, the Receptionist provided a copy of the Maintenance Request Log dated 1/3/22 through 1/5/22.
On 1/10/22 at 11:40 AM, the surveyor reviewed the Maintenance Request Log dated 1/3/22, which revealed two separate notations indicating Resident #27's call bell was not working and needed to be checked by maintenance.
A review of the facility's Answering the Call Bells Policy and Procedure dated 8/8/21 indicated staff was to report all defective call bells to the Supervisor promptly. The facility's Answering Call Bell Policy and Procedure did not speak to malfunctioning call bells.
NJAC 8:39-31.8(c)9
Based on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to maintain a functioning call bell system. This deficient practice was identified on 2 of 5 nursing units (3 [NAME] and 3 East) and for 2 of 35 residents (Resident #27 and Resident #38) reviewed and was evidenced by the following:
1. On 1/5/22 at 11:39 AM, the surveyor observed Resident #38 seated in a wheelchair in his/her room. The resident stated that his/her call bell had not been working for a couple of days and the facility gave him/her a tap bell to use. The surveyor observed the tap bell on the residents overbed table.
On 1/6/22 at 12:07 PM, the surveyor stood outside of Resident #38's room and observed the call bell light blinking over the door to the residents room.
On 1/6/22 at 12:09 PM, the surveyor observed the resident and his/her friend in the resident's room. The resident's friend stated that they had called the maintenance department to notify them that the call bell was not working. The surveyor observed a tap bell on the overbed table in the resident's room
On 1/6/22 at 1:39 PM, the surveyor stood outside of Resident #38's room and observed the call bell light blinking over the door to the residents room.
On 1/10/22 at 9:30 AM, the surveyor stood outside Resident #38's room and observed the call light above the resident's door blinking. The surveyor entered the resident's room.
On 1/10/22 at 9:32 AM, the surveyor interviewed the resident's roommate who stated that the call bell was, shorted out on Resident #38's side.
On 1/10/22 at 9:33 AM, the surveyor interviewed the resident who stated that the call bell was not working. The resident stated, Problem with it for a long time. Think that it's fixed but then it's not. It needs to be fixed because what if I fell or something? No one would be able to come. They gave me this little bell, but no one will hear that.
On 1/10/22 at 9:40 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA #1) with the assistance of the Assistant Director of Nursing (ADON) who acted as a translator. CNA #1 stated that it was her first time working with the resident and that the call bell was flashing above the resident's door. CNA #1 further stated that she tried to turn the call bell off, but it wasn't working.
On 1/10/22 at 9:46 AM, the surveyor interviewed the Registered Nurse/Unit Manger (RN/UM #1) who was passing medications to the resident that day. RN/UM #1 stated they noticed last week the residents call bell was not working, maintenance knew about it, and was working on it. RN/UM #1 further stated that she thought the plan was to get a new one for the resident. RN/UM #1 stated that the process for notifying the maintenance department when something broke was to text them from her personal cell phone or page them.
On 1/10/22 at 12:24 PM, the surveyor interviewed the Maintenance Director (MD) who stated that if a nurse identified that something was broken and needed to be fixed for a resident, they would call the Receptionist at the front desk, the Receptionist would document the concern, and the maintenance department would follow up first thing in the morning the next day. The MD further stated that he delegates to his maintenance staff to fix the concern unless there was an emergency. The MD stated that he was unaware that Resident #38's call bell was not functioning.
The surveyor reviewed the facility's Maintenance Work Order in the presence of the MD. A review of the Maintenance Work Order indicated a written request dated 01/6/21, to fix the call bell in the resident's room.
On 01/11/22 at 11:16 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the call bell for Resident #38 was fixed on 01/6/21 but continued to malfunction.
On 1/11/22 at 11:17 AM, the Licensed Nursing Home Administrator (LNHA) stated that there was no documentation indicating that the call bell was fixed.
The surveyor reviewed the medical record for Resident #38.
A review of the resident's admission Record (an admission summary) indicated that the resident had resided at the facility for about a year and had diagnoses which included type two diabetes mellitus without complications, muscle weakness, need for assistance with personal care, and acquired absence of right leg below the knee.
A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/21/21, reflected the resident had a Brief Interview of Mental Status (BIMS) score was 15 out of 15 which indicated the resident was cognitively intact.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) document and carry out a Physician's Order (PO) for a urine and sto...
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Based on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) document and carry out a Physician's Order (PO) for a urine and stool culture within an appropriate time frame and b.) notify the resident's physician that staff was unable to obtain the urine and stool sample. This deficient practice was identified for 1 of 35 residents, (Resident #84) reviewed for quality of care and was evidenced by the following:
On 1/05/22 at 11:44 AM, the surveyor was approached by an alert and oriented resident, Resident #34 who was the roommate of Resident #84. Resident #34 stated that his/her roommate was recently admitted to the hospital. Resident #34 stated that he/she was very close with his/her roommate and they looked after one another like family. Resident #34 further stated that his/her roommate, Resident #84 had become delirious in the middle of the night and when that happened, the resident was sent out to the hospital by facility staff.
The surveyor reviewed the medical record for Resident #84.
A review of Resident #84's admission Record (an admission Summary) reflected that that resident was a long term care resident at the facility and had diagnoses which included but were not limited to chronic obstructive pulmonary disease (a group of lung diseases that block air flow and make it difficult to breath), urinary tract infection, sepsis (a life threatening infection throughout the body), congestive heart failure (chronic condition where the heart doesn't pump blood as well as it should), diabetes mellitus type two, and dependence on supplemental oxygen.
A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/21/21 reflected that 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 Progress Notes (PN) dated 12/23/21 and timed at 23:10 (11:10 PM) written by the Registered Nurse (RN) reflected that the resident had two episodes of vomiting. The RN called the resident's physician to notify him of the change in resident's status and received new orders for a urinalysis and a stool culture to test for ova (eggs) and parasites.
A review of the resident's January 2022 Order Summary Report (OSR) did not reflect a PO for the urinalysis or stool culture.
A review of the resident's laboratory results, did not indicate that urine or stool was obtained from the resident and sent to the lab for processing.
A review of the Laboratory Requisition Form dated 12/23/21 reflected that the RN put in a request for a urinalysis and culture to be obtained for the resident. The urine was never obtained and sent to the laboratory.
A review of an additional Laboratory Requisition Form dated 12/23/21 reflected that the RN made an additional request for a stool culture to test for ova and parasites be obtained for the resident. The stool culture was never obtained and sent to the laboratory.
A review of the resident's PN from 12/23/21 to 12/30/21 did not indicate that the resident's physician was made aware that the urine or stool sample was not obtained for the resident. This reflected a seven-day delay in treatment for obtaining the urine and stool sample for the resident.
A further review of the resident's January 2022 OSR reflected a PO dated 12/30/21 for urinalysis and culture.
A further review of the resident's PN's dated 12/30/21 and timed at 22:28 (10:28 PM) written by the Licensed Practical Nurse (LPN) indicated that the resident was in no distress. The 12/30/21 PN indicated that the Nursing Supervisor attempted to obtain urine via straight catheterization (inserting a flexible tube into the bladder to collect urine) and was unable to do so. The PN further indicated that the resident would be provided with fluids to drink and the nurse would try to obtain the urine later in the shift.
A continued review of the resident's PN from 12/30/21 to 1/2/22 did not reflect that urine or stool was obtained or that the resident's physician was notified that the Nursing Supervisor was unable to obtain urine by way of straight catheterization for the Resident #86.
A review of the resident's Care Plan (CP) revised 12/13/21 indicated a focus area that the resident had high blood pressure related to congestive heart failure and was at risk for stoke. The goal of the resident's CP was that the resident would remain free from signs and symptoms of high blood pressure through the next review date. The interventions in the resident's CP indicated to monitor and document abnormalities in urinary output and report significant changes to the resident's physician.
On 01/10/22 at 10:44 AM, the surveyor interviewed the resident's Registered Nurse/Unit Manager (RN/UM) who stated that the resident's primary nurse was not working that day. The RN/UM stated that the resident was alert and oriented and had diagnoses of diabetes and congestive heart failure. The RN/UM told the surveyor that the resident was sent out to the hospital because the resident's blood pressure was low, and the resident became confused which was different from his/her baseline. The RN/UM stated that prior to being sent to the hospital the resident had been complaining of nausea and vomiting. The RN/UM stated that she thought the resident's physician ordered a stool and urine sample for culture, but the staff was unable to obtain the urine. The RN/UM did not mention if the stool was ever obtained. The RN/UM further stated that she was unsure of why the staff were unable to obtain the urine sample and would have to find out. The RN/UM stated that if the physician ordered labs, they were usually done the following morning and if the nurse was unable to obtain the physician ordered urine and stool sample, the physician should have been notified and it should be documented in the resident's medical record.
At 11:53 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident was alert and oriented, very social, non-compliant with care, and made smoking his/her priority. The DON further stated that prior to the resident's hospitalization the resident became weak and lethargic. The DON told the surveyor that when a physician ordered laboratory work to be done, the expectation was to follow the PO. The DON stated that if the staff was unable to obtain the physician ordered lab specimen, the staff would have to let the physician know and then document that the physician was notified in the resident's medical record.
On 01/11/22 at 11:46 AM, the surveyor interviewed the [NAME] President of Clinical Operation (VP) who stated that it wasn't until 12/30/21 that the resident's urine was attempted to be obtained. The VP did not speak to the stool sample or notification of the physician.
At 11:49 AM, the DON stated that when labs were ordered for a resident, the nurse would write a physician's order for the laboratory specimens and document in the laboratory portal to make the lab technician aware. The DON further stated that it was the nurses working at the facility's responsibility to obtain the urine and stool samples, not the laboratory technicians.
At 1:02 PM, the surveyor placed a call to the RN who wrote the PN dated 12/23/21 and timed at 23:10 (11:10 PM) for the urine and stool culture after speaking with the resident's physician, but the RN was unavailable for an interview.
At 1:24 PM, the surveyor conducted an interview with the resident's physician over the telephone who stated that if he gave orders for laboratory specimens to be obtained, it was his expectation that they would be done for the resident. The physician further stated that he expected the nurses would notify him of the laboratory results and he further expected to be notified if the labs were unable to be obtained. The resident's physician further stated that he did not recall being notified that the resident's urine or stool were not obtained as ordered.
A review of the facility's Physician Notification of Change in Resident/Patient Condition Policy and Procedure dated 12/20/21 indicated, Our facility shall promptly notify the resident, his or her attending physician, and the representative (sponsor) of changes in the resident's condition and/or status.
NJAC 8:39-27.1(a)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based off observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) place a splinting device on a resident who had a Phy...
