**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00185571 Based on observation, interviews, and review of pertinent facility documents on 07/01/2025 and 07/02/2025, it was determined that the facility failed to implement a physician-ordered intervention to supervise and provide safety to residents from physical abuse by another resident (Resident #7,) who has a known history of aggressive behaviors towards other residents. The abuse occurred when facility staff failed to supervise, and to provide one-to-one (1:1) monitoring of Resident #7. This allowed the resident the opportunity to strike Resident #5 on the head with a metal object, causing laceration (cut) that required transfer to the hospital for treatment. This deficient practice was identified for Resident #7, 1 of 1 residents reviewed and was evidenced by the following: The surveyor reviewed the Facility Reported Event [FRE] dated 04/14/2025, which revealed that Resident #7 was observed striking Resident #5 with a grabber (a metal device used to assist residents grab items that are out of reach,) causing laceration that required transfer to the hospital for treatment. According to the FRE, the Certified Nursing Assistant (C.N.A.) who was assigned to provide one-to-one monitoring, left Resident #7 alone in the room to provide care for another resident. The FRE revealed that a Registered Nurse (R.N.) monitored Resident #7 from the hallway instead of within an arm's length as ordered. The facility's investigation into this incident showed that the R.N. monitored Resident#7 from 6 feet of the resident's room. According to the FRE, the C.N.A. heard commotion coming from resident's room and went to check the situation. Upon arrival to the room, the C.N.A observed Resident #7 striking his/her roommate (Resident #5) on the head with a grabber. At that time, the R.N. ran from the nurse's station to the resident's room and removed the grabber from Resident #7's hand and assessed both Resident #5 and #7. The R.N. then provided first aide treatment to Resident #5's cut and called the Emergency Services to take Resident #5 to the hospital for more treatment. The R.N. also called the local police department who came and took Resident #7 into custody. Resident#7 no longer resides at this facility.Review of the care plan in place at the time for Resident #7 revealed that the resident was to be on one-to-one (1:1) monitoring within an arm's reach.The staff's failure to provide one-to-one (1:1) monitoring placed Resident #5 and all other residents at harm for abuse and in an immediate jeopardy [IJ] situation. The IJ began on 04/14/2025 and was identified on 07/02/2025 at 3:50 P.M. and was reported to the Licensed Nursing Home Administrator [L.N.H.A.]. The L.N.H.A. was presented with the IJ template at the that time. An acceptable removal plan was mailed electronically on 07/08/2025, indicating the facility's actions to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice. The Director of Nursing (D.O.N.) provided education to all direct care staff, float staff and supervisors regarding the one-to -one (1:1) protocol, documentation and Abuse. The L.N.H.A. implemented an audit daily process for the supervisors to review for any 1:1 assignment and documentation. The L.N.H.A. also instituted a QAPI team weekly review to assess incident trends and compliance. The surveyor verified the removal plan on site on 07/10/2025After the IJ removal plan, the non-compliance continued 07/10/2025, at a scope and severity for no actual harm with the potential for more harm that was not an IJ. This deficient practice was identified for 1 of 1 residents [Residents #5] and was evidenced by the following:On 07/01/2025 at 9:30 A.M. the surveyor conducted a tour of the facility. The surveyor noted that the nurse's station is further than 6 feet from Resident #5 and #7's bedroom which would not have allowed the R.N. to be able to visually monitor into the room from the nurse's station and was not within an arm's length of the resident.The surveyor reviewed Resident #7's Progress note (PN) dated 04/14/2025 which confirmed that Resident #7 was to be on 1:1 monitoring while in his/her room. The PN further revealed that the assigned C.N.A left Resident #7 alone in the room with Residents #5, while the R.N. monitored from the nurse's station.A review of the closed medical admission Record [AR] for Resident #7 indicated that the resident was admitted to the facility with diagnoses which included but were not limited to Personality disorder, unspecified mood disorder, and unspecified psychosis.According to the Quarterly Minimum Data Set [MDS], an assessment dated [DATE], Resident #7 had a Brief Interview for Mental Status [BIMS] of 9 indicating the Resident #7 was moderately, cognitively impaired. Review of Resident #7's Care Plan [CP] initiated on 03/29/2025, with revisions on 04/06/2025 and 04/10/2025 revealed that Resident #7 was to have 1:1 monitoring by a staff member 24 hours/day until further notice. The CP reflected an updated intervention dated 04/06/2025 for side-by-side monitoring within arm's reach. The CP was revised again on 04/10/2025, to keep Resident #7 at arm's length to be able to get to him/her if him/her acts out aggressively to others. On 07/01/2025 the surveyor attempted to interview the R.N. that was on duty night of the incident and the D.O.N and L.N.H.A. stated that the R.N. was no longer employed with the facility.On 07/02/2025, the surveyor reviewed the employee files from the date of the event. The surveyor attempted to reach the R.N., and the number was not in service. The surveyor attempted to reach the C.N.A. but there was no return call to the surveyor.On 07/01/2025 at 2:194 P.M., the surveyor interviewed the D.O.N who stated that there should be an order for one-to-one (1:1) monitoring. She further defined one-to-one (1:1) monitoring as 1:1 is a specially dedicated person, need to be sitting next to the resident. The surveyor asked the DON for the difference between one-one (1:1) and one-to one (1:1) arm's length. The D.O.N. responded: I don't think there is a difference between one-to-one (1:1) and one-to-one (1:1) arm's length. The D.O.N. further stated that her expectation is staff is right next to the resident and that the staff do nothing but the one-to one (1:1.) She further stated that If someone needs the bathroom, other staff have to sit with the resident. The D.O.N. also stated that her expectation of the nurse was The nurse was near/next to him.On 07/01/2025 at 2:48 P.M. the surveyor interviewed the L.N.H.A. When asked about the expectations for a one-to-one (1:1), she stated: 1:1 is where the staff are within arm's length. You should be able to grab them, so they do not harm another resident. The L.N.H.A. further stated, Be with them at all times and that if the staff Need to use the restroom you need to call someone so they could sit with the resident. When the surveyor asked if monitoring from the nurse's station is considered one-to one (1:1) monitoring, she acknowledged that was not an arm's length. On 07/02/2025 at 2:39 P.M. the surveyor conducted a follow-up interview with the L.N.H.A. regarding the log for the one-to one (1:1) monitoring for the night of the event. She stated, I don't think so. When asked how the staff are trained for one-to-one (1:1) she replied that staff are trained through education. She stated that the R.N. and the C.N.A. were trained but no documentation was provided. She acknowledged that one-to-one (1:1) means staff is close to prevent the one-to-one (1:1) from harming.There is no evidence that the facility closely supervised Resident #7 as ordered by the physician.A review of the facility's policy titled Resident on Resident Abuse with a revision date 2024, revealed that the policy of the facility is to keep all residents free from all forms of abuse, mistreatment, neglect, and misappropriation of property from staff, visitors and other residents.N.J.A.C. 8:39-27.1(a)

Complaint #: NJ183318, NJ183964 Based on interviews, medical records review, and review of other pertinent facility documentation on 3/12/25 and 3/13/25, it was determined that the facility failed to thoroughly investigate an abuse allegation that involved a Certified Nursing Assistant (CNA #1) and Resident #1. The facility also failed to ensure its policy titled Abuse Investigations was implemented during the alleged abuse allegation. On 2/4/25 at approximately 12:40 P.M., the Licensed Nursing Home Administrator (LNHA) was notified by two representatives of the Ombudsman office that CNA #1 was trying to get Resident #1 out of bed, and the resident was screaming. The LNHA went to the resident's room, and Resident #1 told her that he/she did not want CNA #1 touching him/her. Resident #1 expressed to the LNHA and the Registered Nurse (RN #1) that CNA #1 pulled and hurt his/her left arm. RN #1 conducted a skin assessment that revealed bruising to Resident #1's left thumb. The LNHA stated she conducted an investigation and suspended CNA #1 immediately on 2/4/25. The LNHA did not conduct any resident interviews during the abuse investigation. The LNHA did not notify the local police of the abuse allegation. The LNHA concluded that CNA #1 was rough with Resident #1 but allowed CNA #1 to return to work on 2/7/25 after receiving sensitivity training and disciplinary