COMPLETE CARE AT BAYSHORE LLC
For profit - Corporation
232 Beds
COMPLETE CARE
Data: November 2025
Trust Grade
65/100
#113 of 344 in NJ
Photo by Complete Care at Bayshore
Photo by Complete Care at Bayshore
Photo by Complete Care at Bayshore
1 / 10 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Complete Care at Bayshore LLC in Holmdel, New Jersey has a Trust Grade of C+, indicating it is slightly above average but not exceptional. Ranked #113 out of 344 facilities in New Jersey, they are in the top half of the state, and #14 out of 33 in Monmouth County, meaning there are only a few local options that are better. The facility is on an improving trend, with issues decreasing from 10 in 2023 to 9 in 2024. Staffing is a weak point, receiving a 2 out of 5 stars rating, suggesting lower staff retention, but their turnover rate is at 41%, which matches the New Jersey average. There have been no fines, which is a positive sign, but the facility has less RN coverage than 78% of other state facilities, which could impact care quality. Specific incidents noted include the failure to adequately assess and treat a resident's skin issue, which could lead to serious complications, and concerns about kitchen cleanliness that could affect all residents. Additionally, there was a lack of staff interaction during activities, leaving some residents feeling isolated. Overall, while there are notable strengths, such as the lack of fines and an improving trend, the staffing and care quality issues should be carefully considered.
- Trust Score
- C+
- In New Jersey
- #113/344
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 41% turnover. Near New Jersey's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New Jersey facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 25 minutes of Registered Nurse (RN) attention daily — below average for New Jersey. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 36 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 32%
Needs review
10 → 9 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 10 issues
2024: 9 issues
The Good
-
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 quality measures, fire safety.
The Bad
Staff Turnover: 41%
Near New Jersey avg (46%)
Typical for the industry
Chain: COMPLETE CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 36 deficiencies on record
1 actual harm
Oct 2024
7 deficiencies
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 F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop an individualized comprehensive care plan for a resident with chronic...
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Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop an individualized comprehensive care plan for a resident with chronic pain. This deficient practice was identified for 1 of 1 resident reviewed for pain management (Resident #10), and was evidenced by the following:
On 10/22/24 at 12:17 PM, during initial tour of the facility, the surveyor observed Resident #10 in bed with eyes closed.
On 10/24/24 at 10:01 AM, the surveyor reviewed the medical record for Resident #10.
A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with medical diagnoses which included but were not limited to; diabetes (high blood sugar), depressive disorder, and chronic pain syndrome.
A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 9/15/24, revealed the resident had a Brief Interview of Mental Status score of 15 out of 15, meaning the resident was cognitively intact. A review of Section J Health Conditions revealed the resident had frequent pain and was receiving pain medications.
A review of the active Order Summary Report revealed the resident was receiving pain medications. The resident had a physician's orders (PO) dated 9/14/23, for oxycodone (a narcotic pain reliever) 10 milligrams (mg); administer one tablet every four hours as needed for severe pain and a PO dated 9/14/23, for oxycodone 5 mg; administer one tablet every four hours as needed for moderate pain.
A review of the corresponding October 2024 Medication Administration Record (MAR) revealed the resident received pain medication daily during the month of October.
A review of the individual comprehensive care plan (ICCP) did not include a focus area for pain.
On 10/24/24 at 12:24 PM, the surveyor observed Resident #10 in the hallway in a wheelchair. The resident was speaking with the Unit Manager/Licensed Practical Nurse (UM/LPN) of the B wing nursing unit. The resident told the UM/LPN that they needed an appointment related to shoulder pain.
On 10/25/24 at 10:28 AM, the surveyor interviewed the UM/LPN regarding the resident and pain. The UM/LPN told the surveyor that the resident had neck and shoulder pain and was receiving pain medications. The surveyor asked if a resident with pain should have a pain included in their ICCP, and the UM/LPN responded absolutely.
On 10/29/24 at 10:40 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the [NAME] President of Clinical (VPC), and the Director of Nursing (DON) regarding the pain care plan. The VPC stated that the care plan was now initiated and agreed the care plan should have been initiated when the resident began with the pain.
A review of the facility's Care Plans, Comprehensive Person-Centered policy dated October 2022, included a comprehensive, person-centered care plan, that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and function needs is developed and implemented for each resident .
NJAC 8:30-27.1(a)
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure recommendations by the wound care consultant were implemented to preve...
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Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure recommendations by the wound care consultant were implemented to prevent the worsening of a pressure ulcer. This practice was identified in 1 of 2 residents reviewed for pressure ulcers (Resident #13), and was evidenced by the following:
On 10/22/24 at 11:12 AM, during the initial tour of the facility, the surveyor observed Resident #13 in bed. The resident told the surveyor that they had a sore that opened. At that time, the surveyor did not observe a low air mattress (a mattress designed to prevent and treat pressure wounds) pump on the bed. The surveyor asked the resident if they were on a low air mattress or a specialty mattress and the resident replied, No, I don't know what they are doing.
On 10/24/24 at 12:10 PM, the resident was observed in bed with eyes closed. The surveyor did not observe a low air loss mattress on the resident's bed.
On 10/25/24 at 9:35 AM, the surveyor reviewed the medical record for Resident #13.
A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with medical diagnoses which included but were not limited to; major depressive disorder, chronic pain, kidney stones, and cerebral infarction (when blood flow to the brain is blocked).
A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 9/4/24, revealed the resident had a Brief Interview of Mental Status score of 15 out of 15, meaning the resident was cognitively intact. A review of Section M. Skin Assessment revealed the resident had an unstageable pressure ulcer (full-thickness skin and tissue loss) with preventative measures which included a pressure relieving mattress.
A review of the October 2024 Treatment Administration Record (TAR) included a physician's order dated 10/2/24, to cleanse pressure ulcer on left buttock with normal saline solution, pat dry, apply Medihoney (a honey dressing to treat wounds) and calcium alginate (used in wound dressings to promote healing); cover with gauze every day shift for wound care.
A review of the wound consultation report dated 10/15/24, include the Wound Nurse Practitioner (WNP) saw the resident for a stage III pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue layer (deepest layer of skin)) to the left buttock. The WNP recommended for the treatment of the left buttock pressure ulcer, to offload pressure with a low air-loss (LAL) mattress with turning and positioning measures in place.
A review of the individualized comprehensive care plan (ICCP) included a focus area dated 4/26/23, and revised 8/22/24, that the resident had a pressure ulcer to the left buttock. Interventions included to teach the resident, family, and caregivers the importance of changing positions for prevention of pressure ulcers; encourage small frequent position changes; and follow facility policies and protocols for the prevention and treatment of skin breakdown. The ICCP did not include the use of a LAL mattress as recommended by the WNP.
A review of the active Order Summary Report did not include a physician's order for a LAL mattress.
On 10/25/24 at 10:05 AM, the surveyor interviewed Resident #13's Licensed Practical Nurse (LPN), who stated the resident had a stage three pressure ulcer and received wound care daily. The LPN stated that the resident was seen weekly for wound care consultations. The surveyor asked what preventative measures were in place for the resident, and the LPN stated the resident had an air (LAL) mattress. At that time, the surveyor accompanied by the LPN went to Resident #13's room, and the LPN confirmed the resident did not have a LAL mattress.
On 10/25/24 at 10:11 AM, the surveyor observed the resident in bed receiving care from the Certified Nursing Assistant (CNA). At that time, the resident informed the surveyor that the nurse already did wound care for the day. The surveyor asked the resident if they were on an air (LAL) mattress, and the resident replied, No, but I need one.
On 10/25/24 at 10:20 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) regarding the resident's wound, and the UM/LPN stated that the resident had a stage two pressure ulcer (partial thickness loss). The surveyor asked if the resident had an air (LAL) mattress and she stated I think so, but if not, maybe the resident refused. At that time the resident requested documentation of the resident's refusal.
On 10/29/24 at 10:40 AM, during a meeting with the [NAME] President of Clinical (VPC), the surveyor asked about Resident #13's air (LAL) mattress. The VPC acknowledged the resident should have had the air (LAL) mattress prior to surveyor inquiry, and staff needed to be educated to follow wound care consultant recommendations.
No additional information was provided.
A review of the facility's Wound Care policy dated updated May 2023, did not include the process for wound care consultation recommendations and LAL mattresses.
NJAC 8:39-27.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure the accountability of the narcotic shift count logs were complete...
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Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure the accountability of the narcotic shift count logs were completed; and b.) accurately account for and document the administration of controlled medications. This deficient practice was identified on 2 of 2 medication carts reviewed for medication storage, and was evidenced by the following:
During medication storage review on 10/24/24 at 10:39 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1), reviewed the Vent unit medication cart A's September and October 2024 Change of Shift - Controlled Substances Count Sheet (a shift-to-shift controlled substance and narcotics (narc) count sheet signed by the incoming and outgoing nurses each shift) which revealed the following:
The nursing signatures were blank for the incoming nurse for the following shifts:
For the 7:00 AM (7 AM) shift on: 9/14, 9/29, 10/4, 10/5, 10/6, 10/20, and 10/24.
For the 7:00 PM (7 PM) shift on: 9/6, 10/1, 10/15, and 10/22.
For the 11:00 PM (11 PM) shift on: 9/27 and 10/14.
The nursing signatures were blank for the outgoing nurse for the following shifts:
For the 7 AM shift on: 9/7, 10/15, 10/16, and 10/23.
For the 7 PM shift on: 9/15, 9/29, 10/3, 10/4, 10/5, 10/6, and 10/20.
For the 11:00 PM shift on: 9/27.
The narcotic counts Count (Number of Cards) were blank for the following shifts:
For the 7 AM shift on: 9/1, 9/4, 9/6, 9/10, 9/13, 9/14, 9/15, 9/16, 9/19, 9/20, 9/23, 9/25, 9/28, 10/4, 10/5, 10/6, 10/8, 10/9, 10/10, 10/20, 10/21, and 10/24.
For the 3:00 PM (3 PM) shift on: 9/10.
For the 7 PM shift on: 9/1, 9/4, 9/5, 9/6, 9/9, 9/14, 9/15, 9/16, 9/19, 9/20, 9/23, 9/25, 9/26, 10/3, 10/4, 10/5, 10/6, 10/8, 10/12, 10/17, 10/19, 10/20, and 10/21.
For the 11:00 PM (11 PM) shift on: 9/12, 9/13, 9/27, 10/9, and 10/14.
Further review of the cart revealed the individual resident Controlled Drug Administration Record log (declining inventory log) for Resident #291 indicated the 9:00 AM (9 AM) dose of clonazepam (a controlled medication used to treat anxiety) 1 milligram (mg) tablet was not signed out on the declining inventory log. The declining inventory log was missing the [Administered] By signatures for the 10/24/24 at 9 AM dose.
At the time of observation, the surveyor interviewed LPN #1, who stated she administered the 9 AM dose of clonazepam that morning but did not sign Resident #291's declining inventory log. LPN # 1 confirmed that the 9 AM dose was signed out as being administered in the electronic Medication Administration Record (MAR), but was not accounted for on the declining inventory log. LPN #1 further acknowledged that the declining inventory logs should be completed upon dispensing the medication to keep track of the narcotic count. LPN #1 also stated that shift-to-shift logs should be completed by two nurses at each shift change indicating narcotic count was completed and all narcotics were accounted for. LPN #1 stated that shift-to-shift counts were done for accountability of narcotics and there should not have been any missing documentation or signatures. LPN #1 further acknowledged that she forgot to sign the incoming nurse portion for this morning's shift change.
During medication storage review on 10/24/24 at 11:35 AM, the surveyor in the presence of LPN #2, reviewed the A wing medication cart B's October 2024 Change of Shift - Controlled Substances Count Sheet which revealed the following:
The narcotic counts Count (Number of Cards) were blank for the following shifts:
For the 7 AM shift on: 10/22, 10/23, and 10/24.
For the 3 PM shift on: 10/22.
For the 11 PM shift on: 10/21, 10/22, and 10/23.
At the time of observation, LPN #2 stated that she was not sure if the number of cards column should be filled out since there were a lot of blanks. LPN #2 further stated she was going to count the narcotics at the end of her shift and fill out the column then. She further acknowledged that there should be no missing count (number of cards) on the narcotic count sheets. LPN #2 then stated that shift-to-shift count was done for the accountability of the narcotics.
On 10/24/24 at 12:21 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the shift-to-shift narcotic count log should have been completed by the incoming and outgoing nurses together at shift change. The nurses count the number of narcotic cards to ensure there was the correct number of narcotic cards and it matched the shift-to-shift narcotic count log. The DON stated there should be no missing documentation or signatures on the narcotic count logs because it was for accountability. The DON then stated the purpose of the shift-to-shift narcotic log was to keep track of the narcotic card counts. The DON further acknowledged that the declining inventory logs should be completed and filled out for each narcotic dose dispensed immediately at the time the medication was removed from inventory. The DON acknowledged that if it was not documented it was not done.
On 10/29/24 at 10:39 AM, the [NAME] President of Clinical (VPC) in the presence of the DON, Licensed Nursing Home Administrator (LNHA), Regional Food Service Director, Food Service Director, and Assistant Licensed Nursing Home Administrator (ALNHA), acknowledged that the shift-to-shift count sheets were not completed. The VPC also stated that they did an in-service for all nurses and implemented a new shift to shift log. The VPC acknowledged that the shift-to-shift narcotic logs should have not have any missing signatures or counts. The VPC further acknowledged that when dispensing a narcotic, the nurse needed to sign the narcotic declining inventory log immediately.
A review of the facility's Controlled Substance Administration & Accountability policy with a revision date February 2023, included . 1. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must clearly legible with all applicable information provided. All specially compounded or non-stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the Controlled Drug Record supplied with the medication or other designated form as per facility policy. The Controlled Drug Record serves the dual purpose of recording both narcotic disposition and patient administration. The Controlled Drug Record is permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed from the pharmacy. 6. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift .
NJAC 8:39-29.7(c)
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, and review of pertinent facility documents, it was determined that the facility failed to properly store medications. This deficient practice was observed in 1 of 4 me...
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Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medications. This deficient practice was observed in 1 of 4 medication carts reviewed for medication storage and labeling, and was evidenced by the following:
On 10/24/24 at 10:39 AM, the surveyor observed the Vent nursing unit's medication cart A. The medication cart was kept at the nurse's station and was left unattended by the Licensed Practical Nurse (LPN #1) while she administered medication to an unsampled resident. On the cart's unlockable pull-out tray/drawer, was observed packets of individually wrapped medications stored and visible with the tray/drawer in the retracted position. Upon return of LPN #1, the surveyor reviewed the cart and observed the following unsecured medications in the tray/drawer:
One Eliquis 5 milligram (mg) tablet (tab) (medication used to prevent blood clots).
Two midodrine HCl 5 mg tabs (medication used to treat low blood pressure).
Two midodrine HCl 2.5 mg tab.
One memantine HCl 10 mg tab (medication used to treat dementia).
One pravastatin sodium 10 mg tab (medication used to treat high cholesterol).
One oxybutynin chloride 5 mg tab (used to treat overactive bladder).
One levofloxacin 500 mg tab (antibiotic).
Two baclofen 10 mg tab (used to treat muscle spasms).
Two 0.5 tabs of metoprolol tartrate 25 mg (used to treat high blood pressure).
One amiodarone HCl 200 mg tab (used to treat heart disease).
At that time, the surveyor interviewed LPN #1 who stated medication should not be left on that tray as that would not be considered secured. She further stated that there was a risk of someone coming by and taking them since they were unsecured.
On 10/24/24 at 12:21 PM, the surveyor interviewed the Director of Nursing (DON) who stated medication should always be secured and locked, regardless of if residents on the unit were ambulatory or not. The DON further confirmed when presented with a photo of how the medications were observed, that those medications would not be considered secured and should not have been stored that way.
On 10/29/24 at 10:39 AM, the [NAME] President of Clinical (VPC), in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), and DON, confirmed that medication should not have been stored unsecured on the medication cart and that all nurses were to keep medications secured.
A review of the facility's Medication Storage policy with a reviewed date of 11/2022, included the facility shall store all medications and biologicals in a safe, secure, and orderly manner .all medications will be stored in locked cabinet, cart or medication room that is accessible only to authorized personnel .
NJAC 8:39-29.4
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain kitchen equipment in a clean and sanitary manner. This deficient pra...
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Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain kitchen equipment in a clean and sanitary manner. This deficient practice has the potential to affect all residents, and the evidence was as follows:
On 10/22/24 at 9:53 AM, the surveyor in the presence of the Food Service Director (FSD) and Regional Food Service Director (RFSD) toured the kitchen and observed the following:
1. The ice machine had stains, brown and tan debris on the outside and flap of the machine. The FSD stated, it should be cleaned daily. The FSD and RFSD both acknowledge that it looked dirty and was not cleaned.
2. There were two, thirty-two gallon waste receptacles that were not covered which exposed the two food preparation stations to the refuse. The stations were not actively being used. The RFSD acknowledged that the waste receptacles did not have lids and staff were not currently using them. The unlidded thirty-two-gallon waste receptacles at counter height had the potential for cross contamination of food.
3. The eight-burner stove with two catch drip trays, had large quantities of brown, black, and burnt food and yellowed sludge that was on the foil covering. The FSD and RFSD acknowledged that they had not been cleaned and staff were not following the facility policy.
4. The slicer that was covered with a clear plastic bag, had brown, dried, and crusted debris on the prong part of the pusher that was touching the gauge plate. The FSD stated that the clear plastic bag indicated the equipment was clean and ready for use. The FSD and RFSD acknowledged that the pusher was not clean and had potential for cross contamination of food and had the potential to cause a food borne illness.
5. The can opener base had black and brown crusted debris that was wipeable by the FSD. The FSD stated the can opener was cleaned daily and the base of the can opener was included in that cleaning assignment. The FSD acknowledged that the base was dirty and had not been cleaned. She further stated it could cause cross contamination and had the potential to cause food borne illness.
6. Two, six compartment open well steam tables that had hot water in each well. The water in every well had floating debris and debris that had settled on the bottom. The FSD stated it was cleaned daily. The surveyor asked if string beans were served for breakfast and the FSD acknowledged there were no string beans served and that the steam tables had not been cleaned according to facility policy. The FSD and RFSD both acknowledged that the dirty water and sediment had the potential for food borne illnesses.
On 10/25/24 at 12:20 PM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), and survey team acknowledged the concerns.
A review of the undated facility provided Equipment Cleaning Policy included the Director of Dining Services or designee will ensure that all equipment is maintained, kept clean, and in a sanitary condition before and after each use .2. Stove-top; a) clean stove top after each use .d) be sure to clean the grease tray .7. Slicer .b) take slicer apart. Using soap and water to clean it. c) let the slicer air dry before covering it .9. Steam Table; a) after each meal service, drain the water from the steam table. b) It must be cleaned after each use both inside and out using soap and water before you refill it with clean water .13. Can Opener; run the opener shaft through the dish machine or in the 3-compartment sink. b) Clean the base of the can opener and holder using soap and water .
A review of the undated facility provided Ice Machines Sanitation policy included kitchen staff will wash, rinse, and sanitize the ice making machine monthly .
A review of the undated facility provided Ice Machine Maintenance log included .outside of ice machine should be cleaned and sanitized daily .
NJAC 8:39-17.2(g)
Apr 2024
1 deficiency
CONCERN
(E)
📢 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 F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Complaint #: NJ00166783, NJ00171418, NJ00172419
Based on interview and record review on 03/28/24, 04/01/24, and 04/04/24, it was determined that the facility failed to follow acceptable standards of c...
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Complaint #: NJ00166783, NJ00171418, NJ00172419
Based on interview and record review on 03/28/24, 04/01/24, and 04/04/24, it was determined that the facility failed to follow acceptable standards of clinical practice related to a.) consistently documenting the administration of a medication in the electronic Medication Administration Record (MAR) and b.) consistently document that a treatment was completed in the electronic Treatment Administration Record (TAR)
This deficient practice was identified for two residents reviewed (Resident #2 and Resident #3) and was evidenced by the following:
1.) Resident #2 was not at the facility; a closed record review was completed.
A review of the admission Record face sheet (an admission summary) reflected that Resident #2 was admitted to the facility with diagnoses which included but were not limited to, pyelonephritis (a bacterial infection causing inflammation of the kidneys), type 2 diabetes, severe protein-malnutrition, and hypertension.
A review of the 01/21/24 Quarterly Minimum Data Set (MDS), an assessment tool reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated that the resident's cognition was severely impaired. A review of Section K Swallowing/Nutritional Status reflected that the resident received 51% or more of their total calories daily through a feeding tube and received 501 [mL] a day or more of fluids via a feeding tube.
A review of Resident #2's Care Plan reflected a focus, dated 04/12/23 and last revised on 12/15/23, that the resident was at risk for malnutrition and that tube feedings were needed for the resident to receive adequate nutrition. Interventions included to administer tube feedings and flushes as ordered and to monitor for signs of dehydration.
A review of Resident #2's April 2023 Physician Order Summary (POS) reflected an active Enteral Feed Order, dated 03/23/23, to flush tube with 250 mL of water every six hours.
A review of the corresponding April 2023 Medication Administration Record (MAR) reflected that blanks were noted on the following dates:
-04/14/23 at 6 A.M.
-04/15/23 at 12 A.M. and 6 A.M.
-04/24/23 at 12 A.M. and 6 A.M.
A review of the April 2023 progress notes (PN) corresponding to those dates did not reveal any documentation showing that the flushes were administered. The nursing staff assigned to the resident on those dates were not available for interview at the time of the survey.