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Based off observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) place a splinting device on a resident who had a Physician's Order (PO) for one and b.) maintain accurate and consistent accountability for the use of the splinting device for the months of November 2021, December 2021, and January 2022. This deficient practice was identified for 1 of 4 residents, (Resident #43) reviewed for position and mobility.
The deficient practice was evidenced by the following:
On 01/04/22 at 10:02 AM, the surveyor observed Resident #43 glide to the front of the nurse's station on the 3 [NAME] unit in his/her motorized wheelchair. The surveyor further observed that the resident had a splinting device secured around on his/her left hand. The surveyor attempted to interview the resident; the resident softly told the surveyor his/her name.
On 01/05/22 at 12:21 PM, The surveyor observed the resident lying in bed in his/her room. The surveyor observed a trapeze bar over the resident's bed. The surveyor further observed that the resident was not wearing a splinting device on his/her left hand.
On 01/06/22 at 10:53 AM, the surveyor observed the resident sitting upright in bed watching television. The surveyor observed that the residents left hand was not placed in a splinting device. The resident's left hand was observed to be formed in a fist and was placed at the resident's side.
At 1:36 PM, the surveyor observed the resident in bed watching television. The surveyor observed that the resident was not wearing his/her left-hand splint. The surveyor attempted to interview the resident and asked the resident where his/her hand splint was. The surveyor could not understand the resident when he/she spoke. The resident pointed and showed the surveyor that his/her left-hand splint was located on the dresser next to the resident's bed. The residents left hand remained curled in a fist.
On 01/10/22 at 10:03 AM, The surveyor observed the resident in his room, lying in bed. The surveyor observed the resident's left hand under a sheet. The resident's left-hand splint was observed laying on the floor by the resident's closet.
At 10:23 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident wore a splint on his/her left-hand. The CNA told the surveyor that she got the resident up out of bed on Monday's and Wednesday's and on those days, she would put the splint on the resident's left hand. The CNA further stated that on the days she did not put the splint on the resident, the therapist would. The CNA never mentioned that the resident would remove the hand splint.
At 10:55 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that she regularly took care of the resident and she never put the splinting device on the resident. The LPN stated that the resident was alert and oriented, did not speak clearly, had expressive aphasia (decline or loss in the ability to express speech), and could make needs known by speaking very slowly. The LPN was unsure if the resident had a contracture upon surveyor inquiry and stated that the resident did not wear a split to his/her left hand. The LPN further stated that if the resident wore a hand splint, there would be a PO for the use of the hand splint. The LPN reviewed the POs for the resident in the presence of the surveyor and identified that there was a PO for the use of the left-hand splint. The LPN further reviewed the January 2022 Treatment Administration Record in the presence of the surveyor and identified that there was no place for her to sign for the use of the left-hand splint.
At 11:25 AM, the surveyor interviewed the Registered Nurse/Unit Manager who stated that the resident was alert and oriented, had a contracture to his/her left hand, and wore a splinting device. The RN/UM further stated that it was the CNA's or the nurse's responsibility to place the splinting device on the resident and then the nurse would sign for the application of the device on the TAR. The RN/UM stated that sometimes the resident would put the left-hand splint on himself/herself. The RN/UM told the surveyor that the therapy department was not responsible for putting the hand splint on the resident but would educate the nursing staff on how to apply it if needed. The RN/UM never mentioned that the resident would remove the hand splint.
At 11:46 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the person responsible for putting the splinting device on the resident was the restorative nursing aide and the primary nurse would sign for the accountability of putting the hand splint on the resident in the TAR. The DON did not speak to who would place the hand splint on the resident when the restorative nursing aide had off from work.
At 12:20 PM, the surveyor interviewed the Director of Rehab (DR) who stated that Resident #43 wore the splint to his/her left hand, and it was the restorative nursing aide's responsibility to put the left-hand splint on the resident in the morning and document that she put it on and took it off the resident. The DR further stated that the resident would sometimes remove his/her left-hand splint.
At 12:33 PM, the surveyor asked the Administrator if the restorative nursing aide was available for an interview and was told that she had off from work. The Administrator stated that she was unsure who was responsible for putting the hand splint on the resident when the restorative nursing aide was off from work, but she would find out.
At 12:40 PM, the Administrator stated that it was the nurse's responsibility to put the hand splint on the resident when the restorative nursing aide had off work
The surveyor reviewed the medical record for Resident #43.
A review of the resident's admission Record (an admission Summary) reflected that the resident had resided at the facility for several years and had diagnoses which included but were not limited to metabolic encephalopathy (a chemical imbalance in the brain), personal history of traumatic brain injury, flaccid hemiplegia (inability to move one side of the body), muscle spasm, and major depressive disorder.
A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/5/21 indicated that the resident had unclear speech and was usually able to be understood when expressing himself/herself. A further review of the resident's MDS indicated that 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 Section G0400 - Functional Limitation in Range of Motion indicated that the resident had limited range of motion in one upper extremity.
A review of the resident's January 2022 Order Summary Report (OSR) reflected a PO dated 01/10/22 for resting hand splint on left hand. ON after AM care. Off at PM care.
A review of the November 2021 TAR and December 2021 TAR did not reflect a PO for the nurses to sign for the accountability for the resting hand splint. A review of the January 2022 TAR reflected a PO dated 01/10/22 for nurses to sign for the accountability of the resting hand splint to be applied after AM care and removed after PM care.
A review of the resident's November 2021 Restorative Nursing Program Sheet indicated hand splint to prevent contracture on after AM care, off before PM care. A further review of the November 2021 Restorative Nursing Program Sheet reflected that the restorative nursing aide did not sign for the use of the hand splint on 11/6/21, 11/7/21, 11/13/21, 11/14/21, 11/18/21, 11/20/21, 11/21/21, 11/27/21, and 11/28/21.
A review of the resident's December 2021 Restorative Nursing Program Sheet indicated hand splint to prevent contracture on after AM care, off before PM care. A further review of the December 2021 Restorative Nursing Program Sheet reflected that the restorative nursing aide did not sign for the use of the hand splint on 12/4/21, 12/5/21, 12/11/21, 12/12/21, 12/13/21, 12/18/21, 12/19/21, 12/25/21, and 12/26/21.
A review of the resident's January 2022 Restorative Nursing Program Sheet indicated hand splint to prevent contracture on after AM care, off before PM care. A further review of the January 2022 Restorative Nursing Program Sheet reflected that the restorative nursing aide did not sign for the use of the hand splint on 01/1/22, 01/2/22, 01/6/22, 01/7/22, 01/8/22, 01/09/22, and 01/10/22.
A review of the resident's undated Care Plan (CP) reflected a focus area that the resident had a diagnosis of flaccid hemiplegia and needed a lot of help with care in the morning. The goal of the residents CP was for the staff to continue to provide the resident with help and the resident would not sustain injuries or feel unsafe. The interventions for the resident's CP included that the resident had a left-hand grip orthosis splint to be put on after AM care and removed after PM care to prevent further joint limitations and pain. The resident's CP did not reflect that the resident would remove his/her left-hand splint.
On 01/11/22 at 11:27 AM, the surveyor interviewed the [NAME] President of Clinical Operations who stated that she interviewed the resident and the resident stated that sometimes he/she would remove the hand splint during the day and the residents care plan was updated to reflect that the resident had this behavior.
A review of the facility's undated Cast/Splint/Brace/Immobilizer/Sling Care Policy indicated, Cast/Splint/Brace/Immobilizer/Sling Care monitoring is performed on residents. The facility's Cast/Splint/Brace/Immobilizer/Sling Care Policy did not reflect who was responsible for putting the splint on the resident or how the splinting device was monitored or accounted for while in use for a resident.
NJAC 8:39-27.1(a)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) receive a Physician's Order (PO) for a change in a res...
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Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) receive a Physician's Order (PO) for a change in a resident's dialysis schedule and b.) plot medications to be administered according to the resident's dialysis schedule. This deficient practice was identified for 1 of residents, (Resident #15) reviewed for dialysis and was evidenced by the following:
On 1/04/22 at 10:26 AM, the surveyor observed Resident #15 lying in bed. The resident closed his/her eyes when the surveyor entered the resident's side of the room. The surveyor asked the resident if he/she went to dialysis and the resident stated, no. The surveyor did not attempt to further interview the resident because the resident's body language indicated that he/she did not want to further communicate with the surveyor.
The surveyor reviewed the medical record for Resident #15.
A review of the resident's admission Record (an admission Summary) reflected that the resident resided at the facility for approximately half a year and had diagnoses which included but were not limited to end stage renal disease, dependence on renal dialysis, muscle weakness, and adult failure to thrive.
A review of the resident's most recent significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/15/21 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. A further review of the resident's MDS, Section O - Special Treatments, Procedures, and programs reflected that the resident was on dialysis.
A review of the resident's January 2022 MAR reflected a PO dated 12/11/21 for dialysis every Tuesday, Thursday, and Saturday at 5:30 AM.
On 01/10/22 at 10:11 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that for the past two weeks, the resident's dialysis schedule had changed for him/her to be picked up from the facility at 2:30 PM, instead of 5:30 AM on Tuesday's, Thursday's, and Saturday's. The LPN told the surveyor that as of tomorrow (01/11/21), the resident would be going back to his/her regular scheduled dialysis schedule of 5:30 AM. The LPN stated that when the resident went to dialysis early in the morning, he/she would return to the facility around 11:30 AM. This indicated the resident was out of the facility for approximately six hours. The LPN stated that when the resident left for dialysis at 2:30 PM, she was done with her shift at 3:00 PM, so she did not know when the resident was returning to the facility. The LPN stated that the resident's medications should be scheduled to be administered according to the resident's dialysis schedule. The LPN was unaware if the resident's medication times had changed to reflect the change in the resident's dialysis schedule.
At 11:21 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the resident's dialysis schedule had changed because the resident had tested positive for COVID-19. The RN/UM further stated that she assumed the resident's medications were changed according to the resident's dialysis schedule.
At 11:50 AM, the surveyor interviewed the Director of Nursing (DON) who stated that medications should be plotted when the resident was in the building, not when the resident was at dialysis. The DON further stated that if a resident's dialysis schedule changed, the medication times should also be changed.
A review of the December 2021 MAR reflected a PO dated 12/23/21 for strict droplet isolation for 10 days and to notify the Infectious Disease care for changes in clinical status every shift. This indicated that the resident was COVID-19 positive and needed additional infection control measures in place.
A further review of the resident's December 2021 MAR reflected a PO dated 12/12/21 for the supplement medication, Zinc Sulfate Extended Release give 220 milligrams (mg) via g-tube (a flexible tube inserted into the stomach to receive nutrients) in the evening as a supplement. The medication was plotted to be administered at 1700 (5:00 PM). The nurses had signed that the resident was administered the Zinc Sulfate medication at 1700 (5:00 PM) on Thursday 12/23/21, Saturday 12/25/21, Tuesday 12/28/21, and Thursday 12/30/21.