action. After CNA #1 returned, she continued to work until 2/18/25, when she was terminated after a representative from the Ombudsman office reported to the LNHA that several residents had complained that CNA #1 was rough, would not help them and threatened to throw the residents in bed if they did not want to go to bed. The Ombudsman further reported to the LNHA that some residents felt unsafe around CNA #1. On 3/12/25, Resident #2 stated that CNA #1 had taken care of him/her in the past and stated the CNA often humiliated her and that he/she had reported it to the Ombudsman. The facility failed to follow its policies and procedures and protect facility residents by not conducting a thorough investigation into whether other residents had reports of abuse allegations involving CNA #1. This resulted in CNA #1 returning to work after a previous abuse allegation, which placed the residents being cared for by this staff member in an immediate jeopardy (IJ) situation. The IJ began on 2/7/25, was identified on 3/12/25 at 4:45 P.M., and was reported to the LNHA. The LNHA was presented with the IJ template at that time. An acceptable removal plan was electronically mailed to the surveyor on 3/17/25 at 3:27 PM, indicating the facility's actions to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice. CNA #1 was terminated from the facility on 2/18/25; the LNHA conducted an investigation into abuse allegations involving CNA #1, which included resident interviews; all facility staff were re-educated on the facility's abuse policy regarding when to report abuse allegations and to whom, the facility's owner re-educated the LNHA on the abuse and investigation sections of the abuse policy. The Director of Nursing (DON) conducted audits to see if any residents had experienced any form of abuse. The surveyor verified the removal plan on site on 3/18/25 and determined the IJ for F610 J was removed as of 3/18/25. After the IJ removal, the non-compliance continued from 3/18/25 for no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. This deficient practice was identified for 2 of 4 residents (Resident #1 and Resident #2) reviewed and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 2/4/25 revealed that Resident #1 screamed and started to kick CNA #1 as CNA #1 tried to transfer the resident into the chair to keep the resident from falling. The Ombudsman was visiting the facility and witnessed the encounter. The LNHA was notified of the incident by the Ombudsman. The LNHA immediately suspended CNA #1 and did an investigation. CNA #1 was suspended upon further investigation and was allowed to return to work with disciplinary actions and sensitivity training. On 2/18/25, the Ombudsman came to the facility and interviewed several residents who stated CNA #1 was rough, would not help them, and threatened to throw the residents in bed if they did not want to go to bed. The Ombudsman also reported that some residents felt unsafe. The LNHA terminated CNA #1 on 2/18/25. A review of the updated facility policy titled Abuse Investigations revealed under Policy Statement, All reports of resident abuse, neglect and injuries of the unknown source shall be thoroughly and promptly investigated by facility management. Under Policy Interpretation and Implementation, 3. The individual conducting the investigation will, as a minimum: i. Interview other residents to whom the accused employee provides care or services. 1. According to the admission Record (AR), Resident #1 was admitted to the facility in September 2023 with diagnoses which included but were not limited to: Unspecified Dementia, Hyperlipidemia (high cholesterol), and Depression. According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 12/22/24, Resident #1 had a blank space for the Brief Interview for Mental Status (BIMs) score. Under the Assessment section of the electronic medical record (EMR), Resident #1 had a BIMS score of 8 out of 15 on 3/11/2025, which indicated the resident's cognition was moderately impaired. The MDS further revealed that Resident #1 needed partial to moderate assistance with most Activities of Daily Living (ADLs). A review of Resident #1's February 2025 Progress Notes (PNS) dated 2/4/25 at 12:30 PM written by RN #1 revealed that the RN assessed Resident #1 for an incident involving CNA #1. Resident #1 told RN #1 that CNA #1 pulled and hurt his/her left arm. RN #1 observed bruising to the resident's left thumb. The resident complained of difficulty bending his/her left elbow and complained of 10 out of 10 pain to his/her arm. The surveyor was unable to reach RN #1 for an interview. The surveyor was unable to reach CNA #1 for an interview. 2. According to the AR, Resident #2 was admitted to the facility in 12/2024 with diagnoses which included but were not limited to: Unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and depression, unspecified. According to the Quarterly MDS, an assessment tool dated 2/9/2025, Resident #2 had a blank space for the BIMS score. Under the Assessment section of the EMR, Resident #2 had a BIMS score of 15 out of 15 on 3/11/2025, which indicated the resident's cognition was intact. The MDS further revealed that Resident #2 was independent with most ADLs. On 3/12/2025 at 1:26 PM, the surveyor interviewed Resident #2, who stated CNA #1 had taken care of him/her in the past. According to Resident #2, CNA #1 was the only one who was not nice to her. CNA#1 caused her to feel frustrated and humiliated. Resident #2 indicated he/she did not report this to the facility staff because he/she did not want to make a big issue out of it, but he/she had reported this to the Ombudsman when they were at the facility. On 3/12/2025 at 2:14 PM, the surveyor interviewed the LNHA, who stated that the Ombudsman had notified her that CNA #1 was trying to get Resident #1 out of bed and that the resident was screaming. The LNHA indicated that Resident #1 told her that CNA#1 had pulled her arm and hurt it. Resident #1 stated that he/she did not want Resident #1 touching him/her. The LNHA stated she immediately suspended the CNA on 2/4/25 while she conducted an investigation. The LNHA further stated she concluded that CNA #1 was rough with Resident #1 and should have reapproached the resident. The LNHA indicated she allowed CNA #1 to return to work on 2/7/25 after conducting an investigation and provided the CNA with sensitivity training and disciplinary action with the hope there would be no further issues. The LNHA indicated that on 2/18/25, the Ombudsman informed her that several residents complained about how CNA #1 treated them. Some residents felt afraid when CNA #1 provided care to them, which resulted in the LNHA terminating the CNA on that day. The LNHA confirmed she did not interview or obtain statements from other residents in the facility. The LNHA could not speak to why she did not interview or obtain statements from other residents. The LNHA stated she did not call the police about the abuse allegation because she thought the police were only notified for serious injuries and elopements. The LNHA confirmed she did not notify the police about CNA #1 after the Ombudsman told her about the other resident complaints involving the CNA. The LNHA stated she did not follow up on the resident complaints she received from the Ombudsman because she ended up terminating CNA #1 on 2/18/25. On 3/12/2025 at 2:48 PM, the surveyor conducted a follow-up interview with the LNHA, who confirmed that part of the facility's abuse investigation policy included interviewing other facility residents about if they had experienced or witnessed any mistreatment from the staff member involved in an abuse allegation. The LNHA indicated she had never asked the Ombudsman who were the residents that had complaints involving CNA #1. The LNHA stated she should have interviewed the residents that CNA #1 had provided care to as part of her investigation. The LNHA stated it was important to conduct a thorough investigation into an abuse allegation to ensure the safety of all the residents. NJAC 8:39-4.1 (a) 5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part B Based on observation, interview, record review, it was determined that the facility failed to accurately investigate the cause of a fall incident for 1 of 3 residents (Resident #15) reviewed for falls, and was evidenced by the following: On 10/22/24 at 10:45 AM, the surveyor observed Resident #15 seated in their wheelchair in their room with family present. Resident #15's family stated that the resident had a recent fall in the bathroom. The family member also stated that the facility notified them via telephone on the day of the fall incident. A review of Resident #15's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; dementia, low back pain, and retention of urine. A review of a Quarterly Minimum Data Set, dated [DATE], revealed that the resident was unable to complete a Brief Interview for Mental Status (BIMS) due to severe memory impairment. A review of the progress note (PN) dated 9/25/24 at 5:28 AM, revealed that Resident #15 was found lying in the bathroom. The PN also indicated the nursing staff assessed the resident and obtained vital signs. A review of the Fall risk evaluation completed on 6/17/24, revealed that Resident #15 was at a moderate risk for falls. A review of the Physician