A review of the July 2023 POS reflected an active Enteral Feed Order, dated 03/23/23, to flush tube with 250 mL of water every six hours.
A review of the corresponding July 2023 MAR reflected a blank on 07/03/23 at 6 P.M.
A review of the July 2023 PN for the corresponding date did not reveal any documentation showing that the flushes were administered. The nursing staff assigned to the resident on that date was not available for interview at the time of the survey.
A review of the July 2023 MAR reflected an Enteral Feed Order, with a start date of 07/05/23, that the tube was to be flushed with 250 mL of water every four hours. Blanks were noted on the following dates:
-07/05/23 at 4 P.M. and 8 P.M.
-07/06/23 at 12 A.M. and 4 P.M.
A review of the July 2023 PN did not reveal any documentation showing that the flushes were administered. The nursing staff assigned to the resident on those dates were not available for interview at the time of the survey.
A review of the December 2023 POS reflected an active Enteral Feed Order, dated 12/01/23, to flush tube with 240 mL of free-water (water) every six hours.
A review of the corresponding December 2023 MAR reflected a blank on 12/07/23 at 6 A.M.
A review of the March 2024 POS revealed an active Enteral Feed Order, dated 12/14/23, to flush with free-water (water) every six hours.
A review of the corresponding December 2023 MAR reflected blanks on:
-12/23/23 at 6 A.M.
-12/29/23 at 12 P.M.
A review of the December 2023 PN for the corresponding dates did not reveal any documentation showing that the flushes were administered. The nursing staff assigned to the resident on those dates were not available for interview at the time of the survey.
A review of the March 2024 POS revealed an active Enteral Feed Order, dated 12/14/23, to flush with free-water (water) every six hours.
A review of the corresponding March 2024 MAR reflected a blank on 03/14/24 at 6 P.M.
A review of the March 2024 PN for the corresponding date did not reveal any documentation showing that the flush was administered. The nursing staff assigned to the resident on that date was not available for interview at the time of the survey.
2.) Resident #3 was not at the facility; a closed record review was completed.
According to the admission Record, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: hypertension, Type 2 diabetes, and coronary artery disease.
Review of the 02/04/23 Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident had severe cognitive impairment. The MDS also indicated that Resident #3 was at risk for pressure ulcers/injuries.
Review of the 3/17/23 Wound Investigation Report, revealed that the facility discovered that Resident #3 had a Stage II open superficial wound on the sacrum. The open area measured 2 cm [centimeters] x 2 cm. The summary revealed that the wound was, Unavoidable due to several comorbidities: decline in function, poor appetite, anemia, hx [history] of cancer on chemotherapy.
Review of the March 2023 Medication Administration Record (MAR) revealed a 03/26/23 order for Santyl (topical medication that is used for removing dead skin tissue and aid in wound healing). The order instructed to cleanse sacral wound with normal saline and apply Santyl and cover with foam dressing daily. There was no documentation that the treatment was performed on 03/27/23 and 03/28/23 day shift. The nursing staff assigned to the resident on those dates were not available for interview at the time of the survey.
Review of the March 2023 Treatment Administration Record (TAR) revealed that Resident #3 had a 03/24/23 order for Metrogel (topical medication that is commonly used to clean wounds). The order instructed to apply BID [twice a day] to sacral wound for three days. There was no documentation that the treatment was performed on 03/24/23 day shift. The nursing staff assigned to the resident on that date was not available for interview at the time of the survey.
Review of the April 2023 MAR revealed a 03/29/23 order for Santyl (topical medication that is used for removing dead skin tissue and aid in wound healing). The order instructed to cleanse sacral wound with normal saline and apply Santyl and cover with foam dressing daily. There was no documentation that the treatment was performed on 04/06/23 day shift. Further review of the April 2023 MAR revealed a 4/21/23 Santyl order that had no documentation that the treatment was performed on 04/29/23 day shift. The nursing staff assigned to the resident on those dates were not available for interview at the time of the survey.
Review of the May 2023 MAR revealed 04/21/23 order for Santyl (topical medication that is used for removing dead skin tissue and aid in wound healing). The order instructed to cleanse sacral wound with normal saline and apply Santyl and cover with foam dressing daily. There was no documentation that the treatment was performed on 05/26/23 day shift. The nursing staff assigned to the resident on those dates were not available for interview at the time of the survey.
Review of the Resident #3's Progress Notes revealed no documentation that the treatments were completed on the aforementioned dates and shifts.
During an interview with the surveyor on 04/04/24 at 11:46 A.M., the Licensed Practical Nurse (LPN) stated that it is the responsibility of the nurses to perform treatments and administer medications as ordered. She further stated that once the nurse completes the medication administration or treatment the nurse should then sign the appropriate MAR or TAR. The LPN stated, If it wasn't signed off, it wasn't signed off on. When asked if there was a blank, how would someone know that it was completed, the LPN stated, I don't know. The LPN further explained that it is expected that nurses sign of on all care and that there should be no blanks.
During an interview with the surveyor on 04/04/24 at 1:02 P.M., the Director of Nursing (DON) stated that medication administration was documented on the MAR and treatment orders were documented on the TAR. The DON explained that signing the MAR and TAR was important for accountability and continuity of care. She further stated that nurses were to document the completion of the care provided to the resident by signing the MAR and/or TAR accordingly. The DON further stated that there should be no blanks. She stated that there was no way for someone to tell if a medication was administered or if a treatment was provided if there were blanks on the MAR and TAR.
During a post-survey telephone interview with the surveyor on 04/11/24, the Nurse Practitioner (NP) stated that it was her expectation that nurses follow orders as prescribed by the practicing physician. She further stated that nurses should be documenting completion of all care in the resident's electronic record.
Review of the facility's undated Charting and Documentation, policy, revealed that all services provided to residents was to be documented in the residents' medical record. Under Section 2 of the Policy Interpretation and Implementation the policy further indicated, The following information is to be documented in the resident medical record . b.) Medications administered, c.) Treatments or services performed . Under Section 4, the policy further indicated, Entries may only be recorded by licensed personnel in accordance with state law and facility policy.
NJAC 8:39-3.2(a),(b); 11.2(b); 27.1(a); 29.2(d)
Feb 2024
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
C #: NJ00171641
Based on observation, interview, and review of medical records and other pertinent facility documentation on 2/14/24, it was determined that the facility failed to follow professional ...
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C #: NJ00171641
Based on observation, interview, and review of medical records and other pertinent facility documentation on 2/14/24, it was determined that the facility failed to follow professional standards of clinical practice for a). the administration of medications and b.) following a physician's orders, and c). adhering to the facility's policy for using the Medication Administration Record for 1 of 3 residents (Resident #2) reviewed for medication administration.
The deficient practice was evidenced by the following:
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
During the interview with Resident #2 on 2/14/24 at 10:08 a.m., the surveyor observed an uncapped ointment (Clobetasol Propionate USP, 0.5 %). The Resident revealed that she/he had medication at bedside at all times. The Resident further revealed that the nurse gave her/him the medication and she/he apply on her/his skin whenever she/he remembered.
According to the admission record, Resident #2 was admitted with diagnosis that included but was not limited to: Psoriasis.
The Minimum Data Set (MDS), an assessment tool, dated 12/27/23, revealed a BIMS of 15, which indicated the Resident's cognition was intact and needed help during care with Activity of Daily Living.
The PHYSICIAN'S ORDER (PO) for 2/2024 reflected an order for Clobetasol Propionate Cream 0.05 %, apply to upper arm, back topically two times a day for Rash, ordered on 6/19/23.
The MEDICATION ADMINISTRATION RECORD (MAR) for the month of 2/2024 confirmed the aforementioned physician orders. The MAR further indicated that the aforementioned medication was to be given at 9:00 a.m. and 5:00 p.m. and the MAR was signed by the licensed staff indicating that the medication was administered according to the schedule.
During the follow up interview on 2/14/24 at 2:26 p.m., Resident # 2 stated that when she/he asked the aforementioned medication, the nurse just gave it to me and never took it back, she/he further stated that she/he does not apply to his/her skin everyday only when she remembered.
During the interview in the Licensed Nurse Practical (LPN #1) on 2/14/24 at 12:53 p.m., LPN #1 stated that she has been giving the aforementioned medication to Resident #2 and leaving the tube at bedside, (unable to recall date), because Resident #2 asked for it and she/he was alert and able makes needs known. She further stated that every day, during her shift, she would sign the MAR even if she was not sure if the Resident did not apply the ointment to her/his skin because she/he might apply at a later time.
During an interview on 2/14/24 at 1:21 p.m., the Administrator and the Director of Nursing was not aware that Resident #2 was self-medicating her/himself. They further stated that the nurses were not allowed to leave any medication at the resident's bedside table unattended to ensure residents safety.
The facility's policy titled Administering Medications, dated 10/2023, indicated Medications shall be administered in a safe and timely manner .1. Only persons licensed or permitted by this state to prepare, administer .3. Medication must be administered within one (1) hour of their prescribed time .11. Residents may self-administer their own medications only if the Attending Physician, is conjunction with the Interdisciplinary Care Planning Team, has determined hat they have the decision-making capacity to do so safely .
NJAC 8:39-29.4 (h)
Oct 2023
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 update and revise a Care Plan in a timely manner to include...
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Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to update and revise a Care Plan in a timely manner to include a fall intervention for 1 of 3 residents, (Resident #91), reviewed for falls.
This deficient practice was evidenced by the following:
On 10/4/23 at 1:04 PM, the surveyor observed Resident #91 sitting upright in a recliner across from the nursing station. The resident's eyes were closed, and he/she did not respond to the surveyor.
The surveyor reviewed the medical record for Resident #91.
Review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to dementia, difficulty walking, repeated falls, and fracture the of left pubis (either of a pair of bones forming the two sides of the pelvis).
Review of a significant change Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 9/13/23, revealed that the resident had a brief interview for mental status (BIMS) score of 2 out of 15, indicating the resident had a severely impaired cognition.
Review of the electronic progress notes (ePN) dated 8/25/23 at 16:01 (4:01 PM) completed by Licensed Practical Nurse (LPN), included that the resident had an unwitnessed fall in the day room. Then LPN documented that the resident had no complaints of pain and no visible injuries. Documentation included that the resident was assisted back into the wheelchair and was placed in front of the nursing station for monitoring.
Review of a fall investigation dated 8/25/23 at 13:30 (1:30 PM), provided by the Licensed Nursing Home Administrator (LNHA) included that the Interdisciplinary Team (IDT) met and reviewed/discussed the incident. It also included that the care plan was revised to include offering the resident assistance back to bed after lunch. This was authored by the Director of Nursing (DON).
Review of a fall investigation dated 8/28/23, included the resident's care plan which did not reflect the 8/25/23 intervention to offer the resident assistance back to bed after lunch.
Review of the resident's care plan which was provided to the surveyor on 10/19/23 at 8:30 AM by Regional Registered Nurse (RRN#1), included a revised intervention dated 10/8/23, to offer resident assistance back to bed after lunch.
Review of the history version for care plan interventions included the above noted revised intervention which was authored by the DON on 10/8/23.
On 10/17/23 at 9:25 AM, the surveyor interviewed the LPN Unit Manager (LPN/UM) who stated that falls were discussed in the morning meetings which included all the department heads and that new interventions were discussed and determined by the team to keep the resident safe. He further stated that new interventions were communicated verbally to the direct care staff as well as added to the resident's care plan. LPN #2 stated we update care plans almost immediately.
On 10/17/23 at 9:42 AM, the surveyor reviewed the care plan in the electronic medical record (EMR) with the LPN/UM. He acknowledged but could not speak to why the 8/25/23, intervention to offer to assist the resident back to bed after lunch was not added to the care plan until 10/8/23. The LPN/UM further stated he would look into this and get back to the surveyor with additional information.
On 10/17/23 at 11:17 AM, the LPN/UM acknowledged that he still could not speak to why the 8/25/23 intervention to offer to assist the resident back to bed after lunch was not added to the care plan until 10/8/23.
On 10/19/23 at 10:21 AM, the surveyor interviewed the DON in the presence of the survey team and reviewed the history version for care plan interventions in the EMR. The DON acknowledged that the 8/25/23 intervention to offer the resident assistance back to bed after lunch was not added to the care plan until 10/8/23.
Review of the facility policy Falls and Fall Risk Managing updated 10/2019, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
Review of the facility policy Care Plans, Comprehensive Person-Centered updated 10/2023, included that the comprehensive, person-centered care plan will describe the services that that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being. It also included that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The IDT must review and update the care plan when there has been a significant change in the residents' condition and when the desired outcome is not met.
NJAC 8:39-11.2(2)(h)(i), 27.1(a)(b)
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 F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ000162720
Based on interview and review of medical records, it was determined that the facility failed to to follo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ000162720
Based on interview and review of medical records, it was determined that the facility failed to to follow professional standards of clinical practice with respect to a.) clarifing a Physician's Order (PO) for Betadine solution 10% on admission, b.) accurately transcribe a PO for Betadine Solution 10% onto the Feburary 2023 electronic treatment administration (eTAR) and c.) document a wound treatment order as administered on 1/30/23 and 1/31/23. This deficient practice was identified for 1 of 8 residents (Resident # 372) reviewed for closed records.
This deficient practice was evidenced by the following:
Reference: New Jersey Statues, Annotated Title 45, Chapter 11 Nursing Board, The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
On 10/16/23 at 9:48 AM, the surveyor reviewed the closed medical record for Resident # 372.
Review of the Face Sheet (an admission record) revealed Resident # 372 was admitted to the facility on [DATE] with diagnosis which included but not limited to metabolic encephalopathy (brain dysfunction caused by problems with the metabolism), other specified local infections of the skin and subcutaneous tissue, other specified sepsis (the body's response to extreme infection), type 2 diabetes mellitus with other skin complications, type 1 diabetes mellitus with foot ulcer, infection following a procedure, unspecified, subsequent encounter, and local infection of the skin and subcutaneous tissue, unspecified.
Review of the admission Progress Notes (PN) dated 1/30/23, timed at 10:04 PM and documented by a Registered Nurse (RN) indicated L [left] groin with opening that is now treated with betadine and covered with a dry dressing every 6 hours.
Review of an untitled document that had typed and handwritten notes dated 1/30/23, revealed a handwritten note from home 1/20 post op infection still open Q 6 h [every six hours] - betadine, dry dressing.
Review of the physician's orders (PO) revealed a PO dated 1/30/23 for Betadine 10% topical solution. Cleanse L [left] groin opening with Betadine and cover with dry dressing every day at 7:00 am - 7:00 pm.
Further review of the PO's revealed a PO dated 1/30/23 for Santyl 250 unit/gram topical ointment apply by topical route once daily to left foot wound after cleansing with NSS (normal saline solution). Cover with clean dressing every day at 7:00 PM - 7:00 am.
Review of the January 2023 electronic treatment administration record (eTAR) revealed a PO dated 1/30/23 for Betadine 10 % topical solution cleanse left groin opening with Betadine and cover with dry dressing. There was no documented evidence that the Betadine treatment was administered, and the Betadine order did not correlate with the above admission progress note to treat the left groin with betadine and cover with a dry dressing every six (6) hours.
Further review of the January 2023 eTAR revealed the above corresponding Santyl 250 ointment order plotted for 7:00 pm - 7:00 am. There were dashes in the plotted times on 1/30/23 and 1/31/23. There was no documented evidence that the Santyl ointment was administered on 1/30/23 and 1/31/23 to the left foot wound.
Further review of the medical record revealed a Progress Note dated 1/31/23, and timed at 4:59 pm. The PN indicated an assessment by the nurse practitioner (NP) of the resident's left dorsal foot and the left groin wound. The NP's left groin assessment indicated copious amount of drainage present. Serous in nature. Close monitoring is essential. For any thicker drainage, increase in pain, erythema [superficial reddening of the skin], odor or change in vital signs, patient should go to the ED [emergency department]. High risk for infection. The NP's left dorsal foot assessment indicated Chronic wound. Will continue to use Santyl for enzymatic debridement. Plan: Cleanse with NS apply Santyl, abd pad and kling daily.
Further review of the PO's revealed an order dated 2/1/23 for Betadine 10% topical solution cleanse left groin opening with Betadine and cover with dry dressing every 6 (six) hours.
Review of the February 2023 eTAR revealed an order dated 2/1/23 for Betadine 10% solution cleanse left groin opening with Betadine and cover with dry dressing. The order was plotted for 5:30 pm and 11:30 PM. The order for Betadine was not transcribed onto the eTAR to reflect every six hours. It was transcribed to be rendered twice a day at 5:30 pm and 11:30 pm.
On 10/16/23 at 1:30 PM, the Regional Registered Nurse #1 stated that the nurses from 1/30/23 through 2/1/23 no longer work at the facility and were unavailable for interview. She further stated she could not speak to why the Betadine order was changed to every six hours on 2/1/23 or why the treatments were not signed as administered on 1/30/23/ and 1/31/23.
On 10/16/23 at 1:45 PM, the Director of Nursing (DON) confirmed that the admitting nurse for Resident # 372 no longer worked at the facility.
10/17/23 01:31 PM, the surveyor interviewed the DON who stated there were to many inconsistencies and acknowledged that the Betadine was ordered for every six hours on 2/1/23 but plotted onto the eTAR for twice daily.
On 10/19/23 at 11:42 AM, the survey team met with the administrative staff. The Regional Registered Nurse #1 could not confirm if the Betadine order should have been every six hours on admission. She also could not speak to why the Betadine order was changed to every six hours on 2/1/23 and not plotted as ordered. She acknowledged that the Santyl ointment was not signed as administered on 1/30/12 and 1/31/23.
There was no policy provided for obtaining admission orders or for transcription of physician orders.
There was no additional information provided.
NJAC 8:39-11.2(b), 29.4(a)(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on interviews, record review, and review of other facility documentation, it was determined that the facility failed to a.) ensure that a resident received the appropriate care to maintain a Per...
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Based on interviews, record review, and review of other facility documentation, it was determined that the facility failed to a.) ensure that a resident received the appropriate care to maintain a Peripherally Inserted Central Catheter (PICC) (a thin soft tube that is inserted into a vein in the arm for long-term intravenous (IV) antibiotics) consistent with professional standards of practice and b.) update the care plan for a resident with a PICC. This deficient practice was identified for 1 of 1 resident (Resident #30) reviewed for IV therapy.
This deficient practice was evidenced by the following:
The surveyor reviewed the Electronic Medical Record (EMR) for Resident #30.
Review of the admission Record (an admission summary) revealed that the resident was admitted to the facility in September of 2023 with diagnoses which included but was not limited to; acute osteomyelitis (a serious infection of the bone) left ankle and foot, sepsis (the body's extreme response to an infection), and Type 2 Diabetes.
Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/29/23, revealed the resident had a brief interview of mental status of 15, indicating that the resident was cognitively intact. Further review of the MDS revealed the resident was receiving IV medications.
Review of the Order Summary Report (OSR) revealed physician orders for: Cefepime HCL Intravenous Solution 2 GM/100 ML (Cefepime HCL) Use 2 gram intravenously in the morning for osteomyelitis for 28 days, with an order date of 09/18/23; Vancomycin HCl Intravenous Solution 750 MG/150 ML (Vancomycin HCl) Use 750 mg intravenously in the afternoon for MRSA in wound for 28 Days, with an order date of 09/18/23; to Change PICC line dressing weekly one time a day every Mon for infection prevention, with an order date of 10/01/23.
Further review of the OSR did not reveal a physician's order to flush the PICC line or to change the PICC line dressing prior to 10/02/23.
Review of the September 2023 electronic Medication Administration Record (eMAR) revealed that the IV Cefepime HCL was given at 10:00 AM and the IV Vancomycin HCl was given at 2:00 PM and both were signed as being administered as ordered above. Further review of the eMAR did not reveal physician's order for PICC line dressing changes or PICC line flushes.
Review of the October 2023 eMAR revealed that the IV Cefepime HCL was given at 10:00 AM and the IV Vancomycin HCl was given at 2:00 PM and both were signed as being administered as ordered above. Further review of the eMAR revealed the PICC line dressing weekly one time a day every Mon for infection prevention with an order dated of 10/01/23, but the physician's order on the eMAR was not signed as being completed.
Review of the Care Plan revealed a Focus of on antibiotic therapy r/t (related to) infection, UTI (urinary tract infection), s/p (status post) Toe amputation due to OM (osteomyelitis), date Initiated: 10/02/2023. There was no care plan developed and implemented for the PICC line.
On 10/13/23 at 11:38 AM, the surveyor observed a sealed envelope in a clear sleeve in Resident #30's paper chart. The outside of the envelope indicated PICC information; send with patient. The Licensed Practical Nurse/Unit Manger (LPN/UM) verified that the envelope appeared to be unopened. The LPN/UM opened the envelope in the presence of the surveyor. There was a PICC catheter card that contained the resident's name, doctor, date of insertion: 09/14/23, trimmed length: 43 cm, RT. Basilic V (right basilic vein). The LPN/UM verified that the PICC line was inserted on 9/14/23, and confirmed it was before the resident was admitted to the facility. The LPN/UM stated that the envelope should have been opened to confirm the measurements. She stated that when a resident had a PICC line on admission, orders should be written for flushes, assessing the PICC line insertion site, changing the dressing on admission and then weekly. The LPN/UM, in the presence of the surveyor, verified that there were no orders to flush the PICC line and that there was not an order for PICC line dressing changes prior to 10/01/23. She stated flush orders were important to keep the line patent. She confirmed, at that time, that the antibiotics were not added to the Care plan until 10/02/23. She also confirmed that the Care Plan did not reflect the resident's PICC line. The LPN/UM further stated that the care plan should be updated when antibiotics were started and for the care of a resident with a PICC line.