A further review of the December 2021 MAR revealed a PO dated 12/12/21 for the medication, Chlorpromazine 10 mg, give one tablet via g-tube two times a day for hiccups. The medication was plotted to be administered at 0900 (9:00 AM) and 1700 (5:00 PM). The nurses had signed that the resident was administered the medication Chlorpromazine 10 mg at 1700 (5:00 PM) on Thursday 12/23/21 and Saturday 12/25/21.
A further review of the December 2021 MAR reflected a PO dated 12/12/21 for the medication, Dronabinol 2.5 mg, give 1 capsule by mouth two times a day for anorexia. The medication was plotted to be administered at 0900 (9:00 AM) and 1700 (5:00 PM). The nurses had signed that the resident was administered the medication Dronabinol 2.5 mg at 1700 (5:00 PM) on Thursday 12/23/21, Saturday 12/25/21, and Tuesday 12/28/21.
A further review of the December 2021 MAR revealed a PO dated 12/12/21 for the supplement, Nephro 8 ounces (oz) by mouth two times a day. The supplement was plotted to be administered at 0900 (9:00 AM) and 1700 (5:00 PM). The nurses had signed that the resident was administered the Nephro 8 oz supplement at 1700 (5:00 PM) on Thursday 12/23/21, Saturday 12/25/21, Tuesday 12/28/21, and Thursday 12/30/21.
A review of the January 2022 MAR reflected a PO dated 12/12/21 for Vitamin C 500 mg via g-tube in the evening for a supplement. The medication was plotted to be administered at 1700 (5:00 PM). The nurses had signed that the resident was administered the Vitamin C 500 mg at 1700 (5:00 PM) on Saturday 01/1/22, Tuesday 01/04/22, and Saturday 01/8/22.
A further review of the January 2022 MAR reflected a PO dated 12/12/21 for the supplement medication, Zinc Sulfate Extended Release give 220 mg via g-tube in the evening as a supplement. The medication was plotted to be administered at 1700 (5:00 PM). The nurses had signed that the resident was administered Zinc Sulfate 220 mg at 1700 (5:00 PM) on Saturday 01/1/22, Tuesday 01/04/22, and Saturday 01/8/22.
A further review of the January 2022 MAR reveled a PO dated 12/14/21 for the medication, Coreg 25 mg, give 1 capsule via g-tube two times a day every Tuesday, Thursday, and Saturday for high blood pressure. The medication was plotted to be administered at 1700 (5:00 PM). The nurses had signed that the resident was administered Coreg 25 mg at 1700 (5:00 PM) on Saturday 01/1/22, Tuesday 01/04/22, and Saturday 01/8/22.
A further review of the January 2022 MAR reflected a PO dated 12/12/21 for the medication, Dronabinol 2.5 mg, give 1 capsule by mouth two times a day for anorexia. The medication was plotted to be administered at 0900 (9:00 AM) and 1700 (5:00 PM). The nurse signed that the medication Dronabinol 2.5 mg was administered at 1700 (5:00 PM) on Saturday 01/01/22.
A further review of the January 2022 MAR revealed a PO dated 12/12/21 for the supplement, Nephro 8 ounces (oz) by mouth two times a day. The supplement was plotted to be administered at 0900 (9:00AM) and 1700 (5:00 PM). The nurses had signed that the resident was administered the Nephro 8 oz supplement at 1700 (5:00 PM) on Saturday 01/1/22, Thursday 01/06/22, and Saturday 01/8/22.
A further review of the January 2022 MAR reflected a PO dated 12/22/21 for the medication, Calcium Acetate 667 mg, give three (3) capsules via g-tube three times a day every Tuesday, Thursday, and Saturday for high phosphates. The medication was plotted to be administered at 1100 (11:00 AM), 1700 (5:00 PM), and 2100 (9:00 PM). The nurses had signed that the resident was administered the Calcium Acetate 667 mg at 1700 (5:00 PM) on Saturday 01/1/22, Tuesday 01/4/22, and Saturday 01/8/22.
The resident's dialysis chair time had changed to 2:30 PM pick up from the facility on Tuesday's, Thursday's, and Saturday's, this indicates the resident would not have been back at the facility for approximately five to six hours (7:30 PM to 8:30 PM). Therefore, Resident #15 would not have been in the facility at 5:00 PM to have been administered his/her medications.
A review of the resident's undated Care Plan (CP) indicated a focus area that the resident was on dialysis related to renal (kidney) failure. The goal of the resident's CP was the resident would have immediate intervention if complications from dialysis occurred and the resident would show no complications from dialysis through the next review date. The intervention on the resident's CP did not include scheduling the resident's medication according to dialysis times.
On 01/11/22 at 11:30 AM, the surveyor conducted a follow up interview with the DON who stated that on 12/23/21 the resident tested positive for COVID-19 and his/her dialysis chair time changed to 3:30 PM.
At 11:33 AM, the surveyor interviewed the [NAME] President of Clinical Operations (VP) who stated that when the resident's dialysis chair time changed, there was no PO to reflect the change in time, and she was unaware of when the resident went back to his/her normal schedule of 5:30 AM pick up from the facility. The VP further stated that the facility had no policy and procedure for residents on dialysis.
A review of a typed statement provided by the DON indicated that the resident, was diagnosed covid + on 12/23/21. Dialysis center asked to keep [gender redacted] days the same and change chair time to 3:30 PM.
NJAC 8:39-27.1(a)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, it was determined that the facility failed to provide appropriate pharmaceutical services which included ensuring accurate administering and reconci...
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Based on observation, interview, and record review, it was determined that the facility failed to provide appropriate pharmaceutical services which included ensuring accurate administering and reconciliation of all drugs, in accordance with professional standards. This deficient practice was identified for 3 of 4 residents (Resident #47, #156 and #812) during the medication administration observation with 2 of 2 nurses during the medication observation pass.
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.
The evidence was as follows:
1. On 1/6/2022 at 10:42 AM, the surveyor conducted a medication pass observation in the presence of a second surveyor with the Licensed Practical Nurse (LPN #1). The surveyors with the LPN #1 observed on the electronic Medication Administration Record (eMAR) for Resident #812 a single order for Clozapine (Clozaril)150 milligram (mg; an antipsychotic medication). LPN #1 removed two (2) bingo cards (a method of packaging medication doses within clear or light resistant bubbles or blister pack done by the provider pharmacy) from the medication cart with the resident's name on the top right-hand corner. One (1) of the bingo cards for Resident #812 was for Clozaril 100 mg and the other bingo card was for Clozaril 50 mg. Each bingo card had a supplementary note that read 150 mg = 100 mg + 50 mg. The PO had no supplementary instructions.
On 1/6/22 at 11:22 AM, the surveyor interviewed LPN #1 who stated that she administered one (1) tablet of 100 mg and one (1) 50 mg tablet to make the dose of 150 mg. LPN #1 acknowledged that the PO should match what was being administered. LPN #1 added that there should be two (2) PO; one for Clozaril 100 mg and one for 50 mg that she would sign on the eMAR to reflect the medications she was administering. LPN #1 stated she would inform the Unit Manager (UM) to reconcile the discrepancy between the PO and the medication being administered.
On 1/6/2021 at 12:01 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the night nurse received the medications from the pharmacy and reconciled those medications with the PO. The RN/UM further stated if the PO does not match the medication being sent by the pharmacy then they called the pharmacy or the physician and clarified the PO. The RN/UM added that the nurse passing the medication should also call the pharmacy if the PO does not match with the medications being administered. The RN/UM stated that sometimes the pharmacy called when the medication sent was different from the order and instructed the nurse to correct the PO with the physician. The RN/UM confirmed that medications must be administered as ordered.
The surveyor reviewed the medical record for Resident #182
A review of the resident's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included schizoaffective disorder and anxiety.
A review of the current Order Summary Report (OSR) reflected an order dated 12/27/21 with a start date of 12/28/21, for Clozaril (clozapine) 150 mg; give 150 mg by mouth one time a day. There were no supplementary notes associated with the PO.
On 1/10/22 at 11:00 AM, the surveyor conducted an interview with the Assistant Director of Nursing (ADON) who stated that medications being administered must match the PO on the eMAR. The ADON further stated that the physician can be contacted to clarify the PO to reflect the medication being dispensed by the provider pharmacy.
On 1/10/22 at 2:30 PM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated that PO must match what was being administered by the nurses. CP further stated if a PO was for Clozaril 150 mg and the pharmacy sent 100 mg and 50 mg and the label indicated to administer both to equal 150 mg; then the PO should be changed to match the medication that was being dispensed from the pharmacy and administered by the nurses.
On 1/11/22 at 12:16 PM, the Director of Nursing (DON) acknowledged that LPN #1 should have administered the medication as prescribed by the physician.
On 1/11/22 at 1:52 PM, the surveyor in the presence of the survey team interviewed the Licensed Nursing Home Administrator (LNHA), DON, and [NAME] President Clinical (VPC). The VPC stated that when the nurses received a medication from the pharmacy, they were to make sure that the medication matched what was ordered by the physician. The DON further clarified that if there was a discrepancy between the PO and the bingo card, then the physician should be called to clarify the PO.
2. On 1/6/22 at 11:03 AM, the surveyor conducted a medication pass observation in the presence of a second surveyor with LPN #1. The surveyors with LPN #1 observed on the eMAR for Resident #47 a PO for losartan (Cozaar) 25 mg (a medication to reduce high blood pressure); give 1 tablet by mouth one time a day. LPN #1 removed a bingo card from the medication cart with the resident's name on the top right-hand corner for Cozaar 50 mg tablets that were cut in half. The bingo card had a supplementary note for Cozaar which indicated 25 mg = ½ TABS and ½ tablets were dispensed. The PO had no supplementary instructions.
On 1/6/22 at 11:22 AM, the surveyor and LPN #1 reviewed the eMAR which revealed a PO dated 7/27/21, for Cozaar 25 mg; give 1 tablet by mouth one time a day. LPN #1 stated that the pharmacy had already cut the Cozaar 50 mg tablets to make the 25 mg dose. The surveyor asked LPN #1 if the PO and eMAR should match the medication being administered to Resident #47. LPN #1 acknowledged that the PO and eMAR should match the medication administered. LPN #1 stated that she would inform the UM to reconcile the discrepancy between the PO and the medication being dispensed and administered.
On 1/6/2021 at 12:01 PM, the surveyor interviewed the RN/UM who stated the night nurse received the medications from the pharmacy and reconciled those medications with the PO. The RN/UM further stated if the PO does not match the medication being sent by the pharmacy then they should call the pharmacy or the physician and clarify the PO. The RN/UM added that the nurse passing the medication should also call the pharmacy if the PO does not match with the medications being administered. The RN/UM confirmed that medications must be administered as ordered.