Orders (PO) dated 9/25/24 revealed a PO for Right hip x-ray stat rule out (r/o) fracture. A review of Resident #15's comprehensive Care Plan (CP) revealed under focus with a revision date of 9/28/24 titled, The resident is at risk for falls r/t confusion, and had an unwitnessed fall with no injury. Further review of the CP included an intervention dated 9/28/24, to encourage resident to use call bell for help. On 10/24/24 at 9:46 AM, the surveyor interviewed the Director of Nursing (DON), who stated the facility does not complete fall investigation reports and any information regarding a fall incident would be documented under the nursing progress note found in the electronic medical record. The DON further added that there were no witness statements obtained after the fall. On 10/24/24 at 9:55 AM, the DON provided the surveyor a facility policy titled Falls, with an implementation date of 6/2024, under the policy section which revealed, All falls are to be investigated and monitored. The facility will maintain a record that contains a list of all incidents and falls. Under the program steps of the policy included, F . Complete Incident/Event Report. G. Start Investigation Report. H. Obtain detailed statements from any witnessed. Statements must be signed with the correct date and time for fall with serious injuries. On 10/24/24 at 12:21 PM, the survey team met with the Licensed Nursing Home Administrator (LHNA), DON and Business Office Manager (BOM) to review the above concern. The DON stated a complete fall investigation that included statements from witnesses was not completed for Resident #15's fall incident that occurred on 9/25/24. On 10/31/24 at 11:15 AM, the survey team met with the LHNA, DON, BOM and the Operator of the facility to discuss the above concern. There was no additional information provided. NJAC 8:39-27.1(a); 31.4(a); 33.1(d) NJAC 8:39-17.4 (a)1-2; 27.1(a) Part A Based on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to ensure a cognitively impaired resident with a PO (physician's order) for NTL (nectar thick liquid, liquid thickened with an agent for a nectar like consistency) to prevent aspiration (accidental breathing in of fluid or food into the lungs). This deficient practice was identified for 1 of 18 residents reviewed for modified liquid diet consistency. On 10/23/24 at 12:28 PM, during lunch observation, the surveyor observed Resident #19 coughing while the Licensed Practical Nurse (LPN #1) was assisting Resident#19 with their meal. LPN #1 informed the surveyor that the resident started coughing after LPN #1 fed Resident #19 whole mandarin oranges in its own thin juice. LPN #1 stated that Resident #19 was on nectar thickened liquid. The surveyor observed thickened water, thickened coffee, and mandarin oranges in thin liquid juice on the resident's meal tray. The surveyor checked the meal card which revealed a plain yellow dot, and no specialized diet was identified. The surveyor asked LPN #1 what the yellow dot meant; LPN #1 did not know what the yellow dot meant and stated that the resident was on a mechanical soft diet (texture modified diet). The surveyor interviewed the Food Service Director (FSD) who stated that the kitchen staff plated the resident's meal tray, and that a yellow dot indicated a chopped diet (texture-modified). The FSD stated that a yellow dot with a N indicated NTL. Resident #19's meal card did not have a yellow dot with a N. The surveyor interviewed the MD [medical doctor] who confirmed that Resident #19 had a medical diagnosis of Parkinson's Disease (a movement disorder of the nervous system) and had a high risk of aspiration that could lead to pneumonia and death. The surveyor interviewed the Speech Language Pathologist (SLP), who revealed that the resident was on NTL and could not be served mandarin oranges in its own juice because the resident's vocal cords would not be able to close in time and the liquid would go into their lungs and cause aspiration. The facility's failure to ensure a cognitively impaired resident with a PO for NTL was provided the appropriate consistency diet posed a likelihood of choking and aspiration which could result in serious harm, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 10/23/24 at 12:28 PM, when Resident#19 was observed choking after being served whole mandarin oranges in thin liquid. The facility's Administration was notified of the IJ on 10/23/24 at 5:00 PM. The facility submitted an acceptable removal plan (RP) on 10/24/24 at 2:11 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 10/23/24. The evidence was as follows: A review of the facility Food Labels for Dietary Consistency policy with a review date of 2024, included food diets are marked by colored labels . yellow labels are soft chopped . yellow dot with N is nectar thick liquids . the colored dots are placed on the name cards and the tray cart . the color is changed if the diet is changed . On 10/23/24 at 12:28 PM, during the lunch observation, the surveyor observed Resident #19 coughing while LPN #1 was assisting the resident with their meal. LPN #1 informed the surveyor that the resident started coughing after LPN #1 fed Resident #19 whole mandarin oranges in its own thin juice. LPN #1 stated that Resident #19 was on nectar thickened liquid. The surveyor observed thickened water, thickened coffee, and mandarin oranges in thin liquid juice on the resident's meal tray. The surveyor checked the meal card which revealed a plain yellow dot and no specialized diet. LPN #1 stated they did not know what a yellow dot meant and added the resident was on a mechanical soft diet. On 10/23/24 at 12:35 PM, the surveyor interviewed the FSD who stated they plated Resident #19's meal tray and a plain yellow dot indicated a chopped diet and a yellow dot with a N indicated nectar thickened liquid. The surveyor did not observe a N on the resident's meal card. On 10/23/24 at 12:45 PM, the surveyor interviewed LPN #1 and LPN #2 who both stated they did not receive education regarding diet consistencies. On 10/23/24 at 1:19 PM, the surveyor interviewed the facility's MD, who was also Resident #19's primary care physician. The MD stated that the resident had a medical diagnosis which included Parkinson's Disease which contributed to a high risk of aspiration that could lead to pneumonia and death as a result. On 10/23/24 at 2:39 PM, the surveyor conducted a telephone interview with the Registered Dietician (RD) who confirmed that Resident#19 had a PO for NTL, and it was not appropriate for the resident to be served the whole mandarin orange in its own juice as it could lead to aspiration. On 10/23/34 at 3:24 PM, the surveyor interviewed the facility's SLP who stated the mandarin orange in its own juice cannot be served to a resident who was on NTL because the vocal cords would not be able to close in time and the liquid could go down their lungs and cause aspiration. On 10/23/24 at 1:10 PM, the surveyor reviewed Resident #19's electronic medical record. A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 7/21/24, reflected Resident#19 had a brief interview for mental status (BIMS) score of 3 out of 15, indicating that the resident had severe impaired cognition. A review of Section K revealed the resident received a mechanically altered diet. A review of the admission Record face sheet (an admission summary) revealed that Resident #19 was admitted to the facility with diagnoses which included but were not limited to: Parkinson's Disease, unspecified abnormal involuntary movements, and unspecified dementia. A review of a PO dated 5/1/23, revealed a diet order for regular diet. mechanical soft texture, nectar/mildly thick consistency, chopped. A review of the individualized comprehensive care plan included a focus area dated 5/31/22, that the resident had a potential nutrition risk due to a mechanically altered diet. The goal included that the resident would tolerate their diet order without signs and symptoms (s/s) of aspiration. Interventions included to provide mechanical soft diet with nectar thickened liquids. A review of the key information section located in the electronic medical record revealed Special Instructions, Takes medications whole with nectar thickened liquids. A Review of the Physician's progress notes dated 8/3/24 at 3:02 PM, included the resident was seen and examined while seated in a chair. The resident was awake but confused with tremors and head movements. A review of the Speech Therapy (ST) Progress Notes (PN) documented by the SLP on 10/7/24 at 12:53 PM, included the resident was seen in their wheelchair in the dining room for dysphagia (difficulty swallowing) evaluation due to reported coughing during meals. The resident was currently on chopped diet with NTL with a recommendation to continue current diet. The recommendation was reviewed with nursing. A review of the Nutrition/Dietary quarterly note dated 10/19/24 at 8:11 AM, documented by the RD included the resident continued on a mechanical soft/chopped diet with NTL. The resident was seen by the SLP on 10/7/24, with no new diet orders, but it was recommended the resident be fed. On 10/23/24 at 5:00 PM, the survey team interviewed the LNHA, DON and Business Office Manager (BOM) who all confirmed Resident #19 should not have been fed the mandarin orange in thin juice since the resident was on a NTL diet. No further information was provided to the survey team. The acceptable RP on 10/24/24 at 2:11 PM, indicated the action the facility will have to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: Resident #19 was assessed by the Registered Nurse and MD; all nursing and kitchen staff were in-serviced on facility's consistency and added diet policy; any food with liquid consistency added such as sauce, gravies, natural juices and syrups will have added thickener for appropriate diet consistency and any diet changes will be communicated to the Charge Nurse who will communicate to the kitchen. The survey team verified the implementation of the RP during the continuation of the on-site survey on 10/24/24.