On 10/13/23 at 11:57 AM, during an interview with the surveyor, Resident #30's Registered Nurse (RN) stated that when a resident was admitted with a PICC line, it should be assessed for redness, pain, and blood return and that it should be documented. She stated that you should call the physician to obtain PICC orders for weekly dressing changes and flushes, which are usually every shift. The RN stated that the purpose of flushing a PICC line every shift was to keep the PICC line patent. The RN, in the presence of the surveyor, stated she was unable to find an order for flushes.
On 10/13/23 at 12:33 PM, the surveyor in the presence of the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), Regional Registered Nurse (RRN) #1, and RRN #2 and discussed the above findings. RRN#1 stated the PICC line dressings should be changed on admission and weekly and that they should be flushed to ensure patency.
On 10/17/23 at 09:48 AM, the surveyor interviewed the DON and the Assistant Director of Nursing (ADON). The ADON confirmed that there were no orders for the care of Resident #30's PICC line upon admission.
On 10/17/23 at 1:30 PM, the surveyor in the presence of the survey team met with the RRN#1 RRN#2, the DON, the ADON, and the LNHA, RRN#1 who provided the surveyor an Investigative Summary signed by RRN#1 for Resident #30 which acknowledged that there were no physician's orders for the PICC line care prior to 10/2/23. There was no documented evidence to support PICC line dressings occurred prior to 10/2/23, no documented evidence that the PICC line was flushed, and there was no care plan for the PICC line.
Review of the facility's policy, Physician Orders updated 3/2023 revealed Purpose: To ensure all medications and treatment orders are received from credentialed practitioner before implementing; Process, Type of Order: 3. IV orders must be written on the appropriate IV protocol sheet (Central, Mid-line, or Peripheral).
Review of the facility's policy, Central Venous and midline Catheter Flushing updated 1/2023 revealed Purpose: The purpose of this procedure are to maintain patency of midline and central venous catheters (CVADS); to prevent mixing of incompatible medications and solutions; and to ensure entire dose of solution or medication is administered into the venous system; General Guidelines: 1. No physician order is needed for this procedure. 3. Consult state Nurse Practice Act for RN/LPN scope of practice and functions. Flushing Protocol 1. Flush catheters at regular intervals to maintain patency AND before and after the following: b. administration of medication.
Documentation: The following information should be recorded in the resident's medical record:
2. Total amount of flush administered.
4. the Condition of the IV site before and after administration
7. The signature and title of person recording the data.
Review of the facility's policy, Central Venous Catheter Dressing Changes updated 1/2023 revealed Purpose: The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines: 5. Change transparent semi-permeable membrane (TSM) dressing at least every 5-7 days and PRN (when wet, soiled, or not intact).
Documentation: 1. The following information should be recorded in the resident's medical record:
A. Date and time dressing was changed.
B. Location and objective description of insertion site.
C. Any complications, interventions that were done.
F. Signature and title of the person recording the data
Review of the facility's policy Care Plans, Comprehensive Person-Centered revised 10/2022, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
NJAC 8:39-25.2 (5)
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 observations, interviews, and record review, it was determined that the facility failed to a.) ensure a physician's order was obtained for a resident receiving oxygen and b.) the care plan wa...
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Based on observations, interviews, and record review, it was determined that the facility failed to a.) ensure a physician's order was obtained for a resident receiving oxygen and b.) the care plan was updated to include the resident was receiving oxygen. This deficient practice was identified for 1 of 1 resident (Resident #111) reviewed for oxygen therapy.
This deficient practice was evidenced by the following:
On 10/04/23 at 12:43 PM, the surveyor observed Resident #111 awake and in bed, wearing oxygen via nasal canula. The oxygen concentrator was set at two liters per minute (LPM). The resident stated that they needed oxygen before their admission to the facility.
The surveyor reviewed the medical record of Resident #111.
Review of the admission Record (an admission summary) revealed that the resident was admitted to the facility in August of 2023 with diagnoses which included but was not limited to; Pneumonia and Chronic Obstructive Pulmonary Disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems) with Acute Exacerbation (COPD, a group of diseases that cause airflow blockage and breathing-related problems).
Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/12/23 indicated that Resident #111 had a Brief Interview for Mental Status score of 14 out of 15, which indicated the resident was cognitively intact. The MDS also indicated the resident used oxygen while as a resident and while not a resident.
Review of the August 2023 Order Summary Report (OSR) revealed an order for WEDNESDAY 11-7 every night shift every Wed Change oxygen tubing weekly, dated 08/06/2023. Further review did not reveal a physician's order for oxygen (O2).
Review of the September 2023 OSR revealed a physician's order for 02 @ 2L (liters) every 24 hours as needed for low SPO2 (percent of oxygen in the blood) maintain SPO2 above 89% during the day time, order date of 09/08/023, and 02 @ 2L every shift for low SPO2 maintain SPO2 above 89%, order date of 09/08/2023.
Review of the electronic progress notes revealed a nurses note dated 8/6/2023 at 07:10 indicated, Alert, Oriented. Received in bed, O2 in place administered as ordered and tolerated, no distress noted.
Further review of the electronic progress notes revealed a Physician/NP (Nurse Practitioner) note dated 8/9/2023 at 19:20 indicated, COPD, no exacerbation, ., O2 @ 2L prn (as needed).
Review of the Weights and Vitals Summary; Vital: O2 sats revealed that Resident #111's SPO2 was assessed and was documented as wearing oxygen via Nasal Cannula 24 times from 08/06/2023 through 09/07/2023.
Review of the care plan (CP) revealed that there was no care plan developed and implemented for oxygen use.
On 10/11/23 at 12:35 PM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that a physician's order should be obtained for a resident requiring oxygen and the oxygen should be added to the resident's CP. She further stated that she reviews the hospital records and updates new admission care plans every morning Monday through Friday to make sure they include the resident's diagnoses and goals. The LPN/UM stated the CP should reflect oxygen related to the diagnosis and goals of care.
On 10/11/23 at 01:03 PM, in the presence of the surveyor, the LPN/UM reviewed the medical record for the physician orders for oxygen and the CP for oxygen for Resident #111. She stated, At this time, I am unable to locate the oxygen order from admission and yes, oxygen should have been care planned. The LPN/UM was unable to locate the CP.
On 10/12/23 at 09:29 AM, during an interview with the surveyor, the Director of Nursing (DON) stated she reviewed Resident #111's physician orders for 8/2023 and verified she did not find an order for oxygen. She then stated that the purpose of a physician's order was so that nurses know how many liters of oxygen to administer and that the resident required oxygen. The DON also stated she reviewed the CP and verified that oxygen was not on the CP prior to 10/11/23, after surveyor inquiry.
On 10/13/2023 at 12:33 PM, the surveyor in the presence of the survey team met with the Licensed Nursing Home Administrator, the DON, Regional Registered Nurse (RRN) #1, and RRN#2 and discussed the above findings. RRN#1 stated that the CP should contain person centered goals, needs of the resident, whatever we need to do, and how we care for them (residents). She then stated that it (CP) should include oxygen therapies.
On 10/16/2023 at 08:45 AM, the facility provided an Investigative Summary for Resident #111 dated 10/16/23, which acknowledged that the resident was admitted with a need for oxygen at 2L/min via nasal canula, that the resident used the oxygen continuously and there was no documented evidence of a physician's order for oxygen, and that oxygen was addressed in the residents care plan after surveyor inquiry.
Review of the facility's policy, Physician Orders updated 3/2023 revealed Purpose: To ensure all medications and treatment orders are received from credentialed practitioner before implementing.
Review of the facility's policy Oxygen Administration revised 10/2023, revealed Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident.
Review of the facility's policy Care Plans, Comprehensive Person-Centered revised 10/2022, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
NJAC 8:39-11.2(a)(e)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 accurately monitor a resident's hemodialysis (the cl...
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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 accurately monitor a resident's hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) treatment access site. This deficient practice was identified for 1 of 1 resident (Resident #93) reviewed for dialysis.
This deficient practice was evidenced by the following:
On 10/12/23 at 10:10 AM, the surveyor observed Resident #93 in bed. The resident was alert, oriented, and responded appropriately to the surveyor. The resident stated that he/she went to hemodialysis (HD) on Monday, Wednesday and Friday in the afternoon. The resident stated that the HD access site was in the right upper chest (the resident pointed to the area).
Review of Resident #93's admission Record (an admission summary) reflected diagnoses which included but was not limited to; acute kidney failure and hypertension.
Review of the Quarterly Minimum Data Set (MDS), an assessment tool to facilitate the management of care dated 9/5/23, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which was indicative of intact cognition.
Review of the resident's Order Summary Report (OSR) included a physician's order (PO) dated 10/4/23, for HD Monday, Wednesday and Friday at 3:30 PM. It also included a PO dated 10/4/23, for Nursing staff to assess ** Fistula site thrill (buzzy feeling) and bruit per auscultation (listening for whoosh sound) each shift and as needed * Report abnormalities to MD/Dialysis immediately; this order was discontinued on 10/16/23. After surveyor inquiry the OSR included a PO dated 10/16/23, for Nursing staff to assess * Right subclavian permcath dressing intact. Monitor for signs and symptoms of infections * Report abnormalities to MD/Dialysis immediately.
Review of the Physician/Nurse Practitioner Note dated 9/22/23, included that the resident had a dialysis catheter in the right chest, had end stage renal disease and went for HD treatments Monday, Wednesday and Friday.
Review of the care plan dated 4/26/23, reflected the resident had a right permcath.
On 10/13/23 at 9:13 AM, the surveyor interviewed the resident's Registered Nurse (RN) who stated the HD access site was in the right upper chest. She acknowledged that there was a PO to check the site for bruit and thrill. The RN stated she was not sure how to assess the residents access site for bruit and thrill. She stated the assessment usually pertained to an arm shunt which was not as deep. The RN further stated, to tell you the truth, I cannot say if you can check thrill, but you must be able to hear bruit because there is blood flow.
On 10/16/23 at 8:55 AM, the surveyor interviewed the Regional RN (RRN#1 ) in the presence of the survey team. She stated that the resident had a permcath and it was possible to check the bruit and thrill.
On 10/16/23 at 10:33 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. She stated the RRN #1 called the resident's physician who stated the resident had a permcath which did not require a check for bruit and thrill. The DON acknowledged that to check for bruit and thrill would have been an inaccurate assessment and that the order should have been clarified. She further stated the nursing supervisor who checked the orders should have identified the error.
On 10/17/23 at 1:48 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Assistant DON, RRN #1 and RRN #2 and discussed the above findings. The DON acknowledged that there was no way to assess a bruit and thrill for a permcath. RRN #1 stated that sometimes if a permcath was new the resident would have a temporary arteriovenous (AV) fistula access site for HD. She further stated that it would have been appropriate to check for bruit and thrill for an AV shunt site, however the resident's permcath was not new and was a long-standing access site. RRN #1 stated the Licensed Practical Nurse (LPN) who transcribed the physician's order was new but should have identified that a bruit and thrill could not be used to assess a permcath and should have called the HD center and the physician to clarify the order.
During that same interview, the RRN #2 stated the nurses were not looking at the site of the permcath and should have realized that they could not check bruit and thrill on a permcath. In addition, the DON stated the nurses thought process should have sparked and they should have called the physician to clarify the order to properly assess and monitor the site.
Review of the facility policy Dialysis Patients with a revised date of 11/2022, included to check fistula for bruit (listening to fistula) or feel for a thrill (by touching the fistula). It further included that if you do not feel a pulse or hear a bruit, check again by placing your fingers gently over fistula and check for a thrill. Call the dialysis unit immediately. If the unit is closed, call the MD.
Review of the facility policy Hemodialysis Access Care with a reviewed date 3/2023, included central catheters for hemodialysis are generally inserted in the neck, chest or groin area. It also included that the dressing change is done in the dialysis center post-treatment and the central catheter site must be kept clean and dry at all times. There was no evidence in the care of central dialysis catheters to check for bruit and thrill.
NJAC 8:39-27.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and review of other pertinent facility documents it was determined that the facility failed to provide adequate indications and documentation supporting...
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Based on observation, interview, record review, and review of other pertinent facility documents it was determined that the facility failed to provide adequate indications and documentation supporting the rationale for COVID-19 related medications for a resident who tested negative for COVID-19. This deficient practice was identified for 1 of 24 residents (Resident #99) reviewed during medical record review and was evidenced by the following:
On 10/5/23 at 10:00 AM, the surveyor observed Resident #99, self-propelling in their wheelchair toward the bathroom. The resident was alert and oriented but did not want to be interviewed. The surveyor observed the resident's room which had no stop sign or isolation signage on the door or wall, and no personal protection equipment (PPE) bin located outside of the resident's room.
The surveyor reviewed the medical record for Resident # 99.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hypertension (elevated blood pressure), cerebral infarction (condition where brain tissue dies as a result of localized hypoxia/ischemia due to cessation of blood flow), Type II diabetes (a chronic condition that affects the way the body processes blood sugar glucose) and COVID-19 (infectious disease caused by the SARS-CoV-2 virus).
A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 08/02/23, reflected that the resident's Brief Interview for Mental Status score was 15 out of 15, which indicated that the resident was cognitively intact.
A review of the October 2023 Order Summary Report (OSR) and the resident's October 2023 electronic medication administration record (eMAR) revealed the following physician's orders (PO) dated 10/2/23 for the following medications:
-Doxycycline (antibiotic) oral tablet 100 mg, give 1 tablet by mouth two times a day for COVID + for 5 days, scheduled on the eMAR for 9 AM and 5 PM.
-Dexamethasone (anti-inflammatory) oral tablet 6 mg, give 1 tablet by mouth one time a day for COVID + for 6 days, scheduled on the eMAR for 9 AM.
-Proventil HFA (medication for shortness of breath) 1 puff orally four times a day for COVID-19 for 14 days, scheduled on the eMAR for 9 AM, 1 PM, 5 PM, and 9 PM.
-Benzonatate Capsule (coughing) 200 mg, give 1 capsule by mouth three times a day for coughing for 14 days, scheduled on the eMAR for 9 AM, 3 PM, and 9 PM.
A review of Resident #99's progress notes (PN) revealed the following nursing note dated 10/02/23 at 3:30 PM which revealed the following documentation, COVID positive, alert, verbally responsive, able to make needs known, no distress noted, T (temperature) 97.4, BP (blood pressure) 130/76, SPO2 (amount of oxygen in the blood) 100%. NP [nurse practitioner] visited new order noted, for Doxycycline 100 mg BID [twice a day] for 5 days, Dexamethasone 6 mg po x 6 days, Albuterol inhaler QID x 7 days and Benzonatate 200 mg TID [three times a day] for 14 days, orders carried out.
On 10/05/23 at 10:25 AM, the surveyor observed Resident #99's room in the presence of the Regional Registered Nurse (RRN#1) . The RRN#1 acknowledged that the resident had no stop sign or signage indicating that the resident was under strict isolation for COVID-19, and that there was no PPE bin outside of the resident's room. The RRN#1 stated that the resident was negative for COVID-19 which was confirmed by the Registered Nurse/Unit Manager (RN/UM).
On 10/05/23 at 10:30 AM, the surveyor interviewed the Unit A RN/UM, who stated that she got a report of all the residents who were COVID-19 positive on her unit, and further stated that she had no confirmation that Resident #99 was positive for COVID-19.
On 10/05/23 at 10:35 AM, the surveyor interviewed the Director of Nursing (DON) who was present on Unit A. The DON stated that the resident was not COVID-19 positive. She stated that she had a list of all the residents who were COVID-19 positive in the facility and Resident #99 was not on that list.
At that same time, the surveyor reviewed Resident #99's medical record in the presence of the DON, RRN#1 and the RN/UM. After reviewing the resident's medical record, the DON and RRN#1 stated that they would retest the resident and obtain a physician's order to put the resident on COVID-19 isolation.
On 10/05/23 at 10:45 AM, the surveyor observed the result for the COVID-19 rapid test for Resident #99 in the presence of the RN/UM. The rapid COVID-19 test revealed that the resident was negative for COVID-19.
On 10/05/23 at 12:43 PM, the surveyor interviewed the facility infection preventionist (IP) who stated that she tested Resident #99 on 10/2/23, and that the resident tested negative for COVID-19. The IP stated that the process for tracking resident COVID-19 testing was to print out the midnight census and to write all the test results on the census sheet. All the residents who tested negative had a check mark to the left of their names while all the positive residents had a plus mark. The IP showed the surveyor a copy of the 10/2/23 midnight census which showed a check mark to the left of Resident #99's name. The IP stated she did not know how the Licensed Practical Nurse (LPN), or the Nurse Practitioner (NP) concluded that the resident was COVID-19 positive. The IP provided a copy of the midnight census with the test result to the surveyor.
On 10/05/23 at 1:45 PM, the surveyor conducted a telephone interview with the NP in the presence of the survey team. The NP stated that she received a phone call from the LPN on 10/2/23 and was told that Resident #99 tested positive for COVID-19. At that time, she gave a telephone order for four medications which included Doxycycline, Dexamethasone, Benzonatate, and Proventil. The NP told the surveyor that Resident #99 had multiple comorbidities and that she wanted to start the resident on medications right away. The NP further stated that she saw the resident earlier in the day and that the resident tested negative. She stated that she discontinued all the medications and isolation precautions but since the resident had a cough with rales, she ordered a chest x-ray to rule out any potential issues.
On 10/05/23 at 2:15 PM, the surveyor conducted a telephone interview with the Licensed Practical Nurse (LPN). The LPN stated that she came to work on 10/2/23, and a staff member informed her that Resident #99 test positive for COVID-19. She was unable to speak to which staff member relayed that information. She also acknowledged that she did not see the resident's test results. She stated that there was a stop sign and signage for strict isolation and a PPE bin outside of the resident's room. She further stated that the NP came to her unit on 10/2/23, and asked her if any of her residents were positive and she told the NP that Resident #99 was positive and that the NP wrote new orders for the resident.
On 10/05/23 at 3:00 PM, the surveyor discussed the above findings to the facility administrative team which included the DON, Licensed Nursing Home Administrator, RRN#1, IP and the Assistant Director of Nursing.
On 10/10/23 at 10:00 AM, the surveyor in the prescence of the survey team met with the administrative staff. The DON confirmed and stated that they did not have an effective system in place to ensure that the facility was communicating a list of COVID-19 residents from shift to shift. She acknowledged that this was what led to Resident # 99 being misdiagnosed as being COVID-19 positive.
A review of the facility's policy for Charting and Documentation dated 3/31/20 and provided by the DON included that Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
NJAC 8:39-29.2 (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, and review of pertinent facility documents, it was determined that the facility failed to a). secure medications in 1 of 4 nursing units inspected, b). secure medicati...
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Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a). secure medications in 1 of 4 nursing units inspected, b). secure medications in 1 of 4 emergency kits (E-kits) inspected, and c). properly label, store and dispose of medications in 3 of 10 medication carts and 1 of 4 medication rooms inspected.
This deficient practice was evidenced by the following:
1. On 10/05/23 at 2:10 PM, the surveyor observed two bags containing medications on the A unit nursing station, no residents were in the vicinity. The two bags included the following medications: Eliquis (blood thinner), Tessalon (medication for coughing), Vitamin D (vitamin), Norvasc (blood pressure), Diltiazem (blood pressure), Tradjenta (diabetes), Carafate (stomach medication), Xarelto (blood thinner), Nadolol (blood pressure) and Sevelamer (phosphate binder).
At that same time, the surveyor interviewed a Licensed Practical Nurse (LPN #1 ) who stated that the medications inside the two bags were discontinued medications that were going to be returned to the pharmacy. LPN #1 also stated that the two bags containing the medication should not have been kept in an unsecure area and that all medication returns should have been brought to the Director of Nursing's (DON) office and placed into a locked box.
On 10/05/23 at 2:20 PM, the surveyor interviewed both the DON and the Regional Registered Nurse (RRN#1), who both acknowledged that all medications should be kept in a secured locked storage area and further acknowledged that all return medications should be brought to the DON's office and placed in a locked storage box.
2. On 10/13/23 at 12:10 PM, the surveyor inspected the E-kit on the 2nd-floor subacute unit in the presence of the LPN /Unit Manager (LPN#/UM#1). The surveyor observed the E-Kit had a broken green tie-lock.
At that time, the surveyor interviewed the LPN/UM#1 who acknowledged that the E-kit tied lock was broken and that once opened, it should be brought down to the DON's office and should have been replaced with a new E-kit.
The E-Kit box contained the following medications:
1. Dexamethasone 10mg/ml injection (2 vials)
2. Dextrose 50% injection (one)
3. Diphenhydramine injection 50 mg (two)
4. Epinephrine 0.3 injection (one)
5. Glucagon Kit 1 mg (one)
6. Glucose-15 40% gel (two)
7. Lidocaine 1% 50 ml multi-dose vial (two)
8. Methylprednisolone 40 mg/ml injection (two)
9. Narcan 4mg/0.1 Nasal Spray (two)
10. Nitroglycerin 0.4 mg sublingual tablets (25 tablets)
A review of the E-Kit contents revealed no missing medications and all medications were accounted for inside the E-Kit.
3. On 10/13/23 at 9:15 AM, the surveyor inspected the medication cart #2 on the Vent unit in the presence of LPN/UM#2. The surveyor observed an expired syringe with an expiration date of 07/25/23.
At that time, the surveyor interviewed LPN/UM#2 who acknowledged that the syringe had an expiration date of 07/25/23 and that the expired syringe should have been removed from the medication cart.