The surveyor reviewed the medical record for Resident #47.
A review of the current OSR reflected an order dated 7/27/20 and a start date of 7/28/20, for Cozaar 25 mg; give 1 tablet by mouth one time a day for hypertension. There were no additional supplementary notes associated with the medication order.
On 1/10/22 at 11:00 AM, the surveyor interviewed the ADON who confirmed that medications being administered must match the PO on the eMAR. The ADON stated that the physician should be contacted to clarify the PO to reflect the medication being dispensed by the provider pharmacy.
On 1/10/22 at 2:30 PM, the surveyor interviewed the CP via telephone who confirmed that PO must match what is being administered by the nurses.
On 1/11/22 at 12:16 PM, the DON acknowledged that LPN #1 should have administered the medication as prescribed by the physician.
On 1/11/22 at 1:52 PM, the surveyor in the presence of the survey team interviewed the LNHA, DON, and VPC. The VPC stated that when the nurses received a medication from the pharmacy, they were to make sure that the medication matched what was ordered by the physician. The DON further stated that if there was a discrepancy then the physician should be called to clarify the PO.
3. On 1/10/22 at 9:09 AM, the surveyor conducted a medication pass observation in the presence of a second surveyor with LPN #2. The surveyors with the LPN #2 observed on the eMAR for Resident #156 a PO for Vitamin D3 (a dietary supplement) 5,000 international units (IU) tablet; give one tablet by mouth once daily for supplement. LPN #2 removed a bottle of Vitamin D3 5,000 IU capsules from the medication cart to administer to Resident #156. LPN #2 stated that the Vitamin D3 5,000 IU capsule was an over the counter (OTC) medication and was obtained by the facility as a house stock product.
On 1/10/22 at 10:30 AM, the surveyors with LPN #2 reviewed the eMAR for Resident #156 which revealed a PO with a start date 6/16/2020, for Vitamin D3 5,000 IU tablet; give one tablet by mouth once daily for supplement. LPN #2 stated the capsule formulation was the only available item in his cart. LPN #2 acknowledged the PO indicated to administer Vitamin D3 5000 IU tablets and that he had administered the capsule. LPN#2 also acknowledged that the PO should match the medication administered. LPN #2 stated that he would have to call central supply to see if they had the tablet formulation. LPN #2 stated that he could also call the prescriber to request for a change of formulation to the capsule because the resident was able to swallow the capsules.
On 1/6/2021 at 12:01 PM, the surveyor interviewed with the RN/UM who stated that OTC medications were the facility's house stock medications and can be ordered from central supply. The RN/UM added that for house stock medications, the nurses can check other medication carts for availability. The RN/UM further stated that the physician can be contacted, and a request made for an alternative medication if a medication was not available.
The surveyor reviewed the medical record for Resident # 156.
A review of the resident's admission Record reflected that the resident was admitted to the facility with diagnoses which included Vitamin D deficiency, osteoarthritis, extrapyramidal and movement disorder (involuntary or uncontrollable movements, tremors, or muscle contractions).
A review of the current OSR reflected an order dated 6/15/2020 with a start date of 6/16/2020, for Vitamin D3 5,000 IU tablet; give 1 tablet by mouth one time a day for supplement.
On 1/10/22 at 11:00 AM, the surveyor interviewed the ADON who confirmed that medications being administered must match the PO on the eMAR. The ADON further stated that the physician should be contacted to clarify the PO to reflect the medication being dispensed by the provider pharmacy.
On 1/10/22 at 2:30 PM, the surveyor interviewed the CP via telephone who confirmed that PO must match what was being administered by the nurses.
A review of the house stock item list provided by the LNHA revealed that Vitamin D3 5,000 IU tablet was on the list and Vitamin D3 5000 IU capsule was not on the list.
On 1/11/22 at 12:16 PM, the DON acknowledged that the nurses should administer a medication as prescribed by the physician.
On 1/11/22 at 1:52 PM, the surveyor in the presence of the survey team interviewed the LNHA, DON, and VPC. The VPC stated that when the nurses received a medication from the pharmacy, they were to make sure that the medication matched what was ordered by the physician. The DON further clarified that if there was a discrepancy between the PO and the bingo card, then the physician should be called to clarify the PO.
A review of the facility's Medication Administration Policy dated revised 12/20/21, included prior to administering the first dose of a new medication, the nurse will verify the order was correctly transcribed by comparing with the physician's order .check the transcribed order on MAR for the dose, time and route of administration .compare medication order on the MAR three (3) times with label on medication (taking out of drawer before opening and compare label again).
A transcription of medication policy was requested, but the facility was unable to provide a policy.
NJAC 8:39-11.2(b); 29.2(a)(b)(d); 29.4(b)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a physician's order was clarified with the phy...
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Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a physician's order was clarified with the physician to prevent an antipsychotic medication (Zyprexa) being administered in excess of the recommended manufacturer's total daily dosage and increased the antipsychotic dosage by doubling the total daily dose from 12/22/21 to 1/5/22 (fifteen days). This deficient practice was identified for 1 of 5 residents (Resident #70) reviewed for unnecessary medications and the evidence was as follows:
On 1/3/22 at 12:30 PM, the surveyor observed Resident #70 walking in the hallway. The resident was dressed and appeared groomed. The resident informed the surveyor that he/she was walking to their room.
The surveyor reviewed the medical record for Resident #70.
A review of the admission Record face sheet (an admission summary) reflected that the resident was re-admitted to the facility in October 2021 with diagnoses which included schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), bipolar disorder (manic depression), and essential hypertension (high blood pressure).
A review of the most recent quarterly Minimum Date Set (MDS), an assessment tool, dated 10/11/21, reflected a brief interview for mental health status (BIMS) score of 14 out of 15, which indicated fully intact cognition.
A review of the Order Summary Report (OSR) reflected a physician's order (PO) dated 10/4/21 for olanzapine disintegrating 10 milligram (mg) tablet (Zyprexa); give one tablet by mouth at bedtime for hallucinations.
A further review of the OSR reflected an additional PO dated 11/24/21 and discontinued for Zyprexa 5 mg tablet; give one tablet by mouth in the morning related to schizoaffective disorder. A review of the corresponding December electronic Medication Administration Record (eMAR) indicated it was discontinued on 12/21/21.
A further review of the OSR reflected a PO dated 12/21/21 for Zyprexa 10 mg tablet; give one tablet by mouth two times a day related to schizoaffective disorder.
A review of the Psychiatric Follow-up Form dated 12/21/21 reflected that the resident was seen today for increased paranoia, fearful, decompensation with a recommendation/plan to start Zyprexa 10 mg twice a day for schizoaffective disorder.
A review of the electronic Progress Notes (ePN) reflected a Health Status Note dated 12/21/21 that this writer spoke to the Psychiatric Nurse Practitioner (Psych NP) who requested the Zyprexa order be discontinued and new order written for Zyprexa 10 mg twice a day; author Care Manager/Coordinator.
A review of the corresponding eMARs reflected that in December, the resident received a total of 25 mg of Zyprexa on 12/21/21 and a total of 30 mg daily from 12/22/21 through 1/5/22, which was double the original daily total dose of 15 mg.
A review of the resident's individualized care plan had a focused area dated revised 1/4/22, included that the resident has impaired cognitive function or impaired thought processes with regards to schizoaffective disorder, psychotropic drug use. The resident experiences psychosis and believes that a pillow caused [him/her] to have a lobotomy, that [he/she] hurts lots of people and belongs in jail, and that [he/she] breaks all [his/her] fingers, but they still work. Interventions included to administer medications as ordered. Monitor/document for side effects and effectiveness.
On 1/6/22 at 12:11 PM, the surveyor observed the resident in bed. The resident stated that his/her brain is empty and has no thoughts. The resident indicated that one of his/her medications was recently changed, but he/she was unsure which medication was changed including if it was a medication that they received in the morning or at night. The resident stated that the unit manager (Care Manager/Coordinator) knew what medication was changed, but she was not at the facility today.
On 1/6/22 at 12:14 PM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident was pleasant and not usually in bed. The CNA stated that the resident was walking around earlier and probably returned to his/her room for lunch. The CNA stated that she had not noticed in the past few weeks any changes in the resident's mood, behavior, or routine.
On 1/6/22 at 12:17 PM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the resident was very pleasant but also had periods of depression. The resident would either stay in their room by themselves or was out socializing with others depending on the day. The LPN stated that she was unaware of a medication change, but the Psych NP visited the resident frequently and would be the one to change his/her psychiatric medications. The LPN stated that the unit manager (Care Manager/Coordinator) communicated with the Psych NP and was responsible for changing those medications in the electronic Medical Record. The LPN stated that the unit manager was currently on a leave from the facility.
On 1/6/22 at 12:43 PM, the surveyor interviewed the Psych NP via telephone who stated that he last saw the resident on 12/21/21 for increased paranoia and increased their Zyprexa from 5 mg in the morning and 10 mg at night, to 10 mg twice a day for a total of 20 mg a day. When questioned, the Psych NP stated that the manufacturer's maximum dosage per day for Zyprexa was 20 mg. When questioned how many milligrams of Zyprexa the resident was supposed to be receiving daily, the Psych NP confirmed 20 mg in total. At this time, the surveyor informed the Psych NP that when reviewing the resident's medical record, the resident was receiving 30 mg of Zyprexa a day. The Psych NP could not speak further.
On 1/6/22 at 1:01 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the process for receiving psychiatric orders would be that the Psychiatrist or Psych NP would make a recommendation either written or verbal and the nurse would call the resident's primary care physician to obtain the order and input the PO into the electronic Medical Record. The nurse should read back the order to the prescriber at the time to verify the order is correct and clarify the order if needed. The Consultant Pharmacist (CP) came to the facility monthly to review all the residents' medications and looked for any discrepancies or concerns. At this time, the surveyor reviewed the Psychiatric Follow-up Form from 12/21/21 as well the PO with the corresponding eMARs with the DON who confirmed that the resident had been and still was receiving since 12/21/21 more than 20 mg of Zyprexa a day. The surveyor informed the DON that they spoke with the Psych NP who confirmed that the resident should only be receiving 20 mg of Zyprexa a day. The DON stated that she would follow-up with the Psych NP to clarify the orders.
On 1/6/22 at 1:25 PM, the surveyor interviewed the CP via telephone who stated that he had not been at the facility yet to review the resident's December physician orders. When the surveyor asked what the manufacturer's maximum dosage for Zyprexa was per day, the CP stated that the total was 20 mg. When asked if a resident's total Zyprexa administered daily increased in double from 15 mg to 30 mg, if that would be something he would look at and question, the CP confirmed yes.