Refer to 760K Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the Consultant Pharmacist (CP) recommendations dated 3/7/23 were acted upon in a timely manner regarding the documentation and administration of critical medications, including anticoagulants and insulin medications to prevent serious adverse outcomes for Resident #13, #19 and #20 who required blood sugar monitoring and were dependent on insulin, and Resident #17 and #230 who had physician orders for an anticoagulant to prevent blood clotting. The failure to act upon the CP recommendations in a timely manner to ensure all residents were accurately receiving the necessary medications in the appropriate timeframe in accordance with their physician's orders to prevent an adverse outcome placed all residents who received critical medications at risk for a serious outcome. The failure to monitor and document blood sugars and administer insulin when indicated per the physician's order is likely to result in hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), which requires immediate emergency intervention if symptomatic. The failure to administer and document an anticoagulant in accordance with a physician's order to prevent blood clots is likely to lead to a heart attack, pulmonary embolism (a blood clot that enters the lung), anoxic stroke (a blood clot that stops oxygen to the brain), or other blood clots throughout the body. This resulted in an Immediate Jeopardy (IJ) situation that began on 3/7/23 when the CP made their recommendations. The facility's Licensed Nursing Home Administrator (LNHA) was notified of the IJ on 6/1/23 at 4:28 PM. The IJ continued until 6/8/23, when the facility implemented its written removal plan. An acceptable written Removal Plan (RP) was received on 6/8/23. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview, and review of records. This deficient practice was identified for 5 of 17 residents reviewed for medication management (Resident #13, #17, #19, #20, and #230). The evidence was as follows: 1. On 5/24/23 at 10:40 AM, the surveyor observed Resident #19 in a wheelchair in the dining area with their eyes closed. The surveyor attempted to interview the resident, but the resident could not answer the surveyor's inquiry. According to the admission Record (AR), an admission summary, Resident #19 was admitted to the facility with diagnoses that included but were not limited to type 2 diabetes mellitus (a chronic disease where the body doesn't produce enough insulin, thereby affecting blood sugar levels) and Alzheimer's disease (impaired cognition). A review of the physician Order Summary Report (OSR) for May 2023 revealed the following Physician's Order (PO) for Novolog (fast-acting insulin) injection solution 100 unit/ml (Insulin Aspart), dated 3/1/23. The orders specified injecting insulin subcutaneously (under the skin) before meals and at bedtime using the sliding scale for insulin coverage: if the fasting blood sugar is 70-130, administer 0 units of insulin; if the fasting blood sugar is 131-180, administer 2 units of insulin; if the fasting blood sugar was181-240, administer 4 units of insulin; if the fasting blood sugar is 241-300, administer 6 units of insulin; if the fasting blood sugar is 301-350, administer 8 units of insulin; if the fasting blood sugar is 351-400, administer 10 units of insulin; if the fasting blood sugar is above 400, give 10 units, then call the physician (MD) for an order. A review of the March 2023 Electronic Medication Administration Reports (eMAR) did not show documentation of the administration of critical medication Novolog insulin for 45 of 120 doses due. A review of April 2023 eMAR did not show documentation of the administration of critical medication Novolog insulin for 31 of 120 doses due. A review of May 2023 eMAR did not show documentation of the administration of critical medication Novolog insulin for 65 of 120 doses due. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 99, which required no Humalog insulin, to 231, requiring 4 units of Humalog to be administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 111, which required no Humalog insulin, to 276, requiring 6 units of Humalog to be administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 100, which required no Humalog insulin, to 192, requiring 4 units of Humalog to be administered. There was no documentation that blood sugar was taken on each of the omitted insulin doses and no documentation of hospitalization, hypoglycemia, or hyperglycemia. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. A review of the March, April, and May 2023 CP recommendations revealed no specific CP recommendations addressing the omissions in the resident's eMAR. The CP Consultant Evaluation form dated 5/4/23 noted an HBA1C of 6.1 results from 4/4/23. 2. On 5/31/23 at 11:40 AM, the surveyor observed Resident #20 in the resident's room in a chair. The resident's eyes were closed. The surveyor attempted to interview the resident, but the resident was unable to answer the surveyor's inquiry. According to the AR, Resident #20 was admitted to the facility with diagnoses that included but were not limited to type 2 diabetes mellitus, atrial fibrillation (AFib) (an irregular, rapid heart rate that typically requires anticoagulants to prevent blood clotting), and psychotic disorder. A review of the OSR for May 2023 revealed the following POs for Humalog (fast-acting insulin) injection solution 100 unit/ml (Insulin Lispro) dated 3/1/23. The order specified to inject the insulin subcutaneously under the skin as per the sliding scale: if the fasting blood sugar is 0-150, administer 0 units of insulin; if the fasting blood sugar is 151-180, administer 2 units of insulin; if the fasting blood sugar is 181-240, administer 4 units of insulin; if the fasting blood sugar is 241-300, administer 6 units of insulin; if the fasting blood sugar is 301-350, administer 8 units of insulin; if the fasting blood sugar is 351-400, administer 10 units of insulin; An additional PO dated 3/1/23 administered Lantus (long-acting insulin) subcutaneous solution 100 unit/ml (Insulin Glargine). The order specified injecting 15 units subcutaneously at bedtime for type 2 diabetes. In addition, there was a physician's order for Xarelto (an anticoagulant) dated 3/1/23. The order specified administering Xarelto 15 milligrams (mg), one tablet by mouth in the evening for AFib. A review of March 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 37 of 120 doses due, Lantus for 12 of 31 doses due, and Xarelto for 8 of 31 doses due. A review of April 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 25 of 120 doses due, Lantus for 5 of 30 doses due, and Xarelto for 4 of 30 doses due. A review of May 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 49 of 120 doses due, Lantus for 15 of 30 doses due, and Xarelto for 13 of 30 doses due. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 58, which required no Humalog insulin, to 389, requiring 10 units of Humalog to be administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 39, which required no Humalog insulin, to 400, requiring 10 units of Humalog to be administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 74, which required no Humalog insulin, to 368, requiring 10 units of Humalog to be administered. There was no documentation revealing a blood sugar taken on each of the omitted insulin doses and no documentation of hospitalization, hypoglycemia, or hyperglycemia. There was no documented evidence that the resident had a hospitalization. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. A review of the March, April, and May 2023 CP recommendations revealed no specific CP recommendations addressing the omissions in the resident's eMAR. The CP Consultant Evaluation form dated 5/4/23 noted an HBA1C of 7.1 results from 4/4/23. 3. On 6/1/23 at 10:45 AM, the surveyor observed Resident #230 in a chair in the resident's room. The surveyor attempted to interview the resident, but the resident was unable to answer. According to the AR, Resident #230 was admitted to the facility with diagnoses that included but were not limited to AFib and dementia. A review of the OSR for May 2023 revealed the following POs for Eliquis (an anticoagulant) 2.5 mg, given 2.5mg by mouth two times a day for Afib with a start date of 5/13/23. A review of May 2023 eMAR did not show documentation of the administration of the critical medications of Eliquis for 13 of 36 doses due. There was no documented evidence of hospitalization. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. A review of the March, April, and May 2023 CP recommendations revealed no specific CP recommendations addressing the omissions in the resident's eMAR. 4. On 6/7/23 at 11:23 AM, the surveyor observed Resident #13 in bed. The resident was unable to answer any questions. The surveyor reviewed the electronic medical record for Resident #13. A review of the AR revealed that the resident had diagnoses that included but were not limited to dementia, AFib, and type 2 diabetes mellitus. A review of the May 2023 OSR revealed the following POs: - start date of 3/1/23 Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth two times a day for A Fib. - start date of 3/1/23 HumaLog injection solution (Insulin Lispro), 100 Unit/ML, inject as per sliding scale: if 0-150=0; 151-200=2; 201-250=3; 251-300=4; 301-350=5;351-400=6, if above 400, give 8 units then recheck after 1 hour, subcutaneously (SC) before meals and at bedtime for DM2. - start date of 3/1/23 Lantus Subcutaneous Solution 100 Units/ML (Insulin Glargine), inject 16 units SC at bedtime for DM2. A review of the March 2023 eMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 10 out of 62 omitted doses. - Humalog had a total of 44 out of 124 omitted doses. - Lantus had a total of 13 out of 31 omitted doses. A review of the April 2023 eMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 6 out of 60 omitted doses. - Humalog had a total of 27 out of 120 omitted doses. - Lantus had a total of 6 out of 30 omitted doses. A review of the May 2023 eMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 26 out of 62 omitted doses. - Humalog had a total of 65 out of 124 omitted doses. - Lantus had a total of 18 out of 31 omitted doses. There was no documentation revealing a blood sugar taken on each of the omitted insulin doses and no documentation of hospitalization, hypoglycemia, or hyperglycemia. There was no documentation revealing any blood clotting concerns identified nor any documentation of hospitalization for this resident. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 98, which required no Humalog insulin, to 299, requiring 4 units of Humalog that were administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 80, which required no Humalog insulin, to 324, requiring 5 units of Humalog that were administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 103, which required no Humalog insulin, to 314, requiring 5 units of Humalog that were administered. A review of the March, April, and May 2023 CP recommendations revealed no specific CP recommendations addressing the omissions in the resident's eMAR. The CP Consultant Evaluation form dated 5/4/23 noted an HBA1C of 8.1 results from 4/4/23 was noted. There was no specific recommendation made for the facility or the physician. 5. On 6/7/23 at 11:39 AM, the surveyor observed Resident #17 in a wheelchair at the back of the dining/day room. The resident ended a phone call using the facility telephone. The resident stated that they had called their physician because they wanted to check on something. The resident also said that they received their medications because they see LPN#1 all the time and knew that they were supposed to take their antibiotic, Augmentin, with food. The resident was unable to speak to all medications that were administered or what times they were administered. The surveyor reviewed the electronic medical record for Resident #17. A review of the AR revealed that the resident had diagnoses that included but were not limited to dementia and AFib. A review of the May 2023 OSR revealed a PO with a start date of 3/1/23 for Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth every 12 hours for AFib. - start date of 3/1/23 Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth two times a day for A Fib. A review of the March 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 17 out of 62 omitted doses. A review of the April 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 10 out of 60 omitted doses. A review of the May 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 29 out of 62 omitted doses. There was no documentation revealing any blood clotting concerns identified nor any documentation of hospitalization for this resident. A review of the Progress Notes revealed no follow-up with the physician regarding medication omissions in the eMARs. A review of the CP recommendations and monthly evaluations for March, April, and May 2023 revealed no specific CP recommendation addressing omissions from the resident's eMAR. A review of the CP monthly report, dated 3/7/23, revealed that the pharmacist indicated a general note that blanks were noted in the eMAR and issues discussed with the administrator. No specific resident was pointed out on the monthly report to show which resident's charts had omissions. There was no indication that the facility reviewed this recommendation, and no signature or follow-up note was written. A review of the CP monthly report, dated 4/5/23, revealed that the pharmacist indicated frequent charting omissions noted in March, with some improvement in April, and that pharmacy recommendations still need to be addressed from March. No specific resident was pointed out on the monthly report to indicate which resident's charts had omissions and the seriousness of omitting the medications prescribed. There was no indication that the facility reviewed this recommendation, and no signature or follow-up note was written. A review of the CP monthly report, dated 5/5/23, revealed that the pharmacist indicated that there were frequent charting omissions from the resident's charts and the report specified e.g., 0600 4/3, 4/4, 4/6, 4/7, 4/17, 4/18, 4/19, 4/21, 4/25, 5/1, 5/3; 0900 4/1, 4/6, 4/16, 4/19, 4/24, 5/1, 5/3; 1400 4/1, 4/6, 4/10, 4/16, 4/19, 4/24; 2100 4/5, 4/7, 4/16, 4/21, 4/27, 5/2. There was no specific resident note on the monthly report to indicate which resident this note referred to and which charts had medication omissions. There was no indication that the facility reviewed this recommendation, and no signature or follow-up note was written. On 6/1/23 at 11:00 AM, the surveyor interviewed LPN #1 regarding the omitted medication administration in the eMARs, and LPN #1 stated that she was signing the medication she administers but could not speak for other nurses if they were signing for them or not. LPN #1 added that she did not have time to check those signatures. On 6/1/23 at 3:08 PM, the surveyor attempted to contact the CP via telephone. On 6/1/23 at 4:13 PM, the surveyors interviewed the Director of Nursing (DON) and the LNHA, who stated that LPN #1 was not fast enough to complete her work and was being pulled to do other tasks. On 6/1/23 at 4:28 PM, the facility LNHA was notified of the IJ. On 6/2/23 at 10:09 AM, the surveyor interviewed the CP supervisor, who stated that the pharmacy recommendation reports get sent to the DON, and it is up to the facility's nursing staff to respond to the report. The CP supervisor stated that days and times for frequent charting omissions might not specify the resident or drugs omitted. The CP's responsibility is to identify any irregularities and report them to the facility. On 6/5/23 at 10:24 AM, the surveyor interviewed the CP via telephone, who stated that he was covering for the regular CP during April and May and was familiar with the reports. The CP stated that he had reviewed with the LNHA the charting omissions he had noticed. The CP also said that he emailed the CP reports to the facility, and it was the facility's responsibility to respond to the recommendations. The surveyor continued to meet with the LNHA to review the components of the Removal Plan (RP) necessary to remove the immediacy on 6/6/23 at 12:45 PM, 6/7/23 at 10:00 AM, and 12:40 PM when the RP was not provided. On 6/08/23 at 10:45 AM, the surveyors reviewed the RP sent by the facility, and after review, it was rejected based on insufficient evidence, which was needed to remove the immediacy. The surveyor discussed this with the LNHA. After the facility revised the RP, they were accepted. On 6/8/23 at 10:30 AM, the surveyor interviewed the Medical Director (MD), who stated that he was unaware of concerns about the quality issues of missing blood sugars and insulin coverage. MD added, If I had known that, I would have addressed that at our quality meetings. The MD stated that he had not gotten medication error reports from the facility. He also said he did not know why the facility did not notify him of the pharmacy consultant's recommendations. On 6/8/23 at 12:00 PM, DON stated that the pharmacy consultant's recommendations go to the LNHA, and then they are given to the DON, and sometimes there is a delay. DON did not indicate if she was aware of this recommendation made by the pharmacist. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview, and review of records. NJAC 8:39-27.1(a)