On 10/13/23 at 11:15 AM, the surveyor inspected the medication room on the A-wing in the presence of the Registered Nurse (RN/UM #1). The surveyor observed a bag of nebulizer tubing with an expiration date of 9/17/23. At that time, the surveyor interviewed RN/UM#1 who acknowledged that the bag of nebulizer tubing was expired and should have been removed from the active medication stock.
On 10/13/23 at 12:10 PM, the surveyor inspected the second subacute unit medication cart #3 in the presence of LPN/UM#1. The surveyor observed an opened Humalog insulin pen (medication for diabetes) that had no opened date. At that time, the surveyor interviewed LPN/UM#1 who stated that once an insulin syringe was opened, there should have been an opened date.
On 10/13/23 at 12:20 PM, the surveyor inspected the B-unit A side low side medication cart in the presence of LPN/UM#3. The surveyor observed a bottle of Blood Glucose test strips that was opened and not dated and a bottle of Neurontin 250mg/5ml solution (medication for seizures) with a label to store in the refrigerator.
At that time, the surveyor interviewed LPN/UM#3 who stated that an opened bottle of Glucose blood strips should have been dated and that a bottle of Neurontin solution should have been stored in the medication refrigerator.
A review of the Manufacturer's Specifications for the following medications revealed the following:
1. Humalog insulin pen once opened have an expiration date of 28-days.
2. Glucose blood strips once opened have an expiration date of 90-days
3. Neurontin solution should be stored in the refrigerator.
On 10/16/23 at 1:30 PM, the surveyor discussed the above observations and findings with the administrative team which included the DON, Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), RRN #1 and the RRN #2.
There was no additional information provided.
A review of the facility's policy for Storage of Medications dated 1/31/22 and provided by the DON included that Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity control. Only person authorized to prepare and administer medications have access to locked medications.
Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.
Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured locations. Medications are stored separately from food and are labeled accordingly.
NJAC: 8:39-29.4 (a) (h) (d)
CONCERN
(E)
📢 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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
3). On 10/4/2023 at 12:36 PM the surveyor observed, resident #112 resting in bed, awake, alert and offered no concerns. Resident's daughter at bedside.
The surveyor reviewed the medical record for Re...
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3). On 10/4/2023 at 12:36 PM the surveyor observed, resident #112 resting in bed, awake, alert and offered no concerns. Resident's daughter at bedside.
The surveyor reviewed the medical record for Resident #112.
A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included but not limited to malignant neoplasm of pancreas (cancer of pancreas), chronic viral hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), Adult Failure to Thrive (syndrome of weight loss, decrease appetite and poor nutrition, and inactivity), hypertension (elevated blood pressure), HIV (human immunodeficiency virus).
A review of admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 8/30/2023, reflected that the resident's cognitive skills for daily decision-making score was 12 out of 15, which indicated that the resident's cognition was moderately impaired. Section O indicated that the resident was receiving Hospice care prior to admission and while a resident within the facility.
A review of the August, September, and October 2023 OSR and eMAR revealed the following:
1. An order dated 8/23/23 for Lactulose oral solution 10 Grams/15 ml, give 30 ml by mouth three times a day for constipation with plotted time of 9AM, 1500 (3 PM), and 2100 (9 PM) which revealed the following omissions: 8/23/23.
2. An order dated 8/25/23 for Lactulose oral solution 10 Grams/15 ml, give 30 ml by mouth one time a day for constipation with plotted time of 9AM which revealed the following omissions: 8/31/23, 9/22/23, and 9/30/23.
3. An order dated 08/23/23 for Lidocaine External Patch 4%, apply to back topically one time a day for chronic pain with plotted time of 9 AM which revealed the following omissions: 8/31/23 9/22/23 and 10/5/23.
4. An order dated 9/18/23 for Melatonin tablet 3 mg, give one tablet by mouth at bedtime for SUPPLEMENT with plotted time of 2100 (9 PM) which revealed the following omissions: 9/23/23.
5. An order dated 8/23/23 for Montelukast Sodium 15 mg, give one tablet by mouth in the morning for asthma with plotted time of 9 AM which revealed the following omissions: 8/31/23, 9/22/23.
6. An order dated 8/23/23 for Sulfamethoxazole-Trimethoprim oral tablet 800-160 mg, give one tablet by mouth one time a day every Mon, Wed, Fri for prophylaxis with plotted time of 9 AM which revealed the following omissions: 9/22/23.
7. An order dated 9/10/23 for Ativan oral tablet 0.5 mg (Lorazepam), give 0.5 mg by mouth every 12 hours for anxiety with plotted time of 9 AM and 9 PM which revealed the following omissions: 9/23/23 at 2100 (9 PM).
8. An order dated 9/20/23 for Cyclobenzaprine HCL oral tablet 10 mg, give one tablet by mouth two times a day for spasms with plotted time of 9 AM and 1700 (5 PM) which revealed the following omissions: 9/23/23 at 1700 (5 PM).
9. An order dated 8/23/23 for DSS oral capsule 100 mg (Docusate sodium), give one capsule by mouth two times a day of constipation with plotted time of 9 AM and 1700 (5 PM) which revealed the following omissions:
8/31/23 at 9 AM,
9/23/23 at 1700 (5 PM)
9/28/23 at 1700 (5 PM)
10. An order dated 8/28/23 for diazepam oral tablet 2 mg, give one tablet by mouth every 12 hours for Anxiety with plotted time of 9 AM and 2100(9 PM) which revealed the following omissions:
9/10/23 at 2100 (9 PM)
9/11/23 at 9 AM
9/11/23 at 2100 (9 PM)
9/12/23 at 9 AM
9/12/23 at 2100 (9 PM)
11. An order dated 8/24/23 to 9/8/23 for Oxycodone HCI oral tablet 20 mg, give one tablet by mouth three times a day for pain management with plotted time of 9 AM, 1500 (3 PM), 2100 (9 PM) which revealed the following omissions:
8/31/23 at 9 AM
12. An order dated 9/8/23 to 10/5/23 for Oxycodone HCI oral tablet 20 mg, give one tablet by mouth every eight hours for pain with plotted time of 6 AM, 1400 (2 PM), and 2200 (10 PM) which revealed the following omissions:
9/13/23 at 6 AM
9/16/23 at 6 AM
9/22/23 at 1400 (2 PM)
9/23/23 at 2200 (10 PM)
9/29/23 at 1400 (2 PM)
13. An order dated 8/23/23 for Simethicone oral tablet 80 mg, give one tablet by mouth every six hours for Flatulence with the plotted time of 0000 AM, 6 AM, 12 PM and 1800 (6 PM) which revealed the following omissions:
8/31/23 at 12 PM
9/02/23 at 6 AM
9/16/23 at 12 AM
9/16/23 at 6 AM
9/22/23 at 12 PM
9/23/23 at 1800 (6 PM)
9/28/23 at 1800 (6 PM)
14. An order dated 8/24/23 for Pancrelipase (Lip-Prot-Amyl) oral capsule delayed release particles 24000-76000 UNIT, give one capsule by mouth before meals and at bedtime for Supplement with the plotted time of 07:30 AM, 11:00 AM, 1600 (4 PM) and 2100 (9 PM) which revealed for following omissions:
9/22/23 at 11:00 AM
9/23/23 at 1600 (4 PM)
9/23/23 at 2100 (9 PM)
9/28/23 at 1600 (4 PM)
9/30/23 at 11 AM
15. An order dated 9/5/23 for Refresh Plus Ophthalmic Solution 0.5%, instill one drop in both eyes two times a day for dry eyes with the plotted time of 8 AM and 2000 (8 PM) which revealed the following omissions:
9/22/23 at 8 AM
9/23/23 at 2000 (8 PM)
10/5/23 at 8 AM
16. An order dated 10/12/23 for Fleet Enema 7/19 gram/118 ml (Sodium Phosphates), insert 1 application rectally one time a day for constipation for 1 day with the plotted time of 6:30 AM on 10/13/23 which revealed the following omissions: 10/13/23
17. An order dated 8/23/23 for Senna oral tablet 8.6 mg (Sennosides), give one tablet by mouth at bedtime for constipation with the plotted time of 2100 (9 PM) which revealed the following omissions: 8/23/23, 8/29/23, 9/23/23.
18. An order dated 8/24/23 for Baclofen tablet 10 mg, given one tablet by mouth every eight hours for muscle spasms with the plotted time of 6 AM, 1400 (2 PM), 2200 (10 PM) which revealed the following omissions:
8/31/23 at 1400 (2 PM)
9/2/23 at 6 AM
19. An order dated 9/15/23 for Mirtazapine tablet 15 mg, give one tablet by mouth at bedtime for DEPRESSION ADMINISTER WITH 7.5 MG TABLET TO EQUAL 22.5 MG TOTAL with the plotted time of 2100 (9 PM) which revealed the following omissions: 9/23/23
20. An order dated 9/15/23 for Mirtazapine tablet 7.5 mg, give one tablet by mouth at bedtime for DEPRESSION ADMINISTER WITH 15 MG TABLET TO EQUAL 22.5 MG TOTAL with the plotted time of 2100 (9 PM) which revealed the following omissions: 9/23/23
On 10/17/23 at 09:42 AM, the surveyor interviewed the License Practical Nurse (LPN#1) who stated that she is an agency nurse and had been working at the facility for one month. The LPN#1 stated if a resident refuses medication, then I will let my supervisor know or check with the resident again after ten minutes.
10/17/23 at 09:56 AM, the surveyor interviewed LPN#2 who stated that she is an Agency Nurse, and this was her first day of work on the unit and the second week at this facility. The surveyor interviewed the Nurse about the medication administration process. She stated, I knock on the resident's door, check the blood pressure first for parameter medication, then check the resident's Identification band or picture on the computer to make sure it is the right patient. I then administer medication and make sure they swallow their medications. I then wash my hands afterwards. If the resident is sleeping, I awaken the resident and tell them it's time for their medication. If they don't want to take it at that time, I then check back with them. The surveyor asked LPN#2 to explain the process of documenting on the eMAR, specifically what it means when the medication administration box is empty and she stated, if it is not signed off, means it wasn't given.
10/17/23 10:05 AM, the surveyor interviewed LPN#3/Unit Manager (LPN#3/UM) regarding omissions on Resident #117's eMAR. The surveyor and LPN#3/UM reviewed the resident's eMAR from August and September 2023 which revealed multiple omissions. LPN#3/UM stated, I do not know if the medications were given or not. She further stated that the nurses should document if a medication was given or not given. It was not acceptable practice for not documenting on the eMAR and it's the nurse's responsibility to document the eMAR if the medication was given or refused.
On 10/18/2023 at 12:33 PM, The surveyor interviewed the Consultant Pharmacist (CP) via the telephone, in the presence of the survey team. The CP stated that she comes to the facility once a month to review the residents' charts. She stated her responsibilities included checking for irregularities, observing med pass, unit inspections, chart reviews and providing in-service when needed. The surveyor asked the CP what is the process if she observes omissions on the medication administration records. She stated, I let the nurses know if there are omissions on the medications administration record that are infrequent and if there are frequent omissions, I then report it to the Director of Nursing because it is a trend, and they need to investigate it. She further stated that she also communicates her findings to the Director of Nursing and Administrator via a written report.
The surveyor requested the written copy of the Pharmacy Consultant report which she provided to the surveyor on 10/18/2023 at 1:51 pm.
Review of the Pharmacy Consultant Report dated 9/22/2023, indicated in the facility wide that charting gaps were noted.
10/19/23 at 12:12 PM, the surveyor in the presence of the survey team met with the LNHA, RRN#1, RRN#2, DON, ADON, and Regional Social Worker and discussed the above findings. The RRN#2 stated, There are bunch of refusal notes in the Electronic Medication Administration Record. She further stated, They are writing stuff in here instead of writing a separate note.
A review of the facility's policy for Documentation of Medication Administration updated 10/2019, which was provided by Regional Registered Nurse #1 (RRN #1) included the following, A nurse of certified Medication Aide (Where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented immediately after (never before) it is given. Documentation must include name, strength of the drug, dosage, method of administration, date and time of administration, reason why a medication was withheld, not administered, or refused; signature and title of the person administering the medication; and Resident's response to the medication, if applicable.
A review of the facility's policy for Administering Medication dated 10/31/22, which was provided by the DON included the following:
If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication will document in medication administration record.
A review of the facility's policy for Charting and Documentation dated 03/31/20, which was provided by the DON included the following:
The following information is to be documented in the resident medical record
b. Medication administered.
NJAC 8:39-11.2 (b), 29.2 (d)
Complaint # NJ 00159893
Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to a.) accurately document the administration of medications in the electronic medical administration record (eMAR), b.) clarify duplicate physician's orders for an over-the-counter medication, aspirin 81 mg, and c). failed to obtain a medication for pain. This deficient practice occurred for 3 of 24 residents, (Resident #58, #112, and #220) reviewed for medication review.
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.
This deficiency was evidenced by the following:
1. On 10/12/23 at 9:00 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN#1) in the room of Resident #220. The surveyor observed RN#1 checking the resident's identification bracelet and informing Resident #220 that she will be administering the resident's medications. The surveyor observed the resident in bed and just finished eating breakfast.
On 10/12/23 at 9:05 AM, the surveyor observed RN#1 preparing to administer five (5) medications to Resident #220 which included Aspirin 81 mg (milligrams) chewable tablet (coronary artery disease). The surveyor observed RN#1 prepared Resident #58's medications for administration and observed RN#1 removed the automated roll of the resident's daily medications. RN#1 was observed reviewing the medications and she pointed out that they were two medications that were scheduled for 6:30 AM, that was not administered.
At that same time, the surveyor observed the two medications were Levothyroxine (medication for the thyroid) 25 mcg (micrograms) and Pantoprazole (medication for the stomach) 40 mg scheduled for 6:30 AM. RN#1 also pointed out there was a duplicate order for Aspirin 81 mg. She stated she would administer one Aspirin tablet and would notify the physician to discontinue one of the Aspirin orders.
On 10/12/23 at 10:20 AM, the surveyor interviewed RN#1 regarding the two omissions from 6:30 AM. RN#1 acknowledge the Pantoprazole and Levothyroxine were not administered at 6:30 AM, but was unable to answer why the medications were not administered to Resident #220.
The surveyor reviewed the medical record for Resident # 220.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to hypertension (elevated blood pressure), cerebral infarction (condition where brain tissue dies as a result of localized hypoxia/ischemia due to cessation of blood flow) and Type II diabetes (a chronic condition that affects the way the body processes blood sugar glucose).
A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 10/10/23, reflected that the resident's cognitive skills for daily decision-making score was 10 out of 15, which indicated that the resident was moderately impaired cognition.
A review of the October 2023 Order Summary Report (OSR) revealed a physician order (PO) dated 10/3/23, for the following medications:
- Pantoprazole oral tablet delayed release 40 mg tablet, give 1 tablet by mouth one time a day for GERD (Gastroesophageal reflux disease; a digestive disease in which the stomach acid or bile irritates the esophagus),
- Levothyroxine oral tablet 25 mcg, give 1 tablet by mouth one time a day for hypothyroidism (a condition when the thyroid gland doesn't produce enough thyroid hormone) take on an empty stomach,
- Aspirin tablet chewable 81 mg, give 1 tablet by mouth one time a day for CAD (Coronary Artery Disease) and
- Aspirin tablet chewable 81 mg, give 1 tablet by mouth one time a day for CAD may increase the risk of bleeding. Please observe for any bruising, dark urine, and black tarry stool.
A review of the October 2023, electronic medication administration record (eMAR) revealed an order for Pantoprazole oral delayed release 40 mg tablet, give 1 tablet by mouth one time a day for GERD scheduled for 6:30AM, revealed that the nurse did not sign the eMAR on 10/12/23 at 6:30 AM as administered.
A review of the October 2023 eMAR revealed an order for Levothyroxine oral tablet 25 mcg, give 1 tablet by mouth one time a day for hypothyroidism take on an empty stomach scheduled for 6:30 AM, revealed that the nurse did not sign the eMAR on 10/12/23 at 6:30 AM as administered.
A review of the October 2023 eMAR revealed two orders of Aspirin 81 tablet chewable, give 1 tablet by mouth one time a day for CAD scheduled for 8:00 AM, revealed that on 10/5/23, 10/8/23, 10/10/23, and 10/11/23, both orders of Aspirin were documented as being administered.
On 10/16/23 at 1:10 PM, the surveyor in the presence of the survey team met with the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA), Regional Clinical Registered Nurse (RCRN#1) and RCRN#2 and discussed the above findings.
On 10/16/23 at 1:25 PM, the surveyor attempted to conduct a telephone interview with the nurse who omitted the 6:30 AM medication on 10/12/23, but was unable to conduct an interview.
On 10/17/23 at 1:30 PM, the DON acknowledge there was a duplicate order for Aspirin 81 mg and that this double order should have been discontinued on 10/4/23. She stated that despite that Aspirin was signed as administered twice on 10/5/23, 10/8/23, 10/10/23 and 10/11/23, the nurses did not administer a double dose. The DON also confirmed that the nurse omitted documenting the eMAR for Pantoprazole and Levothyroxine on 10/12/23. She stated that the resident refused the medications and the nurse failed to document that the resident refused the two medications.
On 10/19/23 at 10:20 AM, the surveyor interviewed RN#1 regarding Resident #220's double dose of Aspirin and the procedure of discontinuing a double order. RN#1 stated that when a double order of a medication is noticed on the eMAR, a nurse should get a discontinued order for one of the medications and that should be done immediately.
2. On 10/5/23 at 10:30 AM, the surveyor observed Resident #58 in bed with their eyes closed.
The surveyor reviewed the medical record for Resident # 58.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear strong enough to interfere with one's daily activities), trigeminal neuralgia(chronic pain condition affecting the trigeminal nerve in the face) and chronic pain due to trauma (pain due to traumatic event).
A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care, dated 08/23/23, reflected the resident's cognitive skills for daily decision-making score was 9 out of 15, which indicated that the resident was moderately impaired cognition.
A review of the September 2022 Physician's Orders (PO) revealed a physician order dated 02/04/22 for Morphine Sulfate Controlled Release (CR) 15 mg, give 1 tablet (15mg) by oral route every 12 hours for pain.
A review of the September 2022 eMAR revealed an order for Morphine Sulfate CR 15 mg tablet, extended release give 1 tablet (15 mg) by oral route time every 12 hours scheduled for 9 AM and 9 PM.
Further review of the eMAR revealed the Morphine Sulfate CR was not administered due to the medication not being available on the following dates and times:
- 9/5/22 at 9PM,
- 9/6/22 at 9AM,
- 9/6/22 at 9PM,
- 9/7/22 at 9AM and
- 9/7/22 at 9PM.
A review of the September 2022 progress notes revealed the following nursing note dated on 9/8/22 at 12:54 AM indicating, Morphine Sulfate CR 15 mg tablet, extended release (standing order every 12 hours) unavailable at this time and no back up supply in the Omni-cell (medication back-up system). Patient has a history of Chronic pain.
Patient resting at this time. Vitals within normal range and no complaints of pain at this time. -11 PM- MD notified by writer that medication is unavailable and none in back up Omni cell at this time. MD explained to writer that a new script will be provided for 9/7/22 and no new orders at this time is necessary.
On 10/16/23 at 10:00 AM, the DON informed the surveyor that the nurse who wrote the 9/8/22 progress note no longer works for the facility. The surveyor was unable to conduct an interview with that nurse.
On 10/17/23 at 1:25 PM, the surveyor met with the DON, LNHA, Assisted Director of Nursing, RCRN#1 and RCRN#2 and discussed the above findings.
On 10/18/23 at 10:15 AM, the surveyor interviewed Resident #58 who stated that he/she was unable to recall if he/she was experiencing any pain back in September of 2022 but has no issues with pain at this time.
On 10/18/23 at 1:35 PM, the ADON acknowledged that the resident went without their Morphine CR 15 mg from 9:00 PM on 9/5/23 through 9 PM on 9/7/23. She stated that the facility was in communication with the pharmacy and that they attempted to call the physician who was unavailable. When the surveyor requested this documentation, she presented the above nursing note from 9/8/22 at 12:54 AM. The surveyor requested the documentation showing the facility was calling the pharmacy and the physician prior to 9/8/22 and the surveyor was told that the facility had no documentation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
4. On 10/12/23 at 10:21 AM, while on the Sub-acute unit, the surveyors observed a stocked PPE caddy on the door and a STOP Contact Isolation sign at the doorway of Resident #378's room. The sign read ...
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4. On 10/12/23 at 10:21 AM, while on the Sub-acute unit, the surveyors observed a stocked PPE caddy on the door and a STOP Contact Isolation sign at the doorway of Resident #378's room. The sign read Stop, Contact Precaution, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. The surveyors then observed LPN #2 enter the room with the vital sign machine. LPN #2 was wearing an N95 mask and no other PPE. The surveyors observed LPN #2 place the blood pressure cuff on the arm of Resident #378 and take the resident's blood pressure.
On 10/12/23 at 10:22 AM, the surveyor brought the Licensed Practical Nurse/Unit Manger (LPN/UM) to the door of Resident #378 and asked what the Stop Contact Precautions signage meant. The LPN/UM stated that everything on the sign should be done before you enter the room. The LPN/UM stated that the resident was on contact isolation due to having diarrhea and that c-diff (Clostridium Difficile, a highly contagious bacterial infection that causes diarrhea and colitis) was being ruled out. The LPN/UM observed LPN #2 in the room, cleaning the blood pressure machine with the purple top wipes (Micro-Kill One, Germicidal Alcohol Wipes), wearing only an N95 mask. The LPN/UM stated that LPN #2 should have performed hand hygiene and then donned a gown and gloves before entering the room. The LPN/UM stated that the purpose of PPE was to not transfer it (infection) to self or others.