On 1/10/22 at 9:33 AM, the surveyor re-interviewed the DON who stated that she followed-up with the Psych NP after surveyor inquiry and confirmed that the resident was supposed to be receiving 10 mg of Zyprexa twice a day for a total of 20 mg per day.
A review of the facility's Verbal Orders policy dated revised 12/9/21 included that the nurse receiving verbal order must write it on the physician's order sheet as v.o. (verbal order) or t.o. (telephone order). The nurse transcribing the verbal order must read the order back to the physician to ensure that the information is clearly understood and correctly transcribed.
A review of the Zyprexa manufacturer's specifications included for dosage and administration for schizophrenia in adults when dosage adjustments are necessary, dose increments/decrements of 5 mg qd (every day) are recommended .Olanzapine is not indicated for use in doses above 20mg/day.
NJAC 8:39-11.2(b); 29.2(d)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0836
(Tag F0836)
Could have caused harm · This affected multiple residents
3. On 1/10/22 at 10:00 AM, the surveyor observed Resident #154 lying in bed. The resident informed the surveyor that he/she has to wait a long time for staff to come into his/her room for assistance. ...
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3. On 1/10/22 at 10:00 AM, the surveyor observed Resident #154 lying in bed. The resident informed the surveyor that he/she has to wait a long time for staff to come into his/her room for assistance. The resident stated that he/she was dependent on staff for help and at times has called on his/her cell phone the lobby Receptionist to ask them to contact the nursing unit to send staff to their room for assistance. The surveyor asked the resident to press their call bell and observed the following:
At 10:03 AM, the resident hit their call bell and a red light on the call bell system lit.
At 10:21 AM, the resident repeatedly hit a tap bell located on their tray table. The red light on the call bell system was still observed lit.
At 10:30 AM, the resident again repeatedly hit their tap bell. The red light on the call bell system was still observed lit.
At 10:31 AM, the surveyor observed a green light on the call bell system lit and an intercom system was activated, but no staff communicated.
At 10:35 AM, the surveyor observed a green light on the call bell system lit and an intercom system was activated. A voice was heard over the intercom that asked the resident if he/she was okay. The resident responded yes. The resident identified the speaker to be the Registered Nurse/Unit Manager (RN/UM #2).
At 10:36 AM, the surveyor observed the resident's red call bell light located outside their room in the hallway turned off.
On 1/10/22 at 10:37 AM, the surveyor interviewed RN/UM #2 who confirmed that she was the person who called over the intercom to Resident #154's room. RN/UM #2 stated that anyone can answer a call bell. A paging system at the nurse's station activated when a resident pressed the call bell and the light outside their room lit to let staff know assistance was required. RN/UM #2 stated that if the resident's call bell was not operating correctly, the resident would also be given a tap bell to ring. RN/UM #2 when questioned what was an acceptable call bell response time, she responded two to three minutes. The RN/UM informed the surveyor that the unit today had only five Certified Nursing Aides (CNAs) and two nurses including herself for a census of 52 residents.
On 1/10/22 at 10:45 AM, the surveyor observed Resident #154 out of bed in their wheelchair with CNA #2 exiting the room. At this time, the surveyor interviewed CNA #2 who stated that she was not the resident's CNA, but she had just assisted the resident out of bed. At this time, CNA #2 showed the surveyor her assignment for the day, which revealed that she had twelve assigned residents for that shift.
On 1/10/22 at 10:52 AM, the surveyor interviewed CNA #3 who stated that she was Resident #154's assigned aide for the day, but she was assisting another resident when the call bell was on. The CNA stated that she had ten assigned residents for today's shift, but she usually had twelve assigned residents for the day shift. When asked, the CNA stated that if she was assisting a resident and another resident's call bell was on, she would ask another CNA for assistance answering the call bell.
A review of the Unit 3 East Runnells Center for Rehabilitation & Healthcare 7-3 Assignment Sheet dated 1/10/22 provided by RN/UM #1 included WE CARE - Call Bells Are Responded to by Everyone IMMEDIATELY Within 3 Minute.
On 1/11/22 at 12:14 PM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), [NAME] President Clinical, and survey team acknowledged that a resident waiting over thirty minutes for a call bell response was unacceptable.
NJAC 8:39-5.1(a)
Based on observation, interview, and review of facility provided documentation, the facility failed to a.) ensure that incontinence care was provided in a timely manner for 1 of 10 residents (Resident #43) reviewed for incontinence care, b.) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 23 of 23-day shifts and 1 of 14 overnight shifts reviewed and c.) ensure call bells were answered timely for 1 of 35 residents (Resident #154) reviewed.
This deficient practice was evidenced by the following:
Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/2021, 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.
1. On 01/10/22 at 10:21 AM, the surveyor observed CNA #1 perform incontinence care on Resident #43. When CNA #1 removed the resident's adult brief, the surveyor observed that the adult brief was saturated in yellow liquid. The surveyor further observed that the sheet underneath where the resident was laying was covered in yellow liquid. The resident's urine had seeped through his/her adult brief onto the bedsheets. At that time, CNA #1 acknowledged that the resident's adult brief was saturated in urine. The surveyor observed that the resident's skin was intact.
After incontinence care was performed the surveyor interviewed CNA #1 who stated that it was her first time changing the resident that day because she had a lot of other hard work to do, the facility was short staffed, and the last time the resident was changed was probably between 6:00 AM and 7:00 AM that morning. CNA #1 stated that she had many other residents on her assignment, had to make rounds, change other residents, and pass out breakfast trays.
On 1/10/22 at 11:03 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the CNA had 14 residents on her assignment that day. The LPN further stated that the CNAs were expected to make rounds and take care of the residents on their assignment who were total care first. The LPN stated that the Resident #43 was total care and incontinent of bladder.
At 11:27 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM #1) who stated that the CNAs shift started at 7:00 AM and it was their job responsibility was to check on the residents at least every two hours and as needed to provide regular incontinence care for the residents. The RN/UM #1 further stated that the purpose of performing regular scheduled incontinence care was to prevent skin breakdown and make the residents feel good about themselves.
At 11:49 AM, the surveyor interviewed the Director of Nursing (DON) who stated that incontinence rounds should be performed every two hours and as needed to prevent skin breakdown.
The surveyor reviewed the medical record for Resident #43.
A review of the resident's admission Record (an admission summary) reflected that the resident had resided at the facility for several years and had diagnoses which included metabolic encephalopathy (a chemical imbalance in the brain), personal history of traumatic brain injury, flaccid hemiplegia (inability to move one side of the body), muscle spasm, and major depressive disorder.
A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/5/21, reflected that the resident had unclear speech and was usually able to be understood when expressing himself/herself. A further review of the resident's MDS indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of Section H Bladder and Bowel further indicated that the resident was occasionally incontinent of urine.
A review of the facility's Incontinence Care Policy and Procedure dated 08/9/21 indicated that it was their policy that residents who were incontinent would be kept clean and dry.
2. The surveyors entered the facility on 01/3/22 to conduct a recertification survey. On 01/3/22, 01/4/22, 01/5/22, 01/6/22, 01/10/22, and 01/11/22 the surveyors observed three to six Certified Nursing Aides (CNA)s working on each of the five units throughout the facility. These CNAs were responsible for providing direct care to the residents who resided at the facility.
A review of the Nurse Staffing Report completed by the facility for the weeks of 12/19/21 to 12/25/21 and 12/26/21 to 1/1/22, the staffing to ratios that did not meet the 1 CNA to 8 residents for the day shift or the total staff for residents on overnight shifts were as follows:
12/19/21 had 11 CNAs for 220 residents on the day shift, required 28 CNAs.
12/20/21 had 21 CNAs for 220 residents on the day shift, required 28 CNAs.
12/21/21 had 19 CNAs for 219 residents on the day shift, required 28 CNAs.
12/22/21 had 19 CNAs for 219 residents on the day shift, required 28 CNAs.
12/23/21 had 19 CNAs for 219 residents on the day shift, required 28 CNAs.
12/24/21 had 21 CNAs for 218 residents on the day shift, required 28 CNAs.
12/25/21 had 13 CNAs for 217 residents on the day shift, required 28 CNAs.
12/26/21 had 11 CNAs for 216 residents on the day shift, required 27 CNAs.
12/27/21 had 19 CNAs for 216 residents on the day shift, required 27 CNAs.
12/28/21 had 20 CNAs for 216 residents on the day shift, required 27 CNAs.
12/29/21 had 24 CNAs for 215 residents on the day shift, required 27 CNAs.
12/30/21 had 22 CNAs for 215 residents on the day shift, required 27 CNAs.
12/31/21 had 15 CNAs for 214 residents on the day shift, required 27 CNAs.
12/31/21 had 15 total staff for 214 residents on the overnight shift, required 16 total staff.
01/01/22 had 20 CNAs for 214 residents on the day shift, required 27 CNAs.
On 01/3/22, the facility census (number of residents who resided at the facility) was 214. There were 19 CNAs who worked the 7:00 AM - 3:00 PM shift that day. This indicated that each CNA had approximately 214/ (divided by) 19 = (equals) 11 residents on their care assignment.
On 01/4/22 the facility census was 215. There were 21 CNAs who worked the 7:00 AM - 3:00 PM shift. This indicated that each CNA had approximately 10 residents on their care assignment.
On 01/5/22 the facility census was 214. There were 17 CNAs who worked the 7:00 AM - 3:00 PM shift. This indicated that each CNA had approximately 13 residents on their care assignment.
On 01/6/22 the facility census was 214. There were 19 CNAs who worked the 7:00 AM - 3:00 PM shift. This indicated that each CNA had approximately 11 residents on their care assignment.
On 01/7/22 the facility census was 215. There were 18 CNAs who worked the 7:00 AM - 3:00 PM shift. This indicated that each CNA had approximately 12 residents on their care assignment.
On 01/8/22 the facility census was 213. There were 12 CNAs who worked the 7:00 AM - 3:00 PM shift. This indicated that each CNA had approximately 18 residents on their care assignment.
On 01/9/22 the facility census was 213. There were 13 CNAs who worked the 7:00 AM - 3:00 PM shift. This indicated that each CNA had approximately 16 residents on their care assignment.
On 01/10/22 the facility census was 214. There were 19 CNAs who worked the 7:00 AM - 3:00 PM shift. This indicated that each CNA had approximately 11 residents on their care assignment.