Refer to F756K, F689L, F835L and F836L Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents are free of significant medication errors regarding the documentation and administration of critical medications, including anticoagulants and insulin medications to prevent serious adverse outcomes for Resident #13, #19 and #20 who required blood sugar monitoring and were dependent on insulin, Resident #17, #25 and #230 who had physician orders for an anticoagulant to prevent blood clotting, and Resident #19 who had a physicians order for an oral hypoglycemic agent (medications to lower blood sugar). The facility failed to ensure that Resident #18 was given medication validated by the physician, and the pharmacy, reviewed for allergies, and entered into the Electronic Medication Administration Record (eMAR) to prevent serious adverse outcomes, including significant allergic reactions. The failure to monitor and document blood sugars and administer insulin and oral hypoglycemic agents when indicated per the physician's order is likely to result in hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), which requires immediate emergency intervention if symptomatic. The failure to administer and document an anticoagulant in accordance with a physician's order to prevent blood clots is likely to lead to a heart attack, pulmonary embolism (a blood clot that enters the lung), anoxic stroke (a blood clot that stops oxygen to the brain), or other blood clots throughout the body. Resident #25 received double dosing of an anticoagulant medication for five days, likely leading to increased bleeding, which would require immediate emergency intervention. The failure to give a medication validated by the physician, the pharmacy, reviewed for allergies, and entered into the eMAR is likely to lead to significant allergic reactions, which would require immediate emergency intervention. This resulted in an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ on 6/1/23, which began on 3/7/23 (the start date on which the Consultant Pharmacist (CP) alerted the facility of concerns on documentation of medications on the eMAR) and continued until 6/8/23 when the facility implemented their written removal plan. The facility's Licensed Nursing Home Administrator (LNHA) was notified of the IJ on 6/1/23 at 4:28 PM. An acceptable written Removal Plan (RP) was received on 6/8/23. The RP was verified by the survey team onsite on 6/8/23, lifting the immediacy, and the survey team continued verification of the RP onsite throughout the remainder of the survey through observation, interview, and review of records. This deficient practice was identified for 7 of 17 residents reviewed for medication management (Resident #13, #17, #18, #19, #20, #25, and #230). The evidence was as follows: 1. On 5/24/23 at 10:40 AM, the surveyor observed Resident #19 out of bed to the wheelchair in the dining area, eyes closed, unable to answer the surveyor's inquiry. According to the admission Record (AR), Resident #19 was admitted to the facility with diagnoses that included but were not limited to Alzheimer's disease (a progressive mental deterioration), type 2 diabetes mellitus (elevated level of blood sugar), and hypertension (high blood pressure). The surveyor reviewed the Quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) dated 3/03/23. The included Brief Interview for Mental Status (BIMS) referenced a score of 0, which identified that the resident's cognition was a severe impairment. A review of the Pharmacy Therapeutic Suggestions Sheets (consult sheet) Final Report revealed under Subject: Therapeutic suggestions dated 04/04/23, The eGFR was found to be 40ml/min on 5/2022. With moderate renal impairment (eGFR = 30-45 mL/min), the recommended dose of Januvia is 50 mg. Currently on 100 mg Januvia and HbA1c = 5.8. Recommended dose decrease. Accepted: handwritten signature by the doctor on 4/26/23. Handwritten order: Reduce Januvia to 50 mg daily. A review of the Progress Notes dated 4/26/23 at 13:00 revealed under Note Text: Visited by Dr. Segaram (for routine). Rcvd. NO. Decrease med dose of Januvia 100 mg to Januvia 50 mg tab 1 tab PO q.d in AM. r/t eGFR & HbA1C results. NO noted and carried out. A review of the Order Summary Report (OSR) for April 2023 revealed on 4/26/23 an order for Januvia Oral Tablet 50 MG (Sitagliptin Phosphate) Give 1 tablet by mouth in the morning for DM II. A review of the Order Summary Report (OSR) for April 2023 revealed on 3/01/23 an order for Januvia Oral Tablet 100 MG (Sitagliptin Phosphate) Give 1 tablet by mouth in the morning for DM 2. A review of the April 2023 and May 2023 electronic Medication Administration Reports (eMARs) revealed that Januvia 50 mg and Januvia 100 mg are reflected as both ordered until 05/31/23. A review of the April 2023 eMAR order for Januvia 100 mg reflected the following signatures showing the administration of the medication on 4/26 and 4/27. The April 2023 eMAR also showed orders for Januvia 100 mg and Januvia 50 mg reflected the following signatures showing the administration of both medications on 4/28, 4/29, and 4/30/23. A review of the May 2023 eMAR orders for Januvia 100 mg and Januvia 50 mg reflected the following signatures showing administration of both of the medications on 5/1, 5/3, 5/4, 5/5, 5/6, 5/7, 5/8, 5/9, 5/10, 5/11, 5/13, 5/14, 5/16, 5/17, 5/18, 5/19, 5/25, 5/26, and 5/30/23. On 05/30/23 at 11:11 AM, the surveyor interviewed a Licensed Practical Nurse (LPN #1), who stated that she worked in the facility for two years. LPN # 1 said that when the medication changed, the person who did the changes would be the one to write the order, she added that she does not have the time to follow the doctor's order, and usually, the Director of Nursing (DON) or Assistant Director of Nursing (ADON) would be the one carrying out that recommendation from the doctor and whoever takes the order from the doctor should be the one to enter it in the electronic health record. LPN #1 added that she accidentally signed the Januvia 100 mg, but the order should be deleted. On 5/30/23 at 11:45 AM, the DON stated that she picked up the order based on the recommendation of the pharmacy and carried out that specific order but forgot to check them one by one. A review of the facility policy revised 2023 revealed under Policy: 3. The Charge Nurse/ADON will make sure: a. All of the recommendations are acted upon. A review of the OSR for Resident # 19 dated 4/23 revealed on 3/01/23 an order for Novolog injection solution 100 unit/ml (Insulin Aspart) Inject as per sliding scale: if 70-130 =0; 131-180 =2; 181-240 =4; 241-300 =6; 301-350 =8; 351-400 =10 If above 400, give 10 units, then call MD for order, subcutaneously before meals and at bedtime for DM2. A review of the March 2023 eMAR did not show documentation of the critical medication novolog insulin administration for 45 of 120 doses due. A review of April 2023 eMAR did not show documentation of the administration of the critical medication Novolog insulin for 31 of 120 doses due. A review of May 2023 eMAR did not show documentation of the administration of the critical medication Novolog insulin for 65 of 120 doses due. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 99, which required no Humalog insulin, to 231, requiring 4 units of Humalog to be administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 111, which required no Humalog insulin, to 276, requiring 6 units of Humalog to be administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 100, which required no Humalog insulin, to 192, requiring 4 units of Humalog to be administered. There was no documentation revealing a blood sugar taken on each of the omitted insulin doses or documentation of hospitalization, hypoglycemia, or hyperglycemia. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. On 6/1/23 at 11:00 AM, the surveyor asked LPN #1 regarding the missing signatures, and LPN #1 stated that she was signing the medication she had been giving but could not speak for other nurses if they were signing or not, and the nurse added that she does not have time to check those signatures. 3. On 5/31/23 at 11:40 AM, the surveyor observed Resident #20 in the resident's room in a chair. The resident's eyes were closed. The surveyor attempted to interview the resident, but the resident was unable to answer the surveyor's inquiry. According to the AR, Resident #20 was admitted to the facility with diagnoses that included but were not limited to type 2 diabetes mellitus, atrial fibrillation (AFib) (an irregular, rapid heart rate that typically requires anticoagulants to prevent blood clotting), and psychotic disorder. The surveyor reviewed the Quarterly MDS, with an ARD dated 5/7/23. The included BIMS referenced a score of 0, which identified that the resident's cognition was a severe impairment. The resident was care planned (11/14/2020) for the diagnosis of diabetes mellitus. Interventions included: Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. The resident was care planned (5/29/2) for using anticoagulant therapy. Interventions included: Administer anticoagulant medications as ordered by a physician . Monitor for side effects and effectiveness Q (every) shift. Monitor/document/report PRN [as needed] adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black, tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s [vital signs]. A review of the OSR for May 2023 revealed the following POs for Humalog (fast-acting insulin) injection solution 100 unit/ml (Insulin Lispro) dated 3/1/23. The order specified to inject the insulin subcutaneously (under the skin) as per the sliding scale: if the fasting blood sugar is 0-150, administer 0 units of insulin; if the fasting blood sugar is 151-180, administer 2 units of insulin; if the fasting blood sugar is 181-240, administer 4 units of insulin; if the fasting blood sugar is 241-300, administer 6 units of insulin; if the fasting blood sugar is 301-350, administer 8 units of insulin; if the fasting blood sugar is 351-400, administer 10 units of insulin; An additional PO dated 3/1/23 administered Lantus (long-acting insulin) subcutaneous solution 100 unit/ml (Insulin Glargine). The order specified injecting 15 units subcutaneously at bedtime for type 2 diabetes. In addition, there was an order for Xarelto (an anticoagulant) dated 3/1/23. The order specified administering Xarelto 15 milligram tablet by mouth in the evening for AFib. A review of March 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 37 of 120 doses due, Lantus for 12 of 31 doses due, and Xarelto for 8 of 31 doses due. A review of April 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 25 of 120 doses due, Lantus for 5 of 30 doses due, and Xarelto for 4 of 30 doses due. A review of May 2023 eMAR did not show documentation of the administration of the critical medications of Humalog insulin for 49 of 120 doses due, Lantus for 15 of 30 doses due, and Xarelto for 13 of 30 doses due. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 58, which required no Humalog insulin, to 389, requiring 10 units of Humalog to be administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 39, which required no Humalog insulin, to 400, requiring 10 units of Humalog to be administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 74, which required no Humalog insulin, to 368, requiring 10 units of Humalog to be administered. There was no documentation revealing a blood sugar taken on each of the omitted insulin doses or documentation of hospitalization, hypoglycemia, or hyperglycemia. There was no documented evidence that the resident had a hospitalization. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. 4. On 6/1/23 at 10:45 AM, the surveyor observed Resident #230 in a chair in the resident's room. The surveyor attempted to interview the resident, but the resident was unable to answer. According to the AR, Resident #230 was admitted to the facility with diagnoses that included but were not limited to AFib and dementia. The resident was care planned (5/27/23) for using anticoagulant therapy related to DVT. Interventions included: Administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness q [every] shift. Monitor/document/report PRN [as needed] adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black, tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s [vital signs]. Review medication list for adverse interactions. Avoid use of aspirin or NSAIDS. A review of the OSR for May 2023 revealed the following POs for Eliquis (an anticoagulant) 2.5 mg given 2.5 mg by mouth two times a day for AFib with a start date of 5/13/23. A review of May 2023 eMAR did not show documentation of the administration of the critical medications of Eliquis for 13 of 36 doses due. There was no documented evidence of hospitalization. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. 5. On 6/7/23 at 11:23 AM, the surveyor observed Resident #13 in bed. The resident was unable to answer any questions. According to the AR, Resident #13 was admitted to the facility with diagnoses that included but were not limited to dementia, AFib, and Type 2 diabetes mellitus (DM2). A review of the resident's Significant Change MDS with an ARD of 2/24/23, reflected the resident had a BIMS score of 5 out of 15, indicating that the resident had a severely impaired cognition. A review of the resident's individualized interdisciplinary care plan (IDCP) reflected as a Focus area with a date initiated and revised of 4/1/22, The resident is on anticoagulant therapy related to (r/t) Atrial Fibrillation (AFib) with an intervention Administer anticoagulant medications as ordered by the physician. Monitor side effects and effectiveness every shift. There was an additional Focus area with a date initiated and revised 3/28/22, Resident #18 has Diabetes Mellitus with interventions Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. Fasting serum blood sugar as ordered by the doctor. Monitor/document the resident/family's ability to manage the treatment program, i.e., medications, dietary, glucose monitoring, exercise, and knowledge of complications. Monitor/document/report PRN any signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggered gait. A review of the May 2023 OSR revealed the following Physician's Orders (PO): - start date of 3/1/23 Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth two times a day for A Fib. - start date of 3/1/23 HumaLog injection solution (Insulin Lispro), 100 Unit/ML, inject as per sliding scale: if 0-150=0; 151-200=2; 201-250=3; 251-300=4; 301-350=5;351-400=6, if above 400, give 8 units then recheck after 1 hour, subcutaneously (SC) before meals and at bedtime for DM2. - start date of 3/1/23 Lantus Subcutaneous Solution 100 Units/ML (Insulin Glargine), inject 16 units SC at bedtime for DM2. A review of the March 2023 eMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 10 out of 62 omitted doses. - Humalog had a total of 44 out of 124 omitted doses. - Lantus had a total of 13 out of 31 omitted doses. A review of the April 2023 EMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 6 out of 60 omitted doses. - Humalog had a total of 27 out of 120 omitted doses. - Lantus had a total of 6 out of 30 omitted doses. A review of the May 2023 eMAR revealed that there was no documentation for the administration of critical medications as follows: - Eliquis had a total of 26 out of 62 omitted doses. - Humalog had a total of 65 out of 124 omitted doses. - Lantus had a total of 18 out of 31 omitted doses. There was no documentation of blood sugar on each of the omitted insulin doses or documentation of hospitalization, hypoglycemia, or hyperglycemia. There was no documentation revealing any blood clotting concerns identified nor any documentation of hospitalization for this resident. A review of the Progress Notes revealed no follow-up with the physician regarding any medication omissions in the eMARs. A review of the March eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 98, which required no Humalog insulin, to 299, requiring 4 units of Humalog that were administered. A review of the April eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 80, which required no Humalog insulin, to 324, requiring 5 units of Humalog that were administered. A review of the May eMAR blood sugar results indicated that the blood sugars were to be taken before meals (6:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (9:00 PM). The documented blood sugar results ranged from 103, which required no Humalog insulin, to 314, requiring 5 units of Humalog that were administered. 6. On 6/7/23 at 11:39 AM, the surveyor observed Resident #17 in a wheelchair at the back of the dining/day room. The resident ended a phone call using the facility telephone. The resident stated that they had called their physician because they wanted to check on something. The resident also said that they received their medications because they see LPN#1 all the time and knew that they were supposed to take their antibiotic, Augmentin, with food. The resident was unable to speak to all medications that were administered or what times they were administered. The surveyor reviewed the electronic medical record for Resident #17. A review of the AR revealed that the resident had diagnoses which included but were not limited to dementia and AFib. A review of the resident's quarterly MDS with an ARD of 3/10/23, reflected the resident had a BIMS of 15 out of 15, indicating that the resident had intact cognition. A review of the resident's IDCP reflected as a Focus area with a date initiated and revised of 4/1/22, The resident is on anticoagulant therapy related to (r/t) Atrial Fibrillation (AFib) with an intervention Administer anticoagulant medications as ordered by the physician. Monitor side effects and effectiveness every shift. A review of the May 2023 OSR revealed a PO with a start date of 3/1/23 for Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth every 12 hours for AFib. -start date of 3/1/23 Eliquis oral tablet 2.5 MG (Apixaban), give 1 tablet by mouth two times a day for A Fib. A review of the March 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 17 out of 62 omitted doses. A review of the April 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 10 out of 60 omitted doses. A review of the May 2023 eMAR revealed no documentation for administering a critical medication, Eliquis, which had 29 out of 62 omitted doses. There was no documentation revealing any blood clotting concerns identified nor any documentation of hospitalization for this resident. A review of the Progress Notes revealed no follow-up with the physician regarding medication omissions in the eMARs. A review of the CP recommendations and monthly evaluations for March, April, and May 2023 revealed no specific CP recommendation addressing omissions from the resident's eMAR. 7. On 5/25/23 at 8:46 AM, during the morning medication pass, the surveyor observed LPN #1 preparing seven (7) medications according to the eMAR for Resident #18. At that time, LPN #1 stated that she was the nurse who worked on the 11 PM to 7 AM shift