On 10/12/23 at 10:25 AM, LPN #2 exited Resident #378's room. The surveyors asked what the STOP Contact Precautions sign meant, she stated that she should wear gloves. She then stated that the Contact sign was precautionary because the resident was a new admission. The surveyor asked if the sign should have been disregarded, LPN #2 stated, no, I should have worn gloves and a gown in the room. LPN#2 then showed the surveyor her shift report that had stool for c-diff written next to the resident's name. LPN #2 stated she was asked to clarify the order for stool for c-diff. The LPN/UM told LPN #2 that Resident #378 was on contact precautions because of loose stools and that they (the facility) were ruling out c-diff.
On 10/12/23 at 10:36 AM, in the presence of the Infection Preventionist (IP), the LPN/UM and LPN #2, the surveyor asked if the purple top wipes were appropriate to kill c-diff. The IP reviewed the purple top wipe container and confirmed that that they were not appropriate to kill c-diff. The IP stated that the blue top bleach wipes (Micro-Kill Bleach, Germicidal Bleach Wipes) were needed to kill c-diff.
On 10/12/23 at 10:41 AM, during a follow up interview with the IP, the IP stated that contact precaution sign tells you exactly what to do before entering the room. She then stated the staff should read and follow the sign before you do anything.
The surveyor reviewed the electronic medical record for Resident #378.
A review of the admission Record revealed the resident was admitted with diagnoses which included but not limited to: Fracture of unspecified part of neck of right Femur and Enterocolitis due to Clostridium Difficile.
A review of the OSR revealed a PO: Resident is on contact precautions for C-Diff every shift for C-Diff for 10 days with a start date of 10/11/23.
A review of the Medication Administration Record (MAR) under Resident is on contact precautions for C-Diff every shift for C-Diff for 10 days order date 10/11/23 13:01 revealed that nursing had signed the MAR as completed for the Eve (evening) and Nigh (night) shifts for 10/11/23.
A review of the Care Plan (CP) revealed a Focus: The resident is at risk for C. Difficile r/t (related to) antibiotic therapy, Date Initiated 10/11/23, and a Goal: The resident will have no complications related to c. difficile through review date, Date Initiated: 10/11/23.
On 10/13/23 at 12:33 PM, during a meeting with the survey team, the surveyor made the LNHA, the DON, RRN #1 and RRN #2 aware of the above findings. RRN#1 stated that the expectation of the staff was to follow the signs posted at the doors.
A review of the Micro-Kill One, Germicidal Alcohol Wipes (purple top wipes) container did not list that it was effective against Clostridium Difficile spores. A review of the Micro-Kill Bleach, Germicidal Bleach Wipes, (blue top wipes) container revealed that they were effective against the Clostridium Difficile spores.
A review of the facility's IN-SERVICE SIGN IN SHEET; Topic: Precautions; Description: Nursing Identifying patients who are on isolation precautions (Airborne, Contact, Droplets and enhanced barrier) revealed that LPN #2 received an in-service on 9/13/23.
A review of the facility's policy Isolation-Categories of Transmission-Based Precautions with a revised date of 1/2023, included the following:
Policy Statement: 1.Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to other;
Policy and Interpretation and Implementation: 1. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection.
Contact Precautions
1. In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the environmental surfaces or resident-care items in the resident's environment.
2. Examples of infections requiring Contact Precautions include but are not limited to: b. Diarrhea associated with Clostridium difficile.
4. Gloves and Handwashing
a. In addition to wearing gloves as outlined under standard precautions, wear gloves (clean, non-sterile) when entering the room.
b. While caring for a resident, change gloves after having contact with infective material (for example, fecal material and wound drainage).
c. Remove gloves before leaving the room and perform hand hygiene.
d. After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room.
5. Gown
a. Wear a disposable gown upon entering the contact precautions room or cubicle.
b. After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces.
7. Resident-Care Equipment
a. When possible, dedicate the use of non-critical resident-care equipment items such as stethoscope, sphygmomanometer, bedside commode, or electronic thermometer to a single resident (or cohort of residents) to avoid sharing between residents.
b. If use of common items is unavoidable, then adequately clean and disinfect them before use of another resident.
8. Signs-the facility will implement a system to alert staff to the type of precaution resident requires: b. The facility utilizes the following system for identification of Contact Precautions for staff and visitors: STOP and SEE NURSE.
Droplet Precautions 1. In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganism's transmitted by droplets (large-particle droplets . that can be generated by the individual coughing, sneezing, talking or by the performance of procedures such as suctioning).
NJAC 8:39-5.1(a)
Based on observations, interviews, record review, and a review of pertinent facility documentation, it was determined that the facility failed to a). follow appropriate infection control practices for proper hand hygiene, b). ensure staff wore the appropriate personal protective equipment (PPE) for three residents who were on transmission-based precautions (TBP) (Resident #19, #56 and #378) c).ensure communication that all COVID-19 positive residents were communicated from shift to shift accurately (Resident #99) and failed to d). ensure that multiuse medical equipment was properly disinfected on 2 of 4 nursing units (A-unit and the 2nd floor subacute unit).
The deficient practice was evidenced by the following:
1. On 10/4/23 at 10:20 AM, during the entrance conference, the facility administration staff told the surveyor that all staff were required to wear full PPE prior to entering a COVID-19 (infectious disease cause by SARS-CoV-2 virus ) room. Full PPE included wearing a N95 mask (respirator mask), goggles, gown and gloves.
On 10/4/23 at 12:45 PM, during the initial tour on the A-unit, the surveyor interviewed a Licensed Practical Nurse (LPN#1) who told the surveyor that all COVID-19 residents have signage outside their rooms identifying them as being on strict contact/droplet isolation precautions.
On 10/4/23 at 1:00 PM, the surveyor observed Resident #56's door open. The resident was in bed watching television. Resident #56 had signage that indicated that the resident was under strict contact/droplet isolation precaution. The surveyor observed a PPE bin outside the resident's room.
On 10/4/23 at 1:10 PM, the surveyor observed a Certified Nursing Assistant (CNA#1 ) who was wearing an N95 mask and goggles enter Resident #56's room without performing hand hygiene and without putting on a gown and gloves. The surveyor then observed CNA #1 exiting the resident's room carrying a meal tray which she placed inside a food truck. The CNA #1 did not perform hand hygiene after exiting the room.
At that time, the surveyor interviewed CNA #1 who acknowledged that Resident #56 had COVID-19 and was on strict contact/droplet isolation precautions. The CNA#1 stated that before entering a COVID-19 room, she had to perform hand hygiene, put on gloves and a gown and when exiting a room, she had to remove all PPE and then perform hand hygiene. The CNA#1 was unaware that she had to wear full PPE to remove a meal tray from a COVID-19 positive room.
The surveyor reviewed the medical record for Resident #56.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but was not limited to; anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activity), acute and chronic respiratory failure with hypoxia (a serious condition that makes it difficult to breath on your own), and COVID-19.
A review of the Order Summary Report (OSR) included a physician's order (PO) dated 9/30/23, for patient on isolation due to COVID-19 Positive at this time.
2. On 10/4/23 at 1:30 PM, the surveyor observed CNA #2 enter a COVID-19 positive room (Resident#19) without performing hand hygiene and putting on a gown, gloves or googles. The surveyor observed the CNA#2 open the door and exit the room exit the room. She then began to put on a pair of gloves.
At that time, the surveyor interviewed CNA#2 who stated that she entered Resident#19's room to wash her hands and then was going to put on PPE before performing care on the resident. The surveyor asked the CNA#2 if she was supposed to perform hand hygiene and put on the PPE before entering the room, she was unable to answer the surveyor's question.
On 10/04/23 at 1:40 PM, the surveyor interviewed the Registered Nurse/Unit manager (RN#1/UM) who stated that the facility's policy was to perform hand hygiene and donning prior to entering a COVID-19 room. She also stated that CNA#2 didn't need to go into the resident's room to wash her hands, they had hand sanitizer located outside the resident's room. She further stated that when the CNA#2 opened the resident's door that she should have perform hand hygiene since the doorknob was a high contact area.
The surveyor reviewed the medical records for Resident #19.
A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; hypertension (elevated blood pressure), glaucoma (pressure in the eye) and COVID-19.
A review of the OSR dated 9/30/23, revealed a physician's order for On isolation precautions secondary to COVID positive every shift for 10 days.
On 10/4/23 at 2:30 PM, the surveyor met with the facility administration team which included the Director of Nursing (DON),the Licensed Nursing Home Administrator (LNHA), and Regional Registered Nurse (RRN#1) and discussed the above findings.
No further information was provided.
3). On 10/5/23 at 10:00 AM, the surveyor observed Resident #99, self-propelling in their wheelchair toward the bathroom. The resident was alert and oriented but did not want to be interviewed. The surveyor observed the resident's room which had no stop sign or isolation signage on the door or wall, and no personal protection equipment (PPE) bin located outside of the resident's room.
The surveyor reviewed the medical record for Resident # 99.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hypertension (elevated blood pressure), cerebral infarction (condition where brain tissue dies as a result of localized hypoxia/ischemia due to cessation of blood flow), Type II diabetes (a chronic condition that affects the way the body processes blood sugar glucose) and COVID-19 (infectious disease caused by the SARS-CoV-2 virus).
A review of Resident #99's progress notes (PN) revealed a nursing note dated 10/02/23 at 3:30 PM which revealed the following documentation, COVID positive, alert, verbally responsive, able to make needs known, no distress noted, T (temperature) 97.4, BP (blood pressure) 130/76, SPO2 (amount of oxygen in the blood) 100%. NP [nurse practitioner] visited new order noted, for Doxycycline 100 mg BID [twice a day] for 5 days, Dexamethasone 6 mg po x 6 days, Albuterol inhaler QID x 7 days and Benzonatate 200 mg TID [three times a day] for 14 days, orders carried out.
On 10/05/23 at 10:25 AM, the surveyor observed Resident #99's room in the presence of the Regional Registered Nurse #1 (RRN). The RRN #1 acknowledged that the resident had no stop sign or signage indicating that the resident was under strict isolation for COVID-19, and that there was no PPE bin outside of the resident's room. The RRN#1 stated that the resident was negative for COVID-19 which was confirmed by the Registered Nurse/Unit Manager (RN#1/UM).
On 10/05/23 at 10:30 AM, the surveyor interviewed the Unit A RN#1/UM, who stated that she got a report of all the residents who were COVID-19 positive on her unit, and further stated that she had no confirmation that Resident #99 was positive for COVID-19.
On 10/05/23 at 10:35 AM, the surveyor interviewed the Director of Nursing (DON) who was present on Unit A. The DON stated that the resident was not COVID-19 positive. She stated that she had a list of all the residents who were COVID-19 positive in the facility and Resident #99 was not on that list.
At that same time, the surveyor reviewed Resident #99's medical record in the presence of the DON, RRN#1 and the RN/UM. After reviewing the resident's medical record, the DON and RRN#1 stated that they would retest the resident and obtain a physician's order to put the resident on COVID-19 isolation.
On 10/05/23 at 10:45 AM, the surveyor observed the result for the COVID-19 rapid test for Resident #99 in the presence of the RN/UM. The rapid COVID-19 test revealed that the resident was negative for COVID-19.
On 10/05/23 at 12:43 PM, the surveyor interviewed the facility infection preventionist (IP) who stated that she tested Resident #99 on 10/2/23, and that the resident tested negative for COVID-19. The IP stated that the process for tracking resident COVID-19 testing was to print out the midnight census and to write all the test results on the census sheet. All the residents who tested negative had a check mark to the left of their names while all the positive residents had a plus mark. The IP showed the surveyor a copy of the 10/2/23 midnight census which showed a check mark to the left of Resident #99's name. The IP stated she did not know how the Licensed Practical Nurse (LPN), or the Nurse Practitioner (NP) concluded that the resident was COVID-19 positive. The IP provided a copy of the midnight census with the test result to the surveyor.
At that time, the DON and RRN#1 who were present for the IP interview acknowledge that their current COVID-19 tracking log did not ensure proper tracking and communication of all COVID-19 positive from shift to shift at the facility. They stated that they are in process of developing a new tracking log that would ensure proper communication from shift to shift.
On 10/05/23 at 1:45 PM, the surveyor conducted a telephone interview with the NP in the presence of the survey team. The NP stated that she received a phone call from the LPN on 10/2/23 and was told that Resident #99 tested positive for COVID-19. At that time, she gave a telephone order for four medications which included Doxycycline, Dexamethasone, Benzonatate, and Proventil. The NP told the surveyor that Resident #99 had multiple comorbidities and that she wanted to start the resident on medications right away. The NP further stated that she saw the resident earlier in the day and that the resident tested negative. She stated that she discontinued all the medications and isolation precautions but since the resident had a cough with rales, she ordered a chest x-ray to rule out any potential issues.
On 10/05/23 at 2:15 PM, the surveyor conducted a telephone interview with the Licensed Practical Nurse (LPN). The LPN stated that she came to work on 10/2/23, and a staff member informed her that Resident #99 test positive for COVID-19. She was unable to speak to which staff member relayed that information. She also acknowledged that she did not see the resident's test results. She stated that there was a stop sign and signage for strict isolation and a PPE bin outside of the resident's room. She further stated that the NP came to her unit on 10/2/23, and asked her if any of her residents were positive and she told the NP that Resident #99 was positive and that the NP wrote new orders for the resident.
On 10/05/23 at 3:00 PM, the surveyor discussed the above findings with the facility administrative team which included the DON, Licensed Nursing Home Administrator, RRN#1, IP and the Assistant Director of Nursing.
On 10/10/23 at 10:00 AM, the surveyor in the prescence of the survey team met with the administrative staff. The DON confirmed and stated that they did not have an effective system in place to ensure that the facility was communicating a list of COVID-19 residents from shift to shift. She acknowledged that this was what led to Resident # 99 being misdiagnosed as being COVID-19 positive.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 00162720
Based on interviews and review of medical records, it was determined that the facility failed to maintai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 00162720
Based on interviews and review of medical records, it was determined that the facility failed to maintain medical records accurately and completely in accordance with acceptable standards and practice by not documenting pertinent clinical documentation on the resident's medical record for a resident who had a change in condition. This was identified for 1 of 8 residents (Resident # 372) reviewed for closed records.
This deficient practice was evidenced by the following:
On 10/16/23 at 12:57 PM, the surveyor reviewed the closed medical record for Resident # 372.
Review of the Face Sheet (an admission record) revealed Resident # 372 was admitted to the facility on [DATE], with diagnosis which included but not limited to metabolic encephalopathy (brain dysfunction caused by problems with the metabolism), other specified local infections of the skin and subcutaneous tissue, other specified sepsis (the body's response to extreme infection), type 2 diabetes mellitus with other skin complications, type 1 diabetes mellitus with foot ulcer, infection following a procedure, unspecified, subsequent encounter, and local infection of the skin and subcutaneous tissue, unspecified.
Review of the electronic progress notes dated 2/1/23, timed at 1:57 AM and documented by a Licensed Practice Nurse (LPN#1) indicated Pt [patient] stable at this time. No adverse reactions noted. Vitals within normal limits.
Review of the electronic progress notes dated 2/1/23, and timed at 2:08 AM and documented by LPN #1 indicated a Nursing Shift Assessment. The assessment revealed the resident's vital signs: blood pressure was 141/70, pulse was 91 beats per minute, respirations were 18, temperature was 97.8 degrees Fahrenheit, weight was 144.8 pounds and oxygen saturation was 98%. The progress note reflected the resident had no early warning signs of sepsis at this time.
Review of the electronic progress notes dated 2/1/23, and timed at 9:45 AM and documented by LPN #2 indicated Resident c/o [complaining of] nausea/diaphoretic/SOB [short of breath], BGM [blood glucose measurement]- 502/O2 [oxygen saturation level] 91% room air, primary nurse made aware/MD [medical doctor] made aware-new orders as follow- 10 units of Novolog stat [immediately], 1x [one time] order for duoneb [nebulizer medication], stat BNP [Brain natriuretic peptide test] (a blood test), recheck BGM in 1 [one] hour after administration -orders carried out.
Review of the electronic progress notes dated 2/1/23, and timed at 10:29 AM indicated documentation from the activities department Delivered daily chronicle to (Resident # 372) along with updated activity calendars for February, encouraged to come to activities.
Review of the electronic progress notes dated 2/1/23, and timed at 3:31 PM indicated documentation from the physical therapy department Treatment withheld today due to pt [patient] stating 'I told my nurse I can't breathe, and I have cold sweats. Not today please.' Patient receiving nebulizer treatment at the time. Per nursing, Pt also had elevated blood sugar level. Pt approached in the afternoon and refused therapy, stating 'please let me rest today.'
Further review of the electronic progress notes dated 2/1/23, and timed at 10:33 PM indicated Call made to [hospital] for follow up. Pt [patient] admitted with sepsis due to PNA [pneumonia].
There was no documented evidence of a change in the resident's clinical condition which resulted in transferring the resident to the hospital including vital signs, notifying the doctor and family.
Review of the New Jersey Universal Transfer Form (UTF) dated 2/1/23, indicated the resident was transferred at 7:00 PM. The UTF did not indicated the reason for transfer or where the resident was transferred to.
Review of the hospital records dated 2/1/23, and timed at 7:45 PM indicated that the resident presented to the emergency department via basic life support ambulance with a chief complaint of high blood sugar along with shortness of breath since 8 am.
On 10/19/23 at 11:42 AM, the surveyor interviewed the Regional Registered Nurse #1 who stated, the nurse should have documented what happened with the resident when sent to the hospital. She further stated there was documentation the morning of 2/1/23, that there was a change in condition and the doctor was notified and new orders were obtained but there was no further documentation of the resident's clinical condition which led to hospitalization.
Review of the facility policy titled Acute Condition Changes-Clinical Protocol revised 1/2023 provided by the Regional Nurse #1 included staff will monitor and document the resident/patient's progress and responses to treatment.
There was no additional information provided.
NJAC 8:39-35.2(d)6,16(e)
Aug 2022
17 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of medical records and other facility documentation, it was determined that from 12/30/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of medical records and other facility documentation, it was determined that from 12/30/2021 through 03/22/2022, the facility failed to properly assess a skin opening of the left intergluteal cleft (groove between the buttocks) immediately upon identification, obtain treatment orders, and consistently implement timely interventions in adherence with the facility wound evaluation policy, physician's orders and the resident's care plan to prevent the development of a Stage 4 Pressure Ulcer. This deficient practice occurred for 1 of 2 residents reviewed, who were previously identified as being at risk for the development of a Pressure Ulcer and for Pressure Ulcer management (Resident #73). The deficient practice was evidenced by the following:
Reference: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf
NPUAP Pressure Injury Stages
The updated staging system includes the following definitions:
Pressure Injury:
A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
Stage 3 Pressure Injury: Full-thickness skin loss
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Stage 4 Pressure Injury: Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss
On 07/19/22 at 11:14 AM, during the initial tour of the the facility, the surveyor observed Resident #73 seated in a wheelchair at the bedside. The resident stated that he/she developed a pressure ulcer about a year ago, and did not receive immediate treatment after the resident's Certified Nursing Assistant (CNA) had reported a wound that was on his/her tail bone to nursing. Resident #73 stated the pressure ulcer then grew in size and resulted in the resident being hospitalized with a diagnosis of sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues, potentially leading to the malfunctioning of various organs, shock and death).
Review of Resident #73's Face Sheet (an admission summary) revealed that the resident was readmitted to the facility in May of 2022, with diagnoses which included but were not limited to: Enterocolitis due to clostridium difficile (results from disruption of normal healthy bacteria in the colon, often from antibiotics but can also be transmitted from person to person by spores (bacterial cell), sepsis, unspecified open wound of unspecified buttock, urinary tract infection, neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), Type 2 diabetes mellitus (an impairment in the way the body regulates glucose (sugar) as fuel, and foot drop in the left foot (difficulty lifting the front part of the foot).
Review of Resident #73's quarterly Minimum Data Set (MDS), an assessment tool dated 05/26/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident was cognitively intact. Further review of the MDS revealed that the resident required extensive assistance of one person for bed mobility, toileting, personal hygiene, required limited assistance of one person for transfers and had a Stage 4 pressure ulcer and was occasionally incontinent of bowel and bladder. The surveyor reviewed the resident's previous quarterly MDS dated [DATE], which identified that the resident was identified to have been at risk for pressure ulcers, and did not have a pressure ulcer, wound or any skin problems at that time. Further review of the MDS revealed that the resident had an indwelling urinary catheter (a tube placed in the bladder to allow urine to drain into a collection bag) and was occasionally incontinent of bowel.
Review of Resident #73's Care Plan Activity Report (CPAR) revealed an entry dated 09/05/2018, which detailed that the resident's Skin Integrity was at risk for skin breakdown based on the Braden Scale Score (a tool for predicting pressure ulcer risk), and the score was not specified, impaired mobility, phabdomyolysis [sic.] (rhabdomyolysis, breakdown of muscle tissue that releases a damaging protein into the blood), bilateral knee surgery, lower extremity fracture repairs, gastric bypass (weight loss surgery), and anemia .Interventions included but were not limited to: Routine skin assessments twice a week. Report signs and symptoms of early skin breakdown to the wound nurse. On 08/27/2019, an intervention was added to notify the resident or POA (power of attorney) and the doctor about significant changes in skin condition or care. Use barrier cream to perineal area (the region between the thighs, bounded by the scrotum and anus in males and by the opening of the vagina and the anus in females). On 11/19/2021, the Wound Care Nurse (WCN) documented that the resident's skin remained without breakdown. Will continue current plan of care. On 02/07/2022, the WCN documented that the resident's skin integrity was well maintained, care plan reviewed and will continue.