On 01/11/22 the facility census was 214. There were 24 CNAs who worked the 7:00 AM - 3:00 PM shift. This indicated that each CNA had approximately 9 residents on their care assignment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility staff failed to a.) appropriately don (put on) and doff (remove) Personal Protective Equipment (PPE), in accordance with Centers for Disease Control and Prevention (CDC) guidelines, before and after exiting a resident's room who was on Transmission Based Precautions (TBP) due to being a Person Under Investigation (PUI) for 1 resident on 1 of 5 units, (Resident #20), b.) appropriately perform hand hygiene and wear PPE at the appropriate time on 1 of 5 units by staff in the nursing department and recreation department, and c.) appropriately disinfect multiuse medical equipment for 1 of 4 nurses during the medication pass.
These deficient practices were evidenced by the following:
CDC COVID-19 Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 9/10/2021, Managing Residents with Suspected or Confirmed SARS-CoV-2 Infection reflects that healthcare personnel caring for residents with suspected SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and NIOSH approved N95 or equivalent higher-level respirator). In addition, the healthcare personnel are to remove gloves, gown, and dispose into a trash receptacle. Then the healthcare provider may exit the patient room and then perform hand hygiene.
According to the U.S. CDC guidelines for Hand Hygiene in Healthcare Settings Hand Hygiene Guidance, updated 1/30/20, included
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 (e.g., placing an indwelling device) or handling invasive medical devices
Before moving from work on a soiled body site to a clean body site on the same patient
After touching a patient or the patient's immediate environment
After contact with blood, body fluids, or contaminated surfaces
Immediately after glove removal
Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands.
According to the U.S. CDC guidelines for Transmission-Based Precautions dated 1/7/2016, indicated to Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens.
1. On 1/4/22 at 10:09 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that Resident #20 was a PUI and had been placed on TBP because yesterday the resident's roommate had tested positive for COVID-19 and was transferred to the COVID-19 positive unit.
On 1/4/22 at 10:12 AM, the surveyor observed a bin, filled with PPE, and a Stop sign outside the door to Resident #20's room. The Stop sign indicated that there were airborne precautions and everyone must clean their hands, don a fit tested N95 mask, gown, and gloves before entering the room, as well as doff when exiting the room.
On 1/4/22 at 10:14 AM, the surveyor observed the Licensed Practical Nurse (LPN#1) preparing medications at the medication cart in the hallway, in front of Resident #20's open doorway. The LPN#1 was wearing a surgical mask and goggles. The surveyor observed, from the hallway, the LPN#1 walk into the resident's room with medications in a cup, hand the medications to the resident who then swallowed the medications with water provided by the nurse. The LPN#1 was observed inside the room for less than 5 minutes. Then, the LPN#1 performed hand hygiene at the sink in the resident's room near the door and walked out of the room to the medication cart in the hallway in front of the resident's open doorway.
At that time, the surveyor interviewed the LPN#1, at the medication cart, who stated that she was an agency nurse and worked on the unit frequently. The LPN#1 stated that the resident was alert and oriented and was on TBP because the resident had been exposed to the roommate who had tested positive for COVID-19. The LPN#1 stated that she was wearing a surgical mask and goggles and did not think she had to wear a gown and gloves when entering the resident's room because she was just giving the resident medications. The LPN#1 added that if a resident was COVID-19 positive then she would have to wear a N95 mask (a NIOSH-approved particulate filtering facepiece respirator), gown and gloves in addition to goggles but if a resident was a PUI she did not think she had to wear a N95 mask, gown, and gloves. The LPN#1 added that she was unsure if she was right or wrong. The LPN#1 also stated that she thought this was a COVID-free unit, which meant that she did not have to wear a N95 mask.
On 1/4/22 at 10:17 AM, the surveyor observed, from the hallway, Resident #20 in their room sitting in a wheelchair with an overbed table in front that had a disposable tray containing breakfast. The surveyor, from the hallway, was able to speak with the resident who stated that he/she was finishing his/her breakfast and that he/she was told to stay in his/her room by the nurse. The resident stated that he/she would rather be out in the dayroom. The resident added that some of the staff wore gowns and gloves when they came into the room, but some did not. The resident then stated that he/she preferred not to talk further.
On 1/4/22 at 10:19 AM, the surveyor further interviewed the RN/UM who stated that any resident on PUI was on TBP and that required the staff to wear full PPE. The RN/UM explained that full PPE meant that a N95 mask, face shield or goggles, gown and gloves were to be donned before entering the room of a resident who was a PUI, and the gown and gloves were to be doffed before exiting and hand hygiene was to be performed. The RN/UM added that all staff were to be wearing a mask and face shield or goggles at all times in the building but before entering the room of a resident on PUI, the staff had to wear a N95 mask.
The surveyor reviewed the medical record for Resident #20.
A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/23/21, 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 Order Summary Report revealed a physician's order (PO) dated 1/5/22 for Isolation for droplet precautions related to exposure to COVID-19 for 14 days.
A review of the interdisciplinary care plan (IDCP) revealed a focus area dated as initiated 1/4/22 was that the resident required care and isolation precautions specifically related to COVID-19 exposure. The intervention indicated to ensure that the resident stayed in their room, away from other people as much as possible with contact and droplet precautions.
A review of the resident's and the LPN#1 vaccination status provided by the Licensed Nursing Home Administrator (LNHA) indicated that the resident and LPN#1 had been fully vaccinated.
On 1/11/22 at 9:39 AM, the surveyor, in the presence of another surveyor, interviewed the Registered Nurse/Assistant Director of Nursing/Infection Preventionist of Nursing (RN/ADON/IP) who explained that staff working on the red zones, which had the COVID-19 positive were expected to wear full PPE, which included a N95, face shield/goggles, gown and gloves. In addition, the RN/ADON/IP stated that any staff member going into a room designated as a PUI were also expected to wear full PPE. The RN/ADON/IP further explained that a resident who was considered a PUI was any resident exposed to COVID 19 or a non-vaccinated new admission. The RN/ADON/IP added that staff that had to care for residents that were considered clean or in a green zone, which meant that the residents had not been exposed, were expected to wear either a KN95 face mask or surgical mask and face shield or goggles. The RN/ADON/IP further explained that all staff were expected to don full PPE when they stepped into a PUI room for any reason, whether to deliver trays, provide medications or care for the resident, and doff the gown and gloves before exiting the room. The RN/ADON/IP added that she provided in services on infection control, as well as another ADON, to all staff. The RN/ADON/IP acknowledged that the LPN should have donned a N95 mask, gown and gloves, in addition to the goggles that she was already wearing, upon entry to Resident #20's room and doffed the PPE before exiting.
On 1/11/22 at 11:07 AM, the survey team met with the Administrative team. The LNHA stated that the LPN#1 had not been scheduled to return to work after 1/6/22 and would have to receive additional in-servicing on PPE usage, infection control and quarantine.
A review of an In-service Record/Meetings sign-in form titled Infection Control, Proper use of PPE dated 1/3/2022 provided by the LNHA reflected that the LPN was instructed by the ADON.
There was no policy provided by the facility reflecting donning and doffing of PPE.
On 1/14/22 at 11:26 AM, the surveyor interviewed the LNHA via telephone who stated that there was no policy for donning and doffing and that was a procedure that was followed.
2. On 1/4/22 from approximately 10:15 AM to 11:00 AM, the surveyor, in the presence of another surveyor observed the Recreation Aide (RA) pushing a cart on wheels that contained supplies for coffee and tea down the hallway on the 3 [NAME] unit. The RA was outside in the hallway on the low side of the 3 [NAME] unit wearing gloves. The surveyor observed the RA pour coffee into Styrofoam cups and enter resident rooms on the low side of the unit to provide coffee to the residents while wearing the same gloves. The RA did not remove gloves and perform hand hygiene in-between resident rooms. The RA was observed wearing the same gloves on the high side of the unit pouring coffee and entering resident rooms to bring the poured cups of coffee into resident rooms on the high side of the unit.
On 1/6/22 from approximately 10:39 AM to 11:03 AM, the surveyor, in the presence of another surveyor who were performing a medication pass with a LPN in the hallway, observed the Recreation Aide (RA) pushing a cart on wheels that contained supplies for coffee and tea down the hallway on the 3 [NAME] unit. The surveyors observed the RA pour coffee into a styrofoam cup, went into room [ROOM NUMBER] and hand the cup to an unsampled resident. The RA continued to pour coffee and/or tea and bring the poured cups into rooms 312, 313 bed A and bed B.
During that time, the surveyor, in the presence of another surveyor, interviewed the RA who stated that this was her usual routine to deliver coffee every morning. The RA stated that she would normally do this in the day room but due to the current situation, group activities were being limited so she was doing more serving room to room.
During the interview, an unsampled resident approached the RA and the RA poured a cup of coffee and handed it to an unsampled resident in the hallway. The RA had then stated that she had completed that hallway.
On 1/10/22 at 9:52 AM, the surveyor observed a Certified Nursing Assistant (CNA) walking in the hallway wearing gloves on the 3 [NAME] unit. The surveyor observed the CNA enter room [ROOM NUMBER]. She spoke with the resident then she came out of the room wearing the same gloves.
At that time, the surveyor observed the CNA remove her gloves in the hallway and discard the gloves inside a clear plastic bag that was tied to a cart on wheels. The CNA did not perform hand hygiene after removing the gloves. The surveyor interviewed the CNA who could not speak to what she should do after removing gloves.
At that same time, the Registered Nurse Unit Manger (RN/UM) instructed the CNA to wash her hands. The CNA re-entered room [ROOM NUMBER] to wash her hands at the sink near the door. The CNA turned the water on, applied soap to her hands and immediately placed her hands under the running water for less than 15 seconds. The surveyor inquired if she hand training when to put on and remove gloves and what to do after removing gloves. The CNA stated, yes. Oh yes, I should have washed my hands. I forgot.
On 1/10/22 at 10:21 AM, the surveyor, in the presence of another surveyor, interviewed the RA who stated that it is not our process to change gloves because my hands are clean after I washed them. I wash my hands and put on gloves, so my hands are clean. I did that kind of impulsively. I did not go into any COVID rooms. I don't normally wear gloves to hand out coffee. So, I did on 1/4/22 impulsively. Yes, there has been training whenever they do training. But you know; I don't know. I just hand the coffee out. You know what I'm saying. You only have to change your gloves and do hand hygiene if COVID; that would be a lot of work for just handing out coffee.
The surveyors had not observed the RA perform hand hygiene at any time.
On 1/10/22 at 1:10 PM, the survey team met with the administrative staff and discussed the above observations and concerns.
On 1/11/22 at 10:00 AM, the surveyor, in the presence of another surveyor interviewed the RA who stated that she had not changed gloves or performed hand hygiene while giving out coffee because she didn't think she had to. The RA stated that would be a lot of work to use hand sanitizer in between every resident that she served coffee to. The RA stated that she does receive infection control in services from the RN/ADON/IP.
On 1/11/22 at 11:07 AM, the survey team met with the administrative team. The administrative team acknowledged that staff should not be wearing gloves in the hallway.