and knew that Resident #18 had been sent to the hospital and returned after midnight with a prescription from the hospital emergency room (ER) physician for Keflex (a cephalosporin antibiotic). LPN #1 added that she wanted to start the Keflex and administer the medication with the other morning medications. LPN #1 then called the Assistant Director of Nursing/Registered Nurse (ADON/RN), who brought over to LPN #1 to show the surveyor a prescription dated 5/24/23 from a hospital ER physician for Cephalexin (Keflex) 500 milligram (MG) capsule, take 1 capsule (500 MG total) by mouth 3 times a day for 5 days. The ADON/RN stated that she was working on faxing the prescription to the provider pharmacy and entering the PO in the electronic computer system. LPN #1 said she had Keflex in the facility backup box, which was kept in the medication cart. The surveyor observed LPN #1 remove two (2) of the 250 MG capsules of Keflex from the backup box and place them in the medication cup with the seven (7) other medications she had prepared for Resident #18. The surveyor had not observed a PO for Keflex in the eMAR that LPN #1 was documenting for Resident #18. On 5/25/23 at 9:01 AM, the surveyor observed LPN #1 preparing thickened water and said she would administer the eight (8) medications to Resident #18. At that time, the surveyor stopped LPN #1 from administering the (8) medications, which included the Keflex capsules. The surveyor asked LPN #1 to review the eMAR for Resident #18. LPN #1 stated that the Keflex PO was not entered electronically and was not on the eMAR. The surveyor then asked LPN #1 to review Resident #18's eMAR profile, particularly the allergy indicated on the eMAR. LPN #1 checked the resident's profile and stated that the resident was allergic to Penicillin (PCN) (an antibiotic with a cross-sensitivity to Keflex). LPN #1 also stated that she could not administer the Keflex and would have to call the primary physician. The surveyor observed LPN #1 remove the two (2) 250 MG Keflex capsules from the medication cup. LPN #1 could not speak to what allergic reaction occurred if the resident received PCN or had received a cephalosporin medication in the past without a reaction. LPN #1 could also not speak to whether the primary physician had approved the PO for Keflex to be administered with a PCN allergy. On 5/25/23 at 9:09 AM, the surveyor interviewed LPN #1 in the presence of the DON and ADON/RN, who stated that she had assumed the emergency room physician had reviewed the allergies. The DON said that LPN #1 should not have assumed. The DON added that the ADON/RN called the primary physician for the resident, and they were waiting to verify whether the Keflex could be administered. At that time, LPN #1 stated that her usual procedure was to call the physician, review any medication orders from the hospital, and review the allergies with the physician. However, this was a different situation. On 5/25/23 at 9:20 AM, the surveyor interviewed the DON, who stated that the ADON/RN called the primary physician, and the physician changed the PO to Bactrim (a sulfa antibiotic). The DON acknowledged that the administration of the Keflex with a PCN allergy was not verified by the physician and had the potential to cause a severe reaction. On 5/25/23 at 9:36 AM, the surveyor interviewed the ADON/RN, who stated that the physician changed the Keflex to Bactrim but that the physician had said that there was a low chance of cross-sensitivity. The ADON/RN added that the ER physician had written the prescription and thought that was sufficient. The ADON/RN acknowledged that the facility had processes to follow for the receipt of new medication orders and that the primary physician was called to verify PO, and the PO would be faxed to the provider pharmacy. The pharmacy usually calls the physician to confirm dispensing the Keflex with a PCN allergy. The ADON/RN acknowledged that she had called the primary physician and faxed the PO for Keflex to the provider pharmacy after LPN #1 was going to administer the Keflex to the resident. On 5/25/23 at 10 AM, the surveyor was provided the AR and OSR for Resident #18 by the DON, who stated that the forms were sent to the hospital. The surveyor reviewed the documents, and an allergy to PCN was noted on both forms. No documentation was provided that the ER physician was aware of the PCN allergy. On 5/25/23 at 11:00 AM, the survey team met with the DON and LPN #1. LPN #1 stated that Resident #18 was readmitted on her shift but that she had not called the primary physician to get approval for the Keflex to be administered and had not faxed the Keflex prescription to the provider pharmacy. The DON acknowledged that the proper procedure for the new medication order was not followed. On 6/1/23 at 3:01 PM, the surveyor interviewed the DON and ADON. The ADON stated that no progress note was completed regarding the issue with the allergy to PCN because she didn't think it was a big issue when she spoke with the physician and the provider Pharmacy. The ADON stated that she entered the new order for Bactrim in the eMAR. The DON verified that the PO was not entered in the eMAR, confirmed by the primary physician, or faxed to the provider pharmacy before LPN #1 was going to administer the Keflex to the resident, and there was no knowledge of the type of allergic reaction that Resident #18 had to PCN. On 6/1/23 at 3:22 PM, the surveyor interviewed the DON, who stated that she had called the family representative for Resident #18, but they did not know about any allergies. The DON added that the unknown allergic reaction to PCN had the potential to be a severe reaction. The DON stated that the provider pharmacy had said the reaction could be mild to moderate, but the physician had to verify that the Keflex could be administered with a PCN allergy. The DON added that every new PO for medication should have the allergies checked before administration. The surveyor reviewed the medical record for Resident #18. A review of the admission Record revealed that the resident had diagnoses that included but were not limited to dementia. A review of the annual MDS with an ARD of 5/7/2023 reflected the resident had a BIMS score of three (3) out of 15, indicating that the resident had severely impaired cognition. A review of the electronic record of Resident #18 revealed an allergy tab that listed the Allergen was PCN, with the Type listed as allergy and the Category listed as drug with no Reaction/Type/Subtype listed and Severity listed as Unknown dated 6/25/2020. A review of the hospital records provided by the DON revealed an After Visit Summary, which indicated that the reason for the visit was an altered mental status, and the diagnoses included generalized weakness and urinary tract infection without hematuria (blood in the urine) and the instructions to start taking Keflex. In addition, there was a prescription written on 5/24/23 by the ER physician for Cephalexin (Keflex) 500 milligram (MG) capsule, take 1 capsule (500 MG total) by mouth 3 times a day for 5 days, with a quantity noted for 15 capsules with a start date of 5/24/23 and an end date of 5/29/23. There was no documentation that the physician stated the PCN allergy. On 6/1/23 at 4:13 PM, the survey team met with the LNHA and DON. The DON stated that she had thought the hospital transfer form had the PCN allergy noted but could not obtain the universal transfer form. The DON then said that LPN #1 was not able to verify the PO or fax the PO to the provider pharmacy because she was the only nurse on duty from 11 PM to 7 AM and then stayed for the 7 AM shift and was also pulled to do other job duties while passing medications. The LNHA stated that the ER physician should have known the resident had a PCN allergy because it was on the resident's profile that was sent with the resident to the hospital. The LNHA acknowledged that the PCN allergy should have been verified with the physician when the resident returned to the facility before the administration of the Keflex. On 6/2/23 at 9:16 AM, the surveyor interviewed the CPS via telephone, stating that the CP assigned to the facility was out on leave. The CPS stated that she would email any completed med passes or in-services. On 6/5/23 at 9:50 AM, the surveyor interviewed LPN #1, who stated that she was not trained at the facility on the electronic records but knew some of the electronic entries for documentation of medication administration from a previous facility. LPN #1 added that she was not that fast at the eMAR and had no knowledge of entering a PO electronically because the DON or ADON had been doing that. On 6/5/23 at 9:58 AM, the surveyor interviewed the CPS via telephone, who stated that she had emailed medication observations that included two (2) completed for LPN #1. The CPS added that there were no in-services performed recently. The CPS said that there was a covering consultant Pharmacist (CP) that may have more information. A review of the Medication Pass Observation completed by the CP, that was on leave dated 12/7/22, revealed that LPN #1 had zero (0) errors which resulted in a zero (0) percent error rate. A review of the Medication Pass Observation completed by the covering CP dated 4/4/23 revealed that LPN #1 had one (1) error, resulting in a nine (9) percent error rate. A review of