Further review of Resident #73's CPAR revealed an entry dated 03/22/2022 that was entered by the WCN and demonstrated the following: Skin Integrity: Pressure Ulcer-resident has a pressure related wound stage 4 to gluteal cleft that evolved from an atypical wound, with full-thickness tissue loss .Interventions that accompanied the entry included but were not limited to: Apply treatment to affected area as ordered. Re-evaluate periodically. Refer to Wound Specialist as needed. Refer to Wound Rounds Team as needed. Alternating pressure low air loss mattress (help treat pressure sores by providing two sets of air cells that expand and contract on an alternating basis to continually shift pressure). Minimize pressure to wounded area to maximize blood flow. Keep incontinence garment loosed [sic.] while in bed to allow air circulation to the affected area. Assess for pain at least every shift. Offer pain medication before wound treatment as needed. The WCN added a note to the entry which specified: Resident is f/u (following up) weakly [sic.] on wound rounds. Wound treatment and plan of care was adjusted to resident needs. Resident is also f/u with plastic surgeon, and was scheduled for skin reduction to facilitate wound healing. Wound is stable with no s/s (signs and symptoms) of infection .Further review of the CPAR revealed that on 03/22/22 at 11:26 AM, the WCN documented that the resident had an atypical (unusual) wound with full-thickness tissue loss to the gluteal cleft (groove that runs just below the sacrum, a triangular bone in the low back to the perineum).
Review of the Progress Notes (PN) contained within the Electronic Health Record (EHR) revealed that on the following dates:
-02/22/2022 at 3:44 AM
-02/23/2022 at 2:34 AM
-02/27/2022 at 2:32 AM
-02/28/2022 at 2:41 AM
-03/04/2022 at 3:12 AM
-03/08/2022 at 3:14 AM
-03/09/2022 at 4:05 AM
Licensed Practical Nurse #1 (LPN#1) documented that Resident #73 had a wound on the left intergluteal cleft, and a wound on the right inner thigh, and indicated that a dressing was applied.
On 03/22/2022 at 11:57 AM, the Licensed practical Nurse/Unit Manager (LPN/UM) documented that she was asked by the night nurse to have the Wound Care Nurse (WCN) take a look at Resident #73's butt (buttocks). The wound care nurse was made aware of the request and assessed the resident. The LPN/UM documented that the WCN then called her (LPN/UM) into the resident's room, and the LPN/UM observed that the resident had a wound on the gluteal cleft.
Further review of Resident #73's PN revealed that on 03/22/2022 at 1:00 PM, the WCN documented that the resident had full-thickness tissue loss to the coccyx/gluteal cleft, that measured about 2 x 0.8 x 0.3 cm, base adipose tissue mixed with slough (dead tissue), periwound (skin surrounding the wound) with no erythema (redness), scant serous non-door [sic.] exudate. The WCN asked the resident when the wound developed? The resident stated that it had started a few weeks before the catheter was inserted. The WCN documented that the catheter was documented in January due to bilateral hydronephrosis (excess fluid in the kidney due to backup of urine).
The surveyor reviewed Resident #73's paper medical record which contained a typed letter written by the resident's attending physician, dated 04/15/2022, which revealed the following: In 2007 the resident had gastric bypass and has since lost approximately 130 pounds (lbs.) Resident continued to lose weight on his/her own. The resident has had complications in relation to excess skin, and has been treated for skin infections under abdominal skin folds, the anterior medial aspects of upper legs, and most recently developed an ulcer in the gluteal cleft in relation to his/her excess skin causing friction and retention of moisture. (He/she was hospitalized from [DATE] until 04/06/22 for sepsis in relation to cellulitis in the upper legs). During that time, the gluteal cleft ulcer worsened, and continued to need regular daily treatment to promote wound healing. The physician requested consideration for removal of excess skin that was now medically necessary to promote wound healing, future skin infections and to provide a better quality of life.
Further review of the paper medical record revealed a Consultation Report Form dated 04/27/2022, in which the Plastic Surgery Group documented that Resident #73 was seen and examined and the chart was reviewed. The Impression was: Stage IV sacral pressure ulcer with chronic granulation tissue (healing surface of wound), mild slough, some periwound maceration (skin surrounding wound was surrounded by moisture), no pus, no cellulitis (inflammation of subcutaneous connective tissue), redundant skin and subcutaneous tissue of the buttocks and lower extremities noted (s/p weight loss). Plan: Patient is not a good medical/surgical candidate for extensive skin/fat removal over buttock and flap advancements with anticipated high risk of complication including wound breakdown. Also, it was unclear if removal of excess skin/fat would expedite healing of chronic sacral ulcer. Recommend continued local care to sacral pressure ulcer and consider periwound protection of skin with barrier cream, as per wound care team.
On 07/26/2022 at 11:07 AM, the surveyor interviewed the LPN/UM who stated that on 03/22/22 during the night shift, Resident #73 who was oriented, requested that the Licensed LPN #1 look at a wound on his/her gluteal cleft. LPN #1 discovered an opened wound on the resident's gluteal cleft and failed to document the finding as required. The LPN/UM stated that LPN #1 had informed her about the wound in the morning before he signed off duty, and he requested that she contact the WCN. The LPN/UM stated that to her knowledge the wound was a new opening. The LPN/UM stated that when she looked at the wound herself, it was opened. The LPN/UM stated that a review of a Skin assessment dated [DATE], revealed that a left intercleft wound was previously identified. The LPN/UM stated that Registered Nurse (RN #1) documented that the resident had a left intergluteal cleft wound and should have known the process for wound care documentation and reporting. She further stated that RN #1 should have alerted the LPN/UM at that time, as well as the doctor, WCN and supervisor. The LPN/UM stated if RN #1 had followed the policy and procedure for notification, it would have initiated a Care Link (a computerized incident report) and also a Skin Integrity Packet could have been initiated. LPN/UM acknowledged that as a result of RN #1's failure to follow the facility policy and procedures, there was a delay in reporting the resident's wound, and also in obtaining and implementing a treatment order for the wound as was required.
On 07/26/22 at 1:37 PM, the surveyor interviewed the Registered Nurse/Educator (RN/E) regarding what the process would entail when a new wound was discovered. The RN/E stated that when a nurse identified a new wound they were expected to inspect the area, and then initiate a treatment based on what they observed, then they should call the doctor and validate that the treatment option was appropriate for the resident, write a PN, initiate a Care Link, and complete a Skin Packet. She stated that the facility utilized both paper and computerized incident reports which doubled the work. She then stated that the WCN also would receive a message to evaluate the, and that by that time, a treatment should have already have been initiated. The doctor and family notification and skin note were part of the Care Link. The RN/E stated that the CNA's (Certified Nursing Assistant) were also required to write a statement and document what they observed in their own words. She stated that skin assessments were completed on shower days and required a 72 hour look back to see if they could have prevented any skin injuries. The RN/E stated any finding discovered on the night shifts should have been passed onto the day shift in report which would ensure that it would be followed through. It should also have been discussed in the morning huddle (a daily clinical meeting) to ensure the supervisor could make rounds as needed and follow-up. She stated, skin issues were not just a little blurb.
The RN/E further stated that if RN #1 had identified a skin issue on 02/17/22, she should have passed it on in the report, and also have documented the finding in the PN. She stated that the WCN evaluated the resident on 02/17/22 at 9:46 AM, and documented the specifics related to an upper thigh wound. The RN/E stated that the CNA who first observed the wound should have written a statement, which should have been included in the 72 hour look back. The RN/E stated that the CNAs should have lifted that skin on the resident's intergluteal cleft to clean it at the very least. The RN/E further stated that Resident #73 was a good historian, and he/she could remember what they ate last week. The RN/E stated that when interviewed, the resident had recalled that the wound had been in place on his/her bottom prior to the urinary catheter insertion which was inserted in January 2022. The RN/E stated that the wound may have developed in December 2021. The RN/E reviewed the EHR in the presence of the surveyor and stated the following: On 12/13/2021 the resident's skin was intact. On 12/30/2021, an opening was identified at the left intergluteal cleft by RN #1. The RN/E stated that further review of the EHR revealed that there were no wound related documented interventions in response to the newly discovered wound, and nothing was documented by the WCN regarding the finding. The RN/E further stated, if the resident's wound was not addressed from 12/30/2021 through 03/22/2022, that was a very long time.
On 07/26/22 at 2:26 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who provided the surveyor with a typed, Investigation Summary and Conclusion dated 03/22/22 which indicated that the Event Date was 12/22/2021. The surveyor asked the LNHA for clarification about the delay in the investigation from the time of discovery of the wound and he stated he was not familiar with the investigation as it was completed under the previous LNHA. The RN/E was present and presented the surveyor with Resident #73's Clinical Assessment form which had a hand written date on it of 12/30/2021, and contained the following entry: Gluteal Abrasion was documented on the form.
Review of Resident #73's Investigation Summary and Conclusion revealed that on 03/22/22, the LPN/UM documented the following: Situation: Skin Integrity: On 12/30/2021, RN #1 did a Care Link for a skin integrity opening found to the left intergluteal cleft. The Braden Score was 19, low risk .The 3-11 CNA was interviewed and the resident had something small on his/her butt back in December. The CNA reported it to the nurse and the nurse initiated a Care Link. After that, the CNA stated that she reported it to multiple nurses over the next couple of months and even told the nurses that it was getting worse. She applied peri guard (used to treat skin irritation associated with incontinence) to the area as ordered and encouraged the resident to remind the nurse to look at it when they administered medications to the resident. The following time line was included in the investigation: On 01/03/2021 a skin assessment was done and showed that the resident had a gluteal abrasion, 01/13/2022 skin assessment showed a small opening to the intergluteal cleft, 01/21/2022 urinary catheter was inserted. Prior to the urinary catheter insertion, the resident was a heavy wetter with some bowel incontinence episodes. On 02/16/2022, a skin assessment showed a left inner thigh wound, and left inner cleft wound. On 02/17/2022, RN #1 noted an opened lesion to the right inner thigh which was addressed with treatment recommended by the WCN and MD (medical doctor) and the wound healed after a few weeks. On 03/14/2022, a skin assessment was rendered and it showed redness to the area, On 03/22/2022, LPN #1 asked the LPN/UM to have the WCN look at the resident's butt. The WCN called the LPN/UM into the resident's room and she observed a full thickness wound to the coccyx/gluteal cleft and the supervisor was made aware.
Further review of the Investigation Summary and Conclusion revealed the following Conclusion/Recommendations: Resident was seen by WCN for full-thickness tissue loss to coccyx (tail bone)/gluteal cleft and observed about 2 x 0.8 x 0.3 cm, base adipose (fat) tissue mixed with slough, periwound, no erythema, scant serous (thin, watery drainage) non-door [sic.] exudate (fluid that leaked out of blood vessels into nearby tissues). Santyl (helps remove dead skin and aid in wound healing) applied and covered with a 4 x 4 gentle dressing and will continue daily and as needed per MD. On 03/31/22, resident was seen by Wound Team which included Wound Care Consultant Nurse Practitioner (WCC/NP), who saw the resident and an atypical wound (no wound staging was identified) to gluteal cleft that measured 2 x 2 x 1 cm, was noted. Treatment continued. Specialty mattress updated to low air loss mattress to promote wound healing. Reinforced the importance on side lying while in bed and to keep the region clean and dry to avoid moisture trap under loose/saggy skin flaps. Care Plan discussed with the resident and nursing staff.
Further review of the Investigation Summary and Conclusion revealed that on 04/01/2022, Resident #73 complained of not feeling well and the vital signs were: blood pressure: 80/58, heart rate 102, respirations 16, temperature 100.5, SPO2 (measures level of circulating level of oxygen circulating in the blood with the use of a probe placed on the fingers) on room air was 96%. The resident was sent to the emergency room and was admitted with a UTI (urinary tract infection), fever, abdominal pain and right thigh cellulitis and returned to the facility on [DATE]. The Wound Team and WCC/NP followed up on 04/07/2022, and documented an atypical wound to coccyx/gluteal cleft and noted that it had worsened s/p recent hospitalization after the resident spent three days in the Intensive Care Unit and the wound evolved into a Stage 4 Pressure Ulcer. On the day of discharge the resident had a bedside wound debridement (the removal of damaged tissue from a wound to promote wound healing). Today on assessment the wound measured 2.5 x 2 x 2 cm, slough mixed with granular tissue and bone exposed which increased the risk for osteomyelitis (bone infection) . Moderate serous exudate, no erythema to periwound, pain present .Area will be difficult to heal due to excess skin from weight loss that covered the ulcer. The resident should be seen by a plastic surgeon or general surgeon to have the skin removed to promote healing. Ongoing weekly WCC/NP follow-up to continue.
On 07/26/22 at 12:58 PM, the surveyor conducted a telephone interview with LPN #1 who confirmed that he terminated his employment with the facility on 05/27/22. He stated that he recalled that,Resident #73 had a sacral wound that was a little lower than the sacrum at the top of his/her butt crack that was tucked away beneath excess skin. He stated that one of the 3:00 PM to 11:00 PM CNAs brought it to his attention, although he did not recall her name. He stated that he inspected the wound himself, wrote a report, and brought it to the attention of the LPN/UM. He stated that the report that he wrote was paper based and was filed with management. He stated that the resident complained of pain at the sight of the wound. He stated that the WCN was required to complete the wound assessment and update the residents CPAR. LPN #1 stated that he was required to document the finding in the Progress Notes (PN) which included documentation of a skin abnormality, who had been notified of the finding, and any actions that were taken. He stated that both the physician and the LPN/UM were required to be notified. The surveyor informed LPN #1 that review of the Shift Assessment that he completed on 03/22/22 at 2:30 AM, on the date that he reported the finding to the LPN/UM, revealed that he documented that the resident's skin/wounds were as follows: color appropriate to ethnicity, warm and dry and failed to document the wound or required interventions as he previously described. He stated that the Shift Assessment was documented prior to the CNA bringing the wound to his attention. The LPN#1 stated that he did not recall seeing the wound prior to 03/22/2022, and that was when he reported it.
On 07/27/2022 at 10:00 AM, the surveyor conducted a phone interview with CNA #1 in the presence of the survey team. She stated that on the 3:00 PM to 11:00 PM shift she was responsible to shower the residents and to report any skin abnormalities to the nurse. CNA #1 stated that Resident #73 was assigned to her in December 2021. She stated that the resident developed a little hole on his/her sacrum and she reported it for the first time to LPN #1 because he was the resident's assigned nurse at that time. CNA #1 stated that she asked LPN #1 for permission to apply barrier cream to the area on the resident's sacrum. CNA #1 stated that she reported the finding to him, and what he did with the information was not part of her job. CNA #1 stated that she had written a statement and provided it to the LPN/UM (statement dated 03/22/2022). CNA #1 stated that LPN #1 was the first nurse that she had reported it to, and that she had also worked with RN #1 and also had reported the skin abnormality to her. CNA #1 explained that she had to lift the resident's skin in order to see the area because the resident lost a lot of weight and the resident's skin flopped on the butt. CNA #1 further explained that in order to see the wound, you must lift the resident's skin up, and then look at the area under the skin when care was provided.
On 07/27/2022 at 11:15 AM, the surveyor conducted a phone interview with Resident #73's attending physician, who stated that about six months ago, the facility alerted him that the resident had a Stage I or Stage II pressure ulcer. He stated we did our best with body repositioning, but the resident had lost a lot of weight and also had neuropathy (disease that affects peripheral nerves causing numbness or weakness). He stated that he doubted that the resident's wound would heal. He stated that he last saw the wound, about four months ago, it had looked the same. The physician described the wound as an irritated area with a little bit of contamination, and had both discharge and secretions coming from the wound. He further stated that he reviewed the WCC/NP's notes, and the LPN/UM always had called him about the wound.
On 07/27/2022 at 12:10 PM, the surveyor interviewed the WCC/NP via telephone. She stated that her colleague who was assigned to Resident #73 completed an initial consult with the resident on 03/24/2022, and the wound was deemed to be atypical with full thickness skin loss. She stated that the assigned NP last saw the resident on 06/23/2022, and was currently out on leave. The WCC/NP stated that she had not seen the resident in her colleague's absence since that time because the resident had orders from the surgeon, and she had wanted to avoid having two providers looking at the wound. She stated based on the notes written by the previous WCC/NP, the following wound treatment was recommended: Cleanse with normal saline solution, pat dry, lightly pack with silver alginate (treatment for at risk or infected wounds) and cover with foam dressing twice daily due to moderate drainage. She stated the wound was staged as a Stage 4 Pressure Ulcer because there was bone exposed. She stated the wound was in a difficult area, and was not necessarily a pressure injury, there was moderate loose skin and trauma related to rubbing from excess skin to the mid-gluteal cleft. The WCC/NP stated that the facility WCN also would monitor the wound but she has been on vacation.
On 07/27/2022 at 12:32 PM, the surveyor interviewed Resident #73 who stated that CNA #1 first identified that she had observed a little skin tear on the resident's bottom. The resident was unable to provide the date CNA #1 observed the skin tear. The resident stated that CNA #1 kept checking it and had reported it to the nurse. The resident stated that CNA #1 and CNA #2 put cream on it and informed the assigned nurse. The resident stated that the tear had gotten bigger, and bigger and there was blood and oozy stuff when he/she wiped that area. The resident stated that by that time, it got very big and really infected and went into my leg. The resident stated that his/her blood pressure went very low ,and the vitals were off, so I was sent out to the hospital that night with a diagnosis of sepsis. Resident #73 stated, that while at the hospital, I was in the ICU and was on a strong antibiotic. The infection came around to the front of my leg from the tail bone. The resident continued, and stated the WCC/NP who was out on leave came in to see him/her a couple of weeks ago, and the facility WCN was currently on vacation. The resident was concerned that no one had looked at the wound recently except for the facility nurses. The resident further stated that the plastic surgery had been postponed as the doctor had not granted medical clearance for the resident to have the procedure.
On 07/27/2022 at 1:01 PM, the surveyor interviewed the LPN/UM who reviewed the EHR in the presence of the surveyor and confirmed that Resident was #73 last seen by the WCC/NP on 07/07/2022, twenty days prior, and the WCN was also present during wound rounds on that date. The surveyor asked for clarification of the date that the resident's left intergluteal cleft wound was initially identified. The LPN/UM stated that on 03/22/2022, the DON and she typed up a statement and there was also an incident report completed related to Resident #73's sacral wound. The LPN/UM stated that the resident's primary nurse, RN #1, documented a skin abnormality on 12/30/2021, and was supposed to initiate an incident report. She stated that to her knowledge, there was no wound treatments rendered to the resident's wound between 12/30/21 and 03/22/2022. She stated that the DON was notified. She stated that both she and the facility WCN looked at the wound together, and when I saw it, I was like wow! The LPN/UM stated that when we lifted and inspected the skin, I could see that it was opened. She clarified that LPN #1 had just informed her that there was something there but I had not expected for the wound to have been opened. The LPN/UM stated that when RN #1 was interviewed during the investigation conducted on 03/22/2022, she stated that she informed the WCN via e-mail and notified her directly of the resident's wound in December 2021. The LPN/UM stated that she informed RN #1 that nursing was required to inform the Unit Manager, and she should have initiated a treatment, notified the WCN, completed a Care Link and notified the Supervisor. The LPN/UM further stated that RN #1 should have also notified the doctor, and was also required to write a PN as she was the initial nurse that had observed the wound.
On 07/27/2022 at 1:28 PM, the DON presented the surveyor with another investigation that pertained to Resident #73's wound. He stated that Z-Guard (skin protectant) and a pressure relief mattress were in place for the Resident #73 prior to December 2021. He stated on 12/30/2021, it was documented that there was some opening on the resident's left intergluteal cleft in the PN. He stated that per skin assessments, a skin issue on the gluteal cleft was documented off and on. On 02/17/2022, the WCN was asked to see the resident related to a wound found on the groin area, and she did not document that she had assessed the resident's sacrum at that time, though she had discontinued the Z-Guard (skin protectant) that was previously ordered, and had added Zinc (prevents diaper rash) instead. He stated that LPN #1 verbally reported a concern on the resident's skin to the LPN/UM on 03/22/2022 and the WCN was notified. He stated that the LPN #1 documented that he could not tell if the wound was opened or the severity of the wound. The DON stated that CNA#1 documented that she notified both LPN #1 and RN #1 in December 2021. The DON stated that CNA #1 documented, I have been reported it as part of my job. He stated that RN #1 should have documented changes in the resident's skin, and a Skin Packet (form of an incident report) should have been completed so that we could have investigated the matter further. He stated that RN #1 [TRUNCATED]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interviews, record review, and other pertinent facility documentation it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (...
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Based on interviews, record review, and other pertinent facility documentation it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) for 1 of 1 residents reviewed (Resident #101) for reportable incidents. This deficient practice was evidenced by the following:
According to the admission Record, Resident #101 was admitted with diagnoses which included, but were not limited to, Dementia and anxiety.
Review of the Minimum Data Set (MDS), an assessment tool, dated 6/14/2022, Resident #101 had a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated that Resident #101 had severely impaired cognition. The MDS documentation also indicated that Resident #101 required extensive staff assistance for Activities of Daily Living (ADLS).