There was no policy provided by the facility reflecting donning and doffing of PPE.
On 1/14/22 at 11:26 AM, the surveyor interviewed the LNHA via telephone who stated that there was no policy for donning and doffing and that was a procedure that was followed.
Review of the facility's Handwashing/Hand Hygiene dated 1/22/21 provided by the Director of Nursing indicated that all personal shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .all personal shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following directions .after removing gloves or aprons .in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following .after removing gloves .hand hygiene is always the final step after removing and disposing of personal protective equipment .the use of gloves does not replace handwashing/hand hygiene. The procedure for washing hands indicated to vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least twenty (20) seconds under a moderate stream of running water, at a comfortable temperature .rinse hands thoroughly
3. On 1/6/2022 at 9:07 AM, during the medication pass, the surveyor in the presence of another surveyor, observed the LPN#2 obtain the oxygen level of an unsampled resident's blood by using a pulse oximeter (a small device that clips onto the fingertip using a light, shines into the tiny blood vessels in the finger and measures the oxygen from the light that is reflected back).
On 1/6/22 at 9:23 AM, during the medication pass, the surveyor in the presence of another surveyor observed the LPN#2 obtain the oxygen level of Resident #156 by using the same pulse oximeter that was used on the unsampled resident. The surveyors had not observed the LPN#2 clean the pulse oximeter device.
On 1/6/22 at 9:26 AM, the surveyor, in the presence of another surveyor, interviewed the LPN#2 who stated that he was supposed to clean all equipment in between residents. The LPN#2 acknowledged that he had not cleaned the pulse oximeter device in between the two residents. The LPN#2 added that he should have cleaned the pulse oximeter with an alcohol wipe. At that time, the LPN removed an alcohol wipe from the medication cart and cleaned the pulse oximeter device.
On 1/11/22 at 11:07 AM, the survey team met with the administrative team. The DON stated that the LPN#2 was supposed to clean the pulse oximeter with an alcohol wipe in between residents. The DON stated that the LPN#2 was in-serviced on proper cleaning of the pulse oximeter on 1/10/22.
A review of the manufacturer's specifications for the cleaning of the pulse oximeter was provided by the DON which reflected that the pulse oximeter sensor was to be cleaned with a 70% isopropyl alcohol solution and allowed to air dry.
NJAC 8:39-19.4(a)(l)(n)
Dec 2019
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to initiate a Care Plan with interventions and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to initiate a Care Plan with interventions and goals to address a skin abrasion for 1 of 38 residents reviewed for Care Plan (Resident #35).
The deficient practice was identified by the following:
On 12/03/19 at 9:59 AM, the surveyor observed Resident #35 in bed with the head of bed elevated with the tube feed running. Resident #35 had a tracheostomy (a surgically created hole into the windpipe to promote breathing) that was attached by a white, padded cloth tie. The surveyor observed oxygen tubing and a humidifier bag attached to the tracheostomy.
Review of the admission Record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses that included anoxic (without oxygen) brain damage and tracheostomy status.
Review of the Annual Minimum Data Set (MDS), an assessment tool dated 05/15/19, revealed Resident #35 had both short and long term memory impairment, was at risk for developing pressure ulcers, and was totally dependent on staff for transferring, bed mobility and activities of daily living (ADL).
Review of the Quarterly MDS, dated [DATE], revealed Resident #35 had both short and long term memory impairment, was at risk for developing pressure ulcers and was totally dependent on staff for transferring, bed mobility and ADLs.
Review of the Progress Note, dated 11/17/19, revealed there was one inch of sheared skin observed on the back of the resident's neck associated with the tracheostomy ties. The note included that the resident would be seen by wound care and that an order for calcium alginate (substance used for wound healing) was needed.
Review of the Progress Note, dated 11/18/19, revealed a wound nurse evaluated the resident's neck and noted a small abrased (skin wound caused by rubbing against a rough surface) area that appeared to be caused by moisture from the resident's humidification and tracheostomy ties.
Review of the Physician's Order, dated 11/18/19, reflected and order for Calcium Alginate, apply to back of neck topically every evening shift for wound treatment.
Review of the November 2019 Treatment Administration Record (TAR) revealed an order for Calcium Alginate, apply to back of neck topically every evening shift for wound treatment with a start date of 11/18/19. The TAR included documentation that the nurses signed that the treatment was administered from 11/18/19-11/30/19.
Review of the December 2019 TAR revealed an order for Calcium Alginate, apply to back of neck topically every evening shift for wound treatment with a start date of 11/18/19. The TAR included documentation that the nurses signed that the treatment was administered from 12/01/19 up to the review date of 12/10/19.
Review of Resident #35's Care Plan, dated 08/21/19, revealed on 11/11/19 that the resident had an impairment to skin integrity related to a skin tear to the left inner thigh that was resolved on 11/18/19. The Care Plan did not include documentation of the skin impairment to the back of the resident's neck.
During an interview with the surveyor on 12/10/19 at 11:29 AM, the direct care Licensed Practical Nurse (LPN) #2 stated Resident #35 had a skin shear on the left inner thigh that was currently healed and a skin shear on the back of the neck that had been discovered about three weeks ago that was still being treated. LPN #2 stated that the process regarding skin tears or concerns would be to document the skin tear, notify the physician, and notify the wound care nurse to evaluate the resident. LPN #2 stated that any new orders would be put on the TAR and on the Care Plan. LPN #2 stated the unit managers are responsible for updating the Care Plan.
During an interview with the surveyor on 12/10/19 at 11:32 AM, the Registered Nurse Unit Manager (RN/UM #2), on Resident #35's unit, stated the facility had a daily morning meeting to discuss newly identified resident concerns which would then be added to the resident's Care Plan. RN/UM #2 stated a previous supervisor did the Care Plan but now the unit managers do it. RN/UM #2 stated examples of concerns that would be on a Care Plan are behaviors, new admissions and wounds. RN/UM #2 stated that she would review the Care Plan for accuracy at least weekly on Fridays. RN/UM #2 reviewed Resident #35's Care Plan, in the presence of the surveyor, and acknowledged the abrasion to the back of the neck along with the interventions and goals had not been added to the Care Plan but should have been. The RN/UM #2 stated that the purpose of the CP was to inform and guide staff in the management of any problems or issues with the residents.
During an interview with the surveyor on 12/10/19 at 12:15 PM, the Assistant Director of Nursing (ADON) stated the Care Plans were to address concerns such as falls, skin tears and fragile skin.
During an interview with the surveyor on 12/10/19 at 12:20 PM, the Director of Nursing (DON) stated the facility had an Interdisciplinary Care Team (IDCT) to review each resident to make sure Care Plans are up to date and that the IDCT meets each morning, weekly and quarterly. The DON stated things such as falls, behaviors, non compliance, skin tears, and pain would be included on the Care Plan. The DON stated that if the staff reported a skin tear, the supervisor gathered the information, and an intervention would be put into place immediately by the primary nurse or supervisor. The DON added that at the next morning meeting, the IDCT would look at the issue as a team and draw a conclusion. The DON stated the purpose of the Care Plan was to provide the plan of care for the resident's needs. The DON stated the identified problem, intervention and follow up would be on the Care Plan.
Review of the facility's undated Care Plan-Comprehensive policy revealed the Care Plan should include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. The Care Plan was designed to reflect treatment goals, timetables and objectives in measurable outcomes. When possible, intervention address the underlying source of the problem area. The Process: Identifying problem areas and their causes, developing interventions that are targeted and meaningful to the resident. Revisions: Assessments of residents are ongoing and Care Plans are revised as information about the resident and the resident's condition change. The IDCT is responsible for the review and updating of Care Plans when there has been a change in the resident's condition.
NJAC 8:39-11.2 (e 2)(i)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**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 obtain a physician order for a ...
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**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 obtain a physician order for a therapy recommended positioning device and to utilize the device in accordance to the therapy recommendation for 1 of 1 residents reviewed for positioning devices (Resident #141).
This deficient practice was evidenced by the following:
According to the admission Record, Resident #141 was admitted to the facility on -06/23/19 with diagnoses which included hemiplegia (weakness) affecting left side, and muscle weakness.
Review of a Quarterly Minimum Data Set (MDS), an assessment tool dated 09/30/19, revealed that the resident had severely impaired cognition, required total care with activities of daily living (ADLs), and had impairment of functional limitation of range of motion to one side of the upper (arms) and lower (legs) extremities.
Review of the resident's Care Plan, dated 06/24/19, revealed that the resident was dependent on staff for ADLs and included an intervention, dated 07/10/19, for a sling to the left upper extremity to protect the limb/joints with skin checks performed before, during, and after use.
Review of the Occupational therapy Discharge summary, dated [DATE], included discharge recommendations for a sling to the left upper extremity with skin checks performed before, during, and after use.
Review of a Rehab Department Endorsement form, dated 07/04/19 and signed by the Rehab Assistant and Registered Nurse (RN) #1, revealed instructions to obtain a telephone order from the physician and document in the physician's order sheet for the following: positioning device, left sling at all times, remove during am [morning] and pm [evening] care and skin checks. Additionally, the form revealed that the resident required the sling for positioning due to a left shoulder subluxation (connecting bone is partially out of the joint) of 1-2 fingers breadth.
On 12/04/19 at 9:49 AM, the surveyor entered Resident #141's room and observed a sign on the wall that read, sling to lue (left upper extremity)! The resident was in bed sleeping and there was no sling observed on the resident's left upper extremity.
On 12/05/19 at 9:46 AM, the surveyor observed the resident in his/her room in bed with eyes closed. There was no sling observed on the resident's left upper extremity. The surveyor observed the sling was on the resident's gerichair (recliner chair).
On 12/10/19 at 10:28 AM, the surveyor observed the resident in bed. There was no sling observed on the resident's left upper extremity. The surveyor noted that the sling was lying on the resident's gerichair.
During an interview with the surveyor on 12/10/19 at 10:28 AM, Licensed Practical Nurse (LPN) #1 stated that the resident required the sling for positioning and was to be put on when the resident was out of bed and that the recommendation was in the resident's medical record.
During an interview with the surveyor on 12/10/19 at 10:49 AM, the Rehab Director stated that the resident was discharged with recommendations for the resident to wear a sling at all times in order to keep the resident's shoulder positioned in place to prevent further subluxation. The Rehab Director stated that when there were therapy recommendations, the therapist in-services the nursing staff on the recommendations, and the nurse signs the form.