Review of Resident #101's Care Plan (CP) revealed a Focus: Anticoagulant therapy, risk for injury bleeding, and/or bruising due to use of anticoagulant secondary to anticoagulant use. Effective 3/24/2021, Interventions: Assess for signs of abnormal bleeding (bruising, bleeding gums, tarry stools, petechiae), effective 4/1/2022. Skin assessments as per protocol. Report bruising and skin discolorations, effective 4/1/2022. Focus: skin integrity: bruising effective 4/14/2022. Focus: climbing .attempts to get out of wheel and Geri (recliner) chair by throwing legs over the Geri chair when in it. Also, when sitting in the wheelchair, wraps legs around the leg rest of the chair., effective 4/18/2022.
Review of a Skin Integrity Incident report dated 4/14/2022, revealed Description: while doing AM care on Resident #101 the aide and I found a large bruise on his/her right knee and thigh. Review of the Event Analysis completed by the Assistant Director of Nursing (ADON) dated 4/18/2022, revealed Investigation: .it was reported by the CNA who took care of the resident on 4/13/2022 that she did not see any bruising on the resident's inner thigh and the resident was in the Geri chair with legs over the chair constantly trying to climb out of it .constantly being reminded and encouraged to put his/her legs back on the chair Due to advanced dementia and wanting to get up and go, he/she is constantly being reminded and encouraged to put legs back on the chair.
Review of the Nursing Progress note dated 4/14/2022 at 08:58 AM revealed: At 1:15am I assisted the Aide to help change Resident #101 in bed. While changing the resident we noticed a huge bruise on his/her right knee and thigh. Supervisor notified.
On 07/22/22 at 11:33 AM, the surveyor interviewed the ADON in the presence of the Director of Nursing (DON). The ADON stated that the process for an injury of unknown origin would include taking statements from all staff who had provided care of a resident during the last 72 hours to determine a timeline as to when the incident occurred and to identify a cause. She further stated it would be reported to the nurse, the supervisor would be notified, an incident report would be completed, an investigation would be started immediately, and it would be reported to the NJDOH within 24 hours. The ADON stated It was reportable if we don't know what happen.
During an interview with the survey team on 07/22/22 at 12:26 PM, the Social Worker (SW), stated that that an injury of unknown origin would be reported to the supervisor. The supervisor would contact the abuse officers: herself, the DON and the Administrator. The abuse officers would discuss the incident, make sure the investigation was completed and would report the incident to NJDOH within 24 hours. The SW reviewed the incident report for Resident #101, she stated she did not know anything about the incident. I would think that I would have been made aware, I should have been consulted. I would think as an abuse officer I should be involved. The SW then stated that all injuries of unknown origin should be reported to the NJDOH and then a determination would be made after the investigation was completed.
During an interview with the surveyor on 7/27/22 at 11:03 AM, the Administrator stated that an injury of unknow origin would be reported to the supervisor and an incident report would be completed. A new bruise required a lookback of 72 hours of all staff members for a potential explanation, interview the resident, the roommate, and all staff that cared for the resident for the last 72 hours. He stated it would be initially treated as abuse until abuse could be ruled out. The Administrator was given the skin incident report packet by the surveyor to review. The Administrator was not at the facility at the time of the incident. After reviewing the skin incident report packet, he stated it seems like there were not statements from staff 72 hours prior to the incident to corroborate the statement of climbing out of the chair.
During an interview with the surveyor on 07/27/22 at 10:22 AM, the Registered Nurse Educator (RDE) stated that there would be a 72 hour look back for a newly identified bruise, the nurse would do a skin packet, an incident report would be done, the supervisor would be notified immediately, and an investigation which included statements from all staff taking care of the resident for 72 hours prior to the discovery of the bruise to try to determine the cause. She further stated that the reason you would go back 72 hours was because sometimes bruises do not always show up immediately and to make sure there isn't a pattern. The RDE stated it would be reported to the NJDOH if the resident could not tell you how it happened.
A review of the facility's policy, Abuse Prevention effective 07/2022 revealed Procedure: 4. All staff will be given information on how to identify and report incidents of abuse, or suspected abuse. A. Staff will be trained on how to identify events, such as suspicious bruising, adverse occurrences involving un-witnessd falls and injuries of unknow origins. Certain patterns and trends may be suspicious of abuse, such as: similar or repeat occurrences on the same shift, involving multiple resident/patients in the same assignment block and occurring after certain family members, friends or other resident/patient visits. 7. Reporting and Response, The following is to be conducted immediately: c. [redacted] must report mistreatment, neglect, abuse, injuries of unknown source .to the State Survey & Certification (S&C) agency. [redacted] must also report the results of their investigation of these violations to the state S&C agency; f. The Administrator and/or designee, HMQC representative and/or Risk Management will conduct an event review all occurrences to determine root causes and what changes are needs, if any, to policies and procedures to prevent further occurrences.
NJAC 8:39-9.4(f)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interviews, record review and pertinent facility documents, it was determined that the facility failed to thoroughly investigate an Injury of Unknown origin for 1 of 2 residents (Resident #10...
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Based on interviews, record review and pertinent facility documents, it was determined that the facility failed to thoroughly investigate an Injury of Unknown origin for 1 of 2 residents (Resident #101) reviewed for injury of unknown origin. This deficient practice was evidenced by the following:
According to the admission Record, Resident #101 was admitted to the facility with diagnoses including but not limited to: Dementia and anxiety.
Review of the Minimum Data Set (MDS), an assessment tool dated 06/14/2022, Resident #101 had a Brief Interview for Mental Status (BIMS) score of 2/15, indicating that Resident #101 had severely impaired cognition. The MDS documentation also indicated that Resident #101 required extensive staff assistance for Activities of Daily Living (ADLS).
Review of Resident #101's Care Plan (CP) revealed Focus: Anticoagulant therapy, risk for injury bleeding, and/or bruising due to use of anticoagulant secondary to anticoagulant use. Effective 3/24/2021, Interventions: Assess for signs of abnormal bleeding (bruising, bleeding gums, tarry stools, petechiae), effective 04/1/2022. Skin assessments as per protocol. Report bruising and skin discolorations, effective 04/1/2022. Focus: skin integrity: bruising effective 04/14/2022. Focus: climbing .attempts to get out of wheel and Geri chair (specialized recliners ) by throwing legs over the Geri chair when in it. Also, when sitting in the wheelchair, wraps legs around the leg rest of the chair., effective 04/18/2022.
Review of the Skin Integrity Incident report dated 04/14/2022, revealed Description: while doing AM care on Resident #101 the aide and I found a large bruise on his/her right knee and thigh.
Review of Employee statements revealed the following:
Licensed Practical Nurse (LPN) #1 that took care of the resident on 04/14/22 while doing am care on resident, a huge bruise was found on knee and inner thigh. Certified Nursing Assistant (CNA) #1 that took care of the resident the evening of 04/13/2022 and the morning of 04/14/2022, Resident was put to bed by nurse and CNA at 1:15 am. When I came back from the break room the nurse informed me that the resident have a bruise on right inner thigh. There was nothing there on 04/12/22. CNA# 2 that took care of the resident on the day shift of 04/13/22, While rendering care on the resident I did not notice any bruising.
Review of the Event Analysis completed by the Assistant Director of Nursing (ADON) dated 04/18/2022, revealed Investigation: .it was reported by the CNA who took care of the resident on 4/13/2022 that she did not see any bruising on the resident's inner thigh and the resident was in the Geri chair with legs over the chair constantly trying to climb out of it .constantly being reminded and encouraged to put his/her legs back on the chair Due to advanced dementia and wanting to get up and go, he/she is constantly being reminded and encouraged to put legs back on the chair.
Review of the Nursing Progress note dated 04/14/2022 at 08:58 AM revealed: At 01:15 am I assisted the Aide to help change Resident #101 in bed. While changing the resident we noticed a huge bruise on his/her right knee and thigh. Supervisor notified. Further review of the nursing progress notes for the month April, 2022, did not reveal any notes of the resident's behavior of legs over the chair and/or trying to climb out of it.
During an interview with the surveyor in the presence of the Director of Nursing (DON) on 07/22/22 at 11:33 AM, the ADON stated that the process for an injury of unknown origin would be to take statements from all staff taking care of a resident for the last 72 hours to determine a timeline as to when the incident occurred and identify a cause. She further stated it would be reported to the nurse, the supervisor would be notified, an incident report would be done, an investigation would be started immediately, and it would be reported to the state within 24 hours. When asked why there were only three (3) staff member statements, the ADON stated she was able to determine when the bruising occurred from what the daytime CNA stated about the resident constantly trying to climb out of the chair, it was determined it was inflicted by the chair.
During an interview with the survey team on 07/22/22 at 12:26 PM, the Social Worker (SW) stated that the process for an injury of unknown origin would be reported to the supervisor. The supervisor would contact the abuse officers: herself, the DON and the Administrator. The abuse officers would discuss the incident, make sure the investigation was completed and would report the incident to the New Jersey Department of Health (NJDOH) within 24 hours. She further stated that statements should be taken from the patient, if they were alert, and if they were not alert, you would speak with the family, take staff statements, anybody that had been around the resident for the last 72 hours, including the roommate and other residents to determine if anyone may have witnessed it. The SW reviewed the incident report for Resident #101, she stated she did not know anything about the incident. I would think that I would have been made aware, I should have been consulted. I would think as an abuse officer I should be involved. The SW then stated that all injuries of unknown origin should be reported to the NJDOH and then a determination would be made after the investigation was completed.
During an interview with the surveyor on 07/27/22 at 10:03 AM, CNA#3 stated that the process if you identify a new bruise was to inform the nurse and the supervisor right away and a statement would be written about when and how you discovered the bruise.
During an interview with the surveyor on 07/27/22 at 10:25 AM, LPN #2 stated that the process if you identify a new bruise was to assess it, a skin incident report package would be started, the manager would go back three days and gets statements to see if anyone knew how the incident happened. She stated that the bruise would be entered into the computer reporting system and an event # would be generated that would be written on the skin incident report. LPN#2 stated that a skin assessment would be done to document were the bruise was located. She further stated that if residents exhibit any kind of behaviors, a new or a current behavior, a behavior progress note should be done.
During an interview with the surveyor on 07/27/22 at 10:40 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that the process if a new bruise was discovered was the nurse would be notified, an incident report was begun, statements would be taken from everybody who was there, primarily the CNA and the nurse caring for the resident. She stated that incident reports were discussed in the morning huddle meetings to discuss interventions to add to the care plan to keep it from happening again. She stated if abuse was suspected, the care giver would be removed immediately, and an investigation would be completed.
During an interview with the surveyor on 07/27/22 at 11:03 AM, the Administrator stated that an injury of unknown origin would be reported to supervisor and an incident report completed. A new bruise required a lookback of 72 hours of all staff members for a potential explanation, interview the resident, the roommate, and all staff that cared for the resident for the last 72 hours. He stated it would be initially treated as abuse until abuse could be ruled out. The Administrator was given the skin incident report packet by the surveyor to review. The Administrator was not at the facility at the time of the incident. After reviewing the skin incident report packet, he stated it seems like there are not statements from staff 72 hours prior to the incident to corroborate the statement of climbing out of the chair.
During an interview with the surveyor on 07/27/22 at 11:18 AM, the DON stated, we gave you everything we have for the investigation. He further stated that the ADON completed the investigation because she knew the resident well and at the time of incident she was working on the unit. The DON was unable to answer why the ADON did not do a statement for the investigation. He stated the purpose of doing a 72 hour look back was to identify a causative factor, timeframe, and identify people that knew what happened.
During an interview with the surveyor on 07/27/22 at 10:22 AM, the Registered Nurse Educator (RNE) stated that there would be a 72 hour look back for a newly identified bruise, the nurse would do a skin packet, an incident report would be done, the supervisor would be notified immediately, and an investigation which included statements from all staff taking care of the resident for 72 hours prior to the discovery of the bruise to try to determine the cause. She further stated that the reason you would go back 72 hours was because sometimes bruises do not always show up immediately and to make sure there wasn't a pattern. The RDE stated it would be reported to the NJDOH if the resident could not tell you how it happened.
During the pre-exit meeting with the survey team on 08/03/22 10:01 AM, the administrator stated that the investigation is what it is, the statements were not done.
A review of the facility's policy, Abuse Prevention effective 07/2022 revealed Procedure: 4. All staff will be given information on how to identify and report incidents of abuse, or suspected abuse. A. Staff will be trained on how to identify events, such as suspicious bruising, adverse occurrences involving un-witnessed falls and injuries of unknown origins. Certain patterns and trends may be suspicious of abuse, such as: similar or repeat occurrences on the same shift, involving multiple resident/patients in the same assignment block and occurring after certain family members, friends or other resident/patient visits. 7. Reporting and Response, The following is to be conducted immediately: c. [redacted] must report mistreatment, neglect, abuse, injuries of unknown source .to the State Survey & Certification (S&C) agency. [redacted] must also report the results of their investigation of these violations to the state S&C agency; f. The Administrator and/or designee, HMQC representative and/or Risk Management will conduct an event review all occurrences to determine root causes and what changes are needs, if any, to policies and procedures to prevent further occurrences.
NJAC 8:39 4.1 (a)
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
Based on observations, interviews, record reviews and review of pertinent facility documentation, it was determined that the facility failed to develop a resident-centered care plan with objectives an...
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Based on observations, interviews, record reviews and review of pertinent facility documentation, it was determined that the facility failed to develop a resident-centered care plan with objectives and time frames to meet the needs of a resident who had an 8.9 pound (lb) weight gain. This deficient practice was identified for 1 of 28 residents (Resident #114) reviewed for Care Plans (CP). This deficient practice was evidenced by the following:
During tour on 07/20/22, the surveyor observed Resident #114 lying in bed and was not responding to the surveyor. The surveyor observed a tube feeding pump with no feeding being infusing at that time.
A review of the medical records revealed that Resident #114 h,ad been recently admitted to the facility with diagnoses which included but were not limited to, persistent vegetative state, Diabetes (elevated blood sugar) due to underlying condition, and moderate protein-calorie malnutrition.
A review of the most recent Significant Change Minimum Data Set (MDS-an assessment tool) dated 06/28/22, revealed under Section G that Resident #114 was totally dependent on staff for Activities of Daily Living. Section K revealed that the resident weighed 170 lbs, required a feeding tube, and obtained 51% or more of calories and 501 cubic centimeters (cc) of fluid intake via the feeding tube.
A review of the Physician's Orders included the following: an order dated 06/17/22 to Infuse Glucerna 1.5, 1170 milliliter (ml) at 65 ml per hour via pump until a volume of of 1170 ml infused. An order dated 06/21/22 for hospice eval (evaluation) and treat. An order dated 07/01/22 to weigh the resident every month on 1st Wednesday.
A review of the facility provided, Clinical Monitoring Detail Report, dated 06/01/22 through 07/31/22, revealed a weight on 06/29/22 of 170.1 lbs, and on 07/07/22, one week later, a weight of 179 lbs. This calculated to an 8.9 lb weight gain.
The surveyor was unable to locate any nutrition admission assessment completed by the Registered Dietitian (RD), or any progress notes regarding the assessment of the 8.9 lb weight gain, or documentation that the physician or hospice agency had been notified of the weight gain.
The surveyor reviewed a hospice note dated 08/02/22. After the surveyor brought the concern to the facility, which revealed Resident #114 had a weight gain of + 8.4 lbs, hospice was going to contact the guardian and the facility RD stated that the resident's feeding would be changed.
On 08/03/22 at 10:10 AM, the facility provided an on-going and Active Care Plan. The CP included but was not limited to a focus area of Nutrition-End of Life-Hospice and that Resident #114 was at risk for unavoidable malnutrition related to end of life, effective 06/19/22. This focus area included that the hospice team and facility team will collaborate regarding nutrition support. The facility provided Care Plan had not been updated to reflect the 8.9 lb weight gain on 07/07/22, or the assessment from hospice on 08/02/22, which resulted in the change of the tube feeding. There were no measurable goals or interventions to address the unplanned significant weight gain reflected on the CP.
This concern was discussed with the facility on 08/02/22. On 08/03/22, the Director of Nursing (DON) stated that Resident #114's CP had not been updated to reflect the significant unplanned 8.9 lb weight gain. The DON acknowledged that if there was an identified weight change, the CP should be updated.
A review of the facility provided, Job Description Dietitian revised 08/31/21, included Job Functions: 2. Assure that nutrition assessments, reassessments and care plans are completed to meet each patient's identified needs.
A review of the facility provided, Job Description RN (Registered Nurse) revised May 2019, included but was not limited to Job Functions: 6. Identify and report all real or potential problems regarding the development or administration of patient care.
A review of the facility provided, Job Description Unit Manager RN not dated, included but was not limited to Job Functions: 4. Works with Interdisciplinary Team to ensure quality services are provided.
A review of the facility provided, Care Plan policy last approved 07/22, included but was not limited to Purpose: To develop a care plan for each resident that includes the interventions needed to provide effective and person-center care of the resident The Care Plan will be consistent with the resident rights that include measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified . Procedure: B. Comprehensive Care Plan: 2.c. reviewed and revised by Interdisciplinary team after each assessment, including both the comprehensive, significant change, quarterly, and annual review assessment.
NJAC 8:39-11.2 (i), 27.1(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
Based on observation, interview, and document review, it was determined that the facility failed to follow professional standards of practice by ensuring that staff did not utilize personal equipment,...
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Based on observation, interview, and document review, it was determined that the facility failed to follow professional standards of practice by ensuring that staff did not utilize personal equipment, a personal blood pressure (BP) monitor, for resident care. This deficient practice was identified for 1 of 2 Licensed Practical Nurses (LPN) observed during medication administration, and was evidenced by the following:
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
On 07/21/22 at 7:33 AM, the surveyor began the medication administration observation on the A unit.
At 8:23 AM, the LPN informed the surveyor that she was going to use her own personal wrist BP cuff because the BP machine was not working. The LPN stated she had reported the malfunctioning BP machine to the supervisor a few days ago. The LPN utilized her personal BP cuff and obtained a BP reading with the BP wrist cuff on an unsampled resident.
On 07/21/22 at 9:24 AM, the surveyor requested to speak to the supervisor on A Wing, and was informed the Unit Manager was not working today.
During an interview with the surveyor on 07/21/22 at 9:30 AM, the Registered Nurse Staff Educator (RN/SE) stated staff should use a vital sign tower to obtain a BP reading, and if that machine was not working, the facility had back-up manual arm and wrist cuff BP cuffs. The RN/SE showed the surveyor the extra manual arm BP cuffs on A wing. The RN/SE showed the surveyor the green Velcro wrist BP cuffs in the nursing office that were available. The RN/SE stated that the facility had back-up BP cuffs and the staff should not be using their own.
During an interview with the surveyor on 07/21/22 at 9:36 AM, the RN/SE and the surveyor went to A Wing. The RN SE informed the LPN that she should not be using her personal BP wrist cuff and stated that the LPN would be provided with a vitals tower that was available. The RN/SE stated the staff should not use their own personal equipment because of germs. She further stated the staff should use what the facility issued and had available.
On 07/21/22 at 9:39 AM, during an interview with the surveyor, the RN SE stated staff are informed not to use their own equipment. She stated the LPN was an agency nurse and would be instructed by her the RN/SE during orientation that the facility provides equipment. The RN/SE further stated there were plenty of vitals towers and BP cuff backups to use.
On 07/21/22 at 9:49 AM, during an interview with the surveyor, the Director of Nursing (DON) stated nurses have vital towers, and wrist BP cuffs to use. The DON stated the facility had other machine towers and manual BP cuffs for back-up. He further stated staff should not be using their personal BP cuffs.
During a follow up interview at 12:00 PM, the DON stated it was not a best practice for staff to use their own BP cuff because the BP cuff should be calibrated.
On 07/22/22 at 12:22 PM, during an interview with the surveyor, the Maintenance Director stated if any new equipment comes into the facility that the maintenance department would assemble and test it. He stated the maintenance department would go over the equipment to ensure that the assembly wires and hardware were tight like our safety inspection to ensure the equipment is working correctly.
On 08/02/22 at 12:42 PM, the surveyor informed the facility of the above concern.
On 08/03/22 at 10:03 AM, the Licensed Nursing Home Administrator (LNHA) stated the facility had a process for broken equipment and acknowledged that staff should not use their own personal equipment because the facility also had back up equipment.
NJAC 8:39-27.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and clinical record reviews, and review of pertinent facility documentation, it was determined...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and clinical record reviews, and review of pertinent facility documentation, it was determined that the facility failed to: a.) provide personal care for 1 of 27 residents reviewed for activities of daily living (ADLs), Resident # 18, and b.) provide a resident (Resident #85) 1 of 27, with the care needed to meet the resident assessed needs. This deficient practice was evidenced by the following:
a) On 07/19/22 at 11:47 AM, the surveyor toured the B Wing of the facility and observed Resident #18 lying in bed. The resident's right hand was partly closed and some jagged, fingernails were exposed with a dark embedded debris underneath. The fingers of the resident's left hand were observed curled into the palm of that hand. When the resident was asked if he/she could open their left hand, he/she opened both hands and the fingernails were observed to be long with a dark coated debris approximately ½ inch underneath the nails.
Another observation on 07/20/22 at 9:25 AM, revealed Resident #18 lying in bed. The fingernails were observed to be jagged with a black debris noted underneath the fingernails.
On 07/20/22 at 11:09 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for Resident #18. The CNA stated that Resident #18 was totally dependent upon staff for care. She stated that Resident #18 had a feeding tube and could not take anything by mouth. She also stated that Resident #18 was admitted with a wound and the CNA told the surveyor that Resident #18 had not been Out of Bed (OOB) because of the wound, and also the facility was short of staff.