During an interview with the surveyor on 12/10/19 at 12:22 PM, the RN Unit Manager (UM) stated that when therapy has a recommendation, they give an in-service to the staff, and the rehab endorsement form is signed. The nurse then obtains a physician order and the order goes on the Treatment Administration Record (TAR) for the nurses to sign off on. The UM stated that she thought Resident #141 required a sling because there was space in between the resident's joints and the sling helped with positioning to prevent further spacing. The UM stated that the sling was to be on during the day when out of bed. The UM reviewed the resident's medical record with the surveyor and was unable to locate a physician's order for the sling recommendation and that the recommendation was not on the TAR.
During an interview with the surveyors on 12/10/19 at 1:22 PM, the Medical Director, accompanied by the Director of Nursing (DON), stated that she never made a recommendation or ordered a sling for the resident. The DON stated that when a recommendation was made from therapy, the staff obtains an order and the order goes on the TAR.
During a follow up interview with the surveyor on 12/11/19 at 9:27 PM, the UM stated that there should have been an order for the sling and if the physician did not agree with the recommendations, that there should be documentation.
During an interview with the surveyors on 12/11/19 at 1:07 PM, the DON confirmed that there was no order for the sling and stated that the nurse should have called the physician to obtain the order.
Review of an undated facility policy titled, Rehabilitation Devices Endorsement Policy, included that an endorsement form would be completed by rehab, the nursing staff would be trained on the endorsement/recommendation, a physician order should be obtained prior to the implementation of rehab's endorsement and recommendation of use of rehab device, and any rehab devices would be included in the care plan.
NJAC 8:39- 27.1(a); 37.1(a)(b)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure adequate starch was provided to resident's in accordance with the facil...
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Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure adequate starch was provided to resident's in accordance with the facility's four-week cycle menus, facility policy and national nutritional standards for 12 of 26 residents prescribed a mechanically altered pureed diet.
This deficient practice was evidenced by the following:
On 12/04/19, the surveyor observed the following:
At 11:43 AM, in the second-floor main dining room, the surveyor observed the lunch meal and noted PUREE 1 slice Garlic Bread indicated on the meal ticket for six residents who did not receive pureed bread.
At 12:30 PM, in the third-floor main dining room, the surveyor observed PUREE 1 slice Garlic Bread indicated on the meal ticket for three residents who did not receive pureed bread.
At 12:33 PM, in the third-floor East day room, the surveyor observed PUREE 1 slice Garlic Bread indicated on the meal ticket for three residents who did not receive pureed bread.
During an interview with the surveyor on 12/11/19 at 11:35 AM, the Food Service Director (FSD) stated that residents had not been receiving pureed bread. She stated that resident's on prescribed pureed diets had received a double portion of starch in the past (not pureed bread); however, approximately five to six weeks ago, the menus were updated with the addition of pureed bread instead. The FSD further stated that the Registered Dietitian(s) involved with updating the menus were no longer employed and her and her staff were not provided with the recipe or education on the process.
During an interview with the surveyor on 12/12/19 at 12:00 PM, a Registered Dietitian (RD), who provided support to the food service department prior to and during the survey, stated that she would have expected that menu items on a resident's tray to adhere to standards and meet the resident's nutritional needs. The RD further stated that she could not speak to why the pureed bread was not provided to the residents on a prescribed puree diet; however, any resident on a mechanically altered diet, should have received the same menu items as a regular consistency diet. She added that to her knowledge someone in food service management oversaw the tray line (a process that involves plating residents' meals) to ensure the menu was followed.
Review of the facility's four-week cycle menus (four weeks of menus that repeat) reflected that pureed bread or the like (including but not limited to the following: muffins, pancakes, waffles, English muffins, biscuits, blintzes, croissants, French toast, pizza, and bread or buns for sandwich meals) should have been served:
For Cycle 1, 17 times out of 21 meals for the week.
For Cycle 2, 19 times out of 21 meals for the week.
For Cycle 3, 18 times out of 21 meals for the week.
For Cycle 4, 19 times out of 21 meals for the week.
Review of a list of residents and their diets reflected that 26 residents were on a prescribed pureed diet.
Review of the facility provided Puree Consistency Policy, undated, reflected that menus should be planned to be nutritionally adequate in all nutrients according to the Dietary References Intakes established by the Food and Nutrition Board: Institute of Medicine and the USDA Dietary Guidelines for Americans 2015-2020. It also reflected the example that bread, pancakes and plain muffins should be pureed or slurried. Review of the sample menu for a puree consistency, further reflected that pureed or slurried bread should be offered for each meal.
Review of the facility provided Menu Planning Policy, undated, reflected that nutritional needs of individuals should be provided in accordance with established national standards to provide a nourishing and well-balanced diet.
NJAC 8:39-17.4(a)(3)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure the consistent provision of hand hygiene to residents prior to meal ser...
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Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure the consistent provision of hand hygiene to residents prior to meal service in 5 of 7 dining areas.
The deficient practice was evidenced by the following:
On 12/03/19, surveyor #1 observed the following during the lunch meal served in the third-floor East day room:
At 12:36 PM, there were seven residents present who were not offered hand hygiene before their lunch meal was served.
At 12:40 PM, the surveyor observed another resident brought to the day room who was not offered hand hygiene before the lunch meal was served.
On 12/04/19, surveyor #1 observed the following during the lunch meal service:
At 11:36 AM, the surveyor observed that there were 32 residents present in the second-floor main dining room who were not offered hand hygiene before their lunch meal was served.
At 12:15 PM, the surveyor observed the lunch meal in the third-floor main dining room. There were 17 residents present who were not offered hand hygiene before their lunch meal was served.
At 12:30 PM, the surveyor observed two more residents brought into the third-floor main dining room who were not offered hand hygiene before their lunch meal was served.
On 12/04/19, surveyor #2 observed the following during the lunch meal in the 2 [NAME] dining area:
At 11:31 AM, the surveyor observed six residents in the unit dining area who were provided with hand hygiene wipes.
At 11:38 AM, the surveyor observed four more residents enter the dining area who were not offered hand hygiene before their lunch meal was served.
At 11:45 AM, the surveyor observed two more residents enter the dining area who were not offered hand hygiene before their lunch meal was served.
At 11:50 AM, the surveyor observed that a resident left and another entered the dining area by wheelchair that he/she self propelled by touching the wheels. The resident was not offered hand hygiene before the lunch meal was served.
At 11:57 AM, the surveyor observed a resident enter the dining area who was not offered hand hygiene before the lunch meal was served.
At 11:58 AM, the surveyor observed a resident enter the dining area who was not offered hand hygiene before the lunch meal was served.
On 12/05/19, surveyor #1 observed the following during the breakfast meal service:
At 8:31 AM, in the third-floor East day room, there were seven residents present who were not offered hand hygiene before their breakfast was served.
At 8:38 AM, in the third-floor [NAME] day room, there were five residents present who were not offered hand hygiene before their breakfast was served.
At 9:01, the surveyor observed a resident brought into the third-floor [NAME] day room who was not offered hand hygiene before the breakfast was served.
During an interview with surveyor #1 on 12/11/19 at 11:35 AM, the Food Service Director stated that the staff should provide residents with hand hygiene before dining service for infection control purposes. She further stated that hand hygiene was important since the residents touch many things, and many received finger foods and sandwiches at meals.
During an interview with surveyor #1 on 12/11/19 at 11:49 AM, a Certified Nursing Assistant stated that hand hygiene should be provided to the residents prior to meals because the residents touch a lot of things and good hand hygiene prevents the spread of germs which would keep the residents and the facility safe.
During an interview with surveyor #1 on 12/11/19 at 11:52 AM, Licensed Practical Nurse (LPN) #3 stated that hand hygiene should be provided to residents prior to mealtime. She further stated that the purpose of performing hand hygiene was to sanitize the residents hands and prevent the spread of germs.
During an interview with surveyor #1 on 12/11/19 at 11:55 AM, LPN #4/Unit Manager stated that hand wipes were used for the residents before meals to disinfect their hands. She further stated that was part of the infection control process.
During an interview with surveyor #1 on 12/11/19 at 12:23 PM, the Infection Control Nurse/LPN stated that hand hygiene should be provided to residents prior to meal service. She further stated that the purpose of doing so was to disinfect the residents' hands.
During an interview with surveyor #1 on 12/11/19 at 1:50 PM, the Director of Nursing stated that hand hygiene should be provided to residents prior to meals to ensure their hands were clean. She further stated that it was part of the infection control process and if hand hygiene was not provided a concern would be that a resident could get sick.
During an interview with surveyor #1 on 12/12/19 at 12:00 PM, an assisting Registered Dietitian stated that residents should receive hand hygiene prior to meals to prevent the spread of germs, bacteria and infection.
Review of the facility provided The Dining Experience, undated, included that individuals would be provided with proper hand hygiene prior to each meal or snack.
NJAC 8:39-19.4(a 1)(m)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 41% turnover. Below New Jersey's 48% average. Good staff retention means consistent care.
Concerns
- • 23 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 63/100. Visit in person and ask pointed questions.
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About This Facility
What is Runnells Center For Rehabilitation & Healthcare's CMS Rating?
CMS assigns Runnells Center for Rehabilitation & Healthcare an overall rating of 4 out of 5 stars, which is considered above average nationally. Within New Jersey, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Runnells Center For Rehabilitation & Healthcare Staffed?
CMS rates Runnells Center for Rehabilitation & Healthcare's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 41%, compared to the New Jersey average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Runnells Center For Rehabilitation & Healthcare?
State health inspectors documented 23 deficiencies at Runnells Center for Rehabilitation & Healthcare during 2019 to 2024. These included: 1 that caused actual resident harm and 22 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Runnells Center For Rehabilitation & Healthcare?
Runnells Center for Rehabilitation & Healthcare is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE ROSENBERG FAMILY, a chain that manages multiple nursing homes. With 300 certified beds and approximately 245 residents (about 82% occupancy), it is a large facility located in BERKELEY HEIGHTS, New Jersey.
How Does Runnells Center For Rehabilitation & Healthcare Compare to Other New Jersey Nursing Homes?
Compared to the 100 nursing homes in New Jersey, Runnells Center for Rehabilitation & Healthcare's overall rating (4 stars) is above the state average of 3.3, staff turnover (41%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Runnells Center For Rehabilitation & Healthcare?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Runnells Center For Rehabilitation & Healthcare Safe?
Based on CMS inspection data, Runnells Center for Rehabilitation & Healthcare has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in New Jersey. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Runnells Center For Rehabilitation & Healthcare Stick Around?
Runnells Center for Rehabilitation & Healthcare has a staff turnover rate of 41%, which is about average for New Jersey nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Runnells Center For Rehabilitation & Healthcare Ever Fined?
Runnells Center for Rehabilitation & Healthcare has been fined $5,160 across 1 penalty action. This is below the New Jersey average of $33,130. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Runnells Center For Rehabilitation & Healthcare on Any Federal Watch List?
Runnells Center for Rehabilitation & Healthcare is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.