On 07/20/22 at 11:45 AM, the surveyor returned to the resident's room and observed the CNA in the room. The CNA told the surveyor that she was going to perform AM [morning] care.
On 07/20/22 at 1:05 PM, the surveyor returned to the room and observed the resident in bed. The surveyor observed Resident #18's nails were not trimmed or cleaned and the black debris was still present underneath the fingernails.
On 07/21/22 at 10:04 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM ) #1 regarding Resident #18's care needs. LPN/UM #1 confirmed that Resident # 18 was dependent upon staff for all ADLs. When asked if Resident #18 could get OOB, LPN/UM #1 replied, They [referring to the staff] should ask the resident if he/she wants to get OOB. LPN/UM #1 could not comment on the CNA's statement that the resident had not been OOB because he/she had a wound to the sacral area and also the facility was short of staff. LPN/UM #1 added that Resident #18 had a wound vacuum [V.A.C. a device used to help wound healing by gently pull fluid from the wound overtime] in place prior and could not get OOB however, the wound V.A.C was discontinued on 05/27/22 and the resident should get OOB.
There was no documentation in the medical record regarding when Resident #18 was last transferred out of bed. There was no documentation of episodes of rejection of care. On 07/21/22 at 10:40 AM, when the surveyor visited Resident #18, he/she told the surveyor he/she would like to get OOB.
On 07/22/22 at 9:00 AM, the surveyor returned to the room and observed Resident #18 in bed. The resident's fingernails had not been trimmed or cleaned.
On 07/22/2022 at 9:30 AM, the surveyor with the assistance of LPN/UM #1, was able to further assess the condition of Resident #18's fingernails. The nails were observed by both to be long with some dark color substances present underneath the fingernails of both hands.
On 07/22/22 at 12:24 PM, the surveyor inquired about how the facility supervised resident care. LPN/UM #1 revealed that she made the CNA assignments and would usually do rounds. She further stated the primary nurses were to do walking rounds with the on-coming/out-going nurse. She added that dependent residents must be dressed, fed, kept dry, clean, shaven, and have nail care completed, and the staff must assess residents on a daily basis and address their needs.
On 07/22/22 at 12:30 PM, during an interview with LPN/UM #2 regarding the care delivery revealed that all were responsible to ensure that the care was being delivered as necessitated by the resident's condition. She stated that the ADL care entailed bathing, shaving, and nail care. She further added that the nurses were to check on residents during walking rounds with the on-coming shift and during their shift. When the surveyor showed LPN/UM #2 Resident #18's nails condition after care had been delivered for the last 4 days, she stated, That was unacceptable and I will in-service the staff.
On 07/22/22 at 11:59 AM, during an interview with the surveyor, another CNA assigned to the B Wing stated all CNAs documented the care provided on the computer in the hallway. The CNA accompanied the surveyor in the hallway, logged on the computer and showed the surveyor how the care area could be accessed. The surveyor noted that the same CNA provided care to Resident #18 for the last 4 days and omitted to provide nails care. The documentation entered in the computer did not include nail care. The documentation only revealed that Resident #18 received care, was totally dependent on staff. The exact care provided was unknown.
On 07/22/22 at 12:30 PM, the surveyor reviewed Resident #18's medical record. The admission Face Sheet revealed that Resident #18 was admitted to the facility with diagnoses which included but were not limited to Type 2 Diabetes Mellitus, cerebro-vascular disease, hemiplegia (paralysis of one side of the body), dysphagia (difficulty speaking) and pressure ulcer of the right buttock.
The Quarterly Minimum Data Set (MDS) an assessment tool dated 07/02/22, coded Resident #18 as scoring a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated that Resident #18 had cognitive impairment. Section G of the MDS which referred to Activities of Daily Living, indicated that Resident #18 was totally dependent upon staff for all activities of daily living. Section E008 which addressed rejection of care was coded with a zero value which indicated that Resident #18 did not reject/refuse care.
An entry in the electronic progress notes dated 06/30/22 timed 10:19 AM, revealed Occupational Therapy Screen (OT) documented the following: Resident remains dependent for all aspects of ADLs bedside. Resident remains NPO [ nothing by mouth ] with PEG tube, therefore feeding NA [not applicable]. Resident remains a [mechanical] lift for OOB [out of bed to] [recliner] chair. Resident may sit upright in [recliner] chair for maximum 2 hours with a cushion due to sacral wound.
A Quarterly entry from the Speech and Language Pathologist (SLP) dated 06/30/22 at 9:50 AM, indicated the following: BIMS: 3. Resident is alert with confusion. Dependent on staff for all assistance. Minimal verbalizations. Remains [NPO] nothing by mouth with tube feedings. No functional change in swallowing or communication status. No ST [speech therapy] warranted at this time.
Another entry in the Progress Notes dated 07/18/22, documented, that Resident #18 was awake and alert but unable to articulate needs verbally. He/she can make gestures by saying yes and no which is not always appropriate to questions.
The comprehensive care plan dated 02/23/22, documented Resident #18 had a focus for ADLs function-impaired with ADLs self-care impairment related to dehydration, sepsis, recent CVA [cerebrovascular accident] with impairments. Generalized weakness.
The goal:
Resident #18 will maintain current ADLs and self-care functional status.
Staff will meet all Resident #18's needs related to ADLs status.
Will remain clean, well groomed, and free of body odor.
The Certified Nursing Assistant electronic Task was reviewed. The documentation revealed that hygienic care was completed, there was no specific entry for nail care.
An interview was conducted 07/22/22 at 11:30 AM with CNA #1 who cared for Resident #18 over the last 4 days. CNA #1 acknowledged Resident #18 was dependent upon staff for care. CNA #1 stated that she provided care to Resident #18 this morning and she could not recall if the nails needed to be trimmed/cleaned.
On 07/26/22 at 10:42 AM, a second interview with the CNA who cared for Resident #18 mostly on a daily basis, confirmed that Resident #18 was totally dependent upon staff for care. When asked to elaborate on the care provided, she added that AM care entailed, washing, mouth care, dressed, changed brief, and communicate with the nurse if the sacral wound needed to be redressed. She informed the surveyor that she would transfer the resident to the Geri (recliner)-chair now. She was not aware that the resident could get OOB. She also added she would provide nail care as part of ADLs. The CNA informed the surveyor that she trimmed and cleaned Resident #18's nails on 07/25/22.
On 07/27/22 at 8:45 AM, the surveyor observed Resident #18 in bed eyes, his/her eyes were opened, feet were elevated, and the resident denied pain. The surveyor observed a splint on the resident's left hand, nails were trimmed and cleaned, and the resident was able to answer simple questions.
The above concerns were discussed with the Director of Nursing (DON) on 07/26/22.
On 07/27/22 at 11:33 AM, the DON provided a policy titled, Nursing and rehabilitation Quality of Life. The policy last revised 07/22, outlined the following: The facility will ensure that the care and services provided are person-centered, and honor and support each resident/patient's preferences, choices and beliefs. The facility will create an environment that humanizes and promotes each resident/patient's overall quality of life. Under Activity of Daily Living the following were noted: If necessary the facility will provide the following care and services: hygiene (including, but not limited to bathing, oral hygiene, nail care, hair care, dressing, grooming, etc.), mobility, elimination, dining, and communication for resident/ patients exhibiting need.
Team members will refer to the Activities of Daily Living Critical Element (CE) Pathway as well as the most recent comprehensive, person-centered care plan, the physician orders and ADLs documentation from previous shifts to determine if facility practices are in place to identify, evaluate, and intervene to maintain, improve or prevent an avoidable decline in ADLs.
The surveyor reviewed the Progress notes from the date the wound vac was discontinued on 05/27/22 to date and could not find documentation regarding Resident #18 being OOB.
The facility could not provide documentation to verify when nail care was last provided to Resident #18. There was no documentation that Resident #18 had been OOB since the wound V.A.C was discontinued on 05/27/22. The surveyor observed Resident #18 OOB in the recliner chair in the room on 07/22/22. At that time, the surveyor interviewed Resident #18, who stated to the surveyor he/she felt good and liked to be out of the bed.
b) A review of Resident #85's medical record revealed the resident was admitted to the facility with diagnoses which included, but were not limited to, Hypertension, diabetes mellitus, legal blindness, Chronic obstructive Pulmonary disease, and weakness.
The Quarterly MDS dated [DATE], revealed that Resident #85 was totally dependent upon staff for ADLs. Resident #85 was coded as required 2 person physical assist for bed mobility and toileting. Resident #85 scored 99 on the BIMS which was indicative of severely impaired cognition.
On 07/27/22 at 9:00 AM, the surveyor observed Resident #85 seated at a table in the dayroom adjacent to the nursing station. The surveyor entered the room and sat at the next table.
Resident #85 was sitting at the table moaning and kept saying bathroom. The surveyor looked at the clock from the nursing station and noted it was 9:40 AM. A staff member who later identified herself as the Unit Secretary (US) could heard the resident from the nursing station. She approached the resident calmly and inquired about why he/she was moaning. Resident #85 told her clearly, bathroom. The US left the dayroom and inform the LPN/UM #2 that Resident #85 requested to use the bathroom. The US returned and sat in the dayroom. Resident #85 kept moaning and repeating bathroom, bathroom it hurts.
On 07/27/22 at 10:15 AM, a staff member from the Activity Department entered the day room, provided 2 residents with a magazine and left the room. The television was on. The staff left the room and did not engage in any conversation with the Resident #85.
Resident #85 became louder and the surveyor asked the US if she informed someone that Resident #85 requested to use the bathroom. The US replied, yes I told the LPN/UM #2 that Resident #85 was moaning and requested to use the bathroom. The US stated that the LPN/UM #2 was looking for the CNA assigned to Resident #85. Resident #85 was assisted to the bathroom at 10:30 AM, after the LPN/UM #2 went to the break room and informed the CNA that Resident #85 needed to use the bathroom.
On 07/27/22 at 10:20 AM the surveyor interviewed the US regarding the protocol to assist any resident with toileting needs. The US stated, Only CNA or nurses could assist residents to the bathroom. The US added, she had reported to the LPN /UM #2 that Resident #85 requested to use the bathroom and that LPN/UM #2 stated she was going to find a CNA to take him/her. The US stated she had told the UM Resident #85 was moaning and she had to go the bathroom. The US stated she believed the CNA assigned to Resident #85 was caring for another resident.
.
On 07/27/22 at 10:26 AM the surveyor interviewed the LPN/UM #1 regarding the protocol to assist any resident in the bathroom. She indicated that any nurse or CNA could assist a resident to the bathroom. She added,I was not aware of the above resident request to go the bathroom. LPN/UM #1 stated the protocol would be to get up, identified the resident and see if you could assist the resident to the bathroom. She stated that should would assist a lot of residents and that she could assist any resident to the bathroom. She further added that a restorative aid could assist the resident to the bathroom also.
On 07/27/22 at 11:15 AM, the surveyor interviewed the CNA who cared for Resident #85. She revealed that Resident #85 was totally dependent on staff for care, was legally blind, did not speak English very well, and was aware of his/her continence needs. She added the resident could not toilet self. She added she transferred Resident #85 to the chair at 8:30 AM, was placed on the toilet and urinated but did not have a bowel movement. She added she was in the break room for her break and the LPN/UM came to the break room and informed her that Resident #85 needed to use the bathroom. She assisted Resident #85 to the bathroom at 10:30 AM after being informed by LPN/UM #2. Resident #85 had a bowel movement and was not soiled. The CNA stated usually if she was on break the other CNA working on the same side would assist residents to the bathroom. The CNA added that Resident #85 could stand and pivot when addressed in his/her native language. She further stated that she informed the US that she was going on break.
On 07/27/22 at 11:26 AM, the surveyor interviewed the LPN/UM #2. She confirmed that the US informed her that Resident #85 needed to go to the bathroom. She stated that she could not remember the exact time but it was before 10:00 AM. She added she went to find the nurse but could not locate the nurse. She thought the resident needed her aid because she Resident #85 stated bathroom now. LPN/UM #2 further stated she went to get the CNA assigned to Resident #85 and had walked in the hallway to locate the CNA assigned to Resident #85. She stated she walked in the hallway, looked in every room and could not locate her [CNA]. LPN/UM #2 stated she walked in the other hallway and could not find any CNA to assist Resident #85 to the bathroom. LPN/UM #2 stated she did not know Resident #85's mode of transfer. LPN/UM #2 stated she walked to the break room and observed the CNA standing in the break room talking to someone so she pulled the CNA aside and informed her that Resident #85 was screaming and needed to go to the bathroom. The CNA left the break room and went to assist Resident #85 to the bathroom. LPN/UM #2 stated she did not know the exact time the resident was assisted to the bathroom.
The surveyor then asked LPN/UM #2 about the facility protocol to meet any resident's needs. She stated, The protocol will be if you know the resident you can assist someone to the bathroom. She confirmed that she did not inform LPN/UM #1 that Resident #85 needed to use the bathroom. She added that there was no one around.
LPN/UM #2 further added that she could have looked up Resident #85's information on the computer and assist him/her to the bathroom. She further stated that she was not familiar about how to use a mechanical left and during her nursing training, she never used a mechanical lift. LPN/UM #2 stated she did not have any idea on how to use a mechanical lift and the facility training did not cover mechanical lifts.
On 08/01/22 at 9:16 AM, during a second interview with LPN/UM #1 regarding Resident #85 issues with being assisted in the bathroom in a timely manner, she confirmed that LPN/UM #2 could have look in the computer, verified the transfer method and assist Resident #85. LPN/UM #1 stated That was unacceptable.
On 08/02/22 at 10:30 AM, the surveyor aided by the CNA and LPN/UM #1, performed a skin assessment on Resident #85 and observed no excoriations/open areas noted on buttocks.
The above concerns was discussed with the facility on 08/02/22 at 2:15 PM.
On 08/03/22 at 9:36 AM, the facility administrative staff presented their findings. The Licensed Nursing Home Administrator stated, We [facility] were embarrassed. This is not how we [facility] care for our residents. I do not allowed that behavior to happen in my building. In-services education was provided.
NJAC 8:39-27.2 (h)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 07/20/22 at 8:58 AM, during the tour of the facility, the surveyor observed the tube feeding pump in the room of Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 07/20/22 at 8:58 AM, during the tour of the facility, the surveyor observed the tube feeding pump in the room of Resident #114. The surveyor observed no tube feeding was infusing at that time. The surveyor observed the resident lying in bed, eyes closed.
A review of the medical records revealed that Resident #114 had been recently admitted to the facility with diagnoses which included but were not limited to persistent vegetative state, Iron deficiency anemia, vitamin deficiency, Diabetes (elevated blood sugar) due to underlying condition with ketoacidosis without coma, and moderate protein-calorie malnutrition.
A review of the facility provided, Clinical Monitoring Detail Report, dated 06/01/22 through 07/31/22, revealed a weight on 06/29/22 of 170.1 lbs, and on 07/07/22, one week later, a weight of 179 lbs. Which indicated a significant unplanned weight gain of 8.9 lbs.
A review of the 07/01/22 Dietary Progress Notes by the RD for Resident #114, with significant change revealed: Nutrition Note for MDS Significant Change in Status:(Resident #114) was now receiving hospice services. She/he continues EN support as ordered: EN support remains at Glucerna 1.5, 1170 ml total volume and 1000 ml water flushes via g-tube. CBW (current body weight) 17 lbs and BMI (body mass index) 27.5. No significant wt [weight] change in 1 month, 6 month, and 1 year lookback period. Noted 10% significant wt loss in previous 3 months, please refer to previous dietary notes .Reviewed careplan, proceed with POC (plan of care). Monthly weights per hospice guidelines. RD will f/u (follow up) as needed.
The surveyor was unable to locate any nutrition admission assessment by the RD, any progress notes regarding any assessment of the 8.9 lb weight gain by the staff, or any documentation that the physician or hospice agency had been notified of the weight gain.
A review of the facility provided Hospice Notes from June 2022 through July 27, 2022, did not reveal any notation that Hospice had been made aware of the resident's 8.9 lbs weight gain.
A review of the most recent Significant Change Minimum Data Set (MDS -an assessment tool) dated 06/28/22, revealed under Section G that Resident #114 was totally dependent on staff for Activities of Daily Living. Section K revealed that the resident weighed 170 lbs, required a feeding tube, and obtained 51% or more of calories and 501 cubic centimeters (cc) of fluid intake via the feeding tube.
A review of the Physician's Orders included the following: an order dated 06/17/22 to Infuse Glucerna 1.5, 1170 milliliter (ml) at 65 ml per hour via pump. Up at 6pm and down at 12pm or until total volume 1170 ml infused. Document downtime and amount infused. An order dated 06/21/22 for hospice eval (evaluation) and treat. An order dated 07/01/22 to weigh the resident every month on 1st Wednesday.
A review of the facility provided Active Care Plan included but was not limited to a focus area of Nutrition-End of Life-Hospice (Resident #114) was at risk for unavoidable malnutrition related to end of life, effective 06/19/22. This focus area included that the hospice team and facility team will collaborate regarding nutrition support.
On 07/22/22 at 10:14 AM, during an interview with the surveyor, the CNA stated Resident #114 required total care, and that she does not touch or do anything with the tube feeding or the pump.
On 07/22/22 at 11:08 AM, during an interview with the surveyor, the Registered Nurse (RN) caring for Resident #114, stated hospice comes to see the resident, if there are any changes in the resident status, we (facility) inform hospice and if we need to see what hospice did, we check the book (hospice book). The RN stated they keep in close communication with hospice. The RN further stated there had been no issues with the resident's tube feedings.
On 08/02/22 at 8:33 AM, during an interview with the surveyor, the UM/RN/ADON stated that resident weights were done on admission, two days consecutively after, and weekly. If there was a two pounds or above weight loss or gain, the staff would need to reweigh the resident. She further stated she was responsible to be to be sure the reweighs were done. The UM/RN/ADON stated hospice follows weights and they are here (at the facility) daily. She stated the facility needs to let hospice know but hospice can also look in the computer as well. The ADON UM and the surveyor reviewed the hospice book. The UM/RN/ADON acknowledged there was no documentation about the 07/7/22 weight gain of 8.9 lbs. She stated the dietician also looks daily at the weights and would address it (the 8.9 lb weight gain). The surveyor asked to be shown documentation in computer that the facility staff informed hospice or RD about the weight gain. The UM/RN/ADON was unable to find any documentation.
On 08/02/22 at 8:47 AM, the RD stated the process was that weights would be done on admission and orders for two days and weekly. She stated that missing weights or fluctuations of five pounds would be reported to her and she would request a reweigh. The RD stated that hospice residents have an order for monthly weights. The RD stated Resident #114 was on hospice and that the nurses should let the hospice staff know and that the staff did not report the weight gain to her. She further stated the weight would have to be reported to her because she doesn't just check .
On 08/02/22 at 9:33 AM, the DON stated a weight discrepancy of 5 lbs either way (loss or gain), would be reported. He stated that any staff could obtain weights. The DON stated that the nurses should report changes to the RD and that was done verbally. The DON stated hospice would be made aware of weight changes by the nurse and that it was important to keep hospice in loop because they ensure what's being done for a proper end of life experience.
The above concerns were shared with the facility on 08/02/22. On 08/03/22, the surveyor was provided a communication form that the hospice agency was informed of the weight gain on 08/03/22 after the surveyor brought it to their attention. The facility informed the surveyor that Resident #114 should have had a nutrition assessment completed upon admission to the facility, but was unable to provide one.
A review of the facility provided, Weight Loss or Gain, Significant Unplanned, revised 03/2010, included Purpose: residents will not experience an unplanned or unexplained weight loss or gain; Policy: all resident's weights will be obtained initially upon admission and then weekly for the first 30 days unless needed more frequently; Procedure: 1. review all residents' weights and compare to previous and current recorded weights. A discrepancy of 5 lbs or greater between previous and current weight requires a reweigh. 2. An Alert Event Report is to be completed on all residents with an unplanned weight variance of 5 percent or more in 30 days, 7.5 percent in 90 days or 10 percent in 180 days. 3. Notify physician of significant unplanned weight variance.6. notify the Dietitian. 7. Dietitian will respond and address issues. 10. A nutritional care plan will be initiated and revised quarterly and as needed.
A review of the facility provided, Hospice Program dated 8/2021, included but was not limited to: Procedure: 5. responsibility of the facility to meet the resident's personal care nursing needs in coordination with the hospice representative, and ensure level of care based on (CP)
5. c.: notifying the hospice about the following:
i: a significant change in the residents physical, mental, social or emotional status
coordinated care plan: 12: coordinated care plan revised and updated as necessary to reflect current status including but not limited to e. nutrition and hydration needs.
A review of the facility provided, Job Description Dietitian revised 08/31/21, included but was not limited to Job Summary: the Dietician role serves as a liaison between the patient, nursing and medical staff regarding optimal nutrition care for the patient. S/he assesses the nutritional needs, develop individualized dietary plans, provides dietary counseling Essential Generic Job Functions: 2. Assure that nutrition assessments, reassessments and care plans are completed to meet each patient's identified needs.
A review of the facility provided, Job Description RN revised May 2019, included but was not limited to Job Summary: As part of a multidisciplinary team to deliver patient-centered nursing services to patients .Provides the highest level of service to all patient's to ensure satisfaction. Responsible for ensuring all assigned residents receive all medications, treatments, and nursing care as ordered. Essential Generic Job Functions: 5. Maintains accurate informative records on all patients in the unit. 6. Identify and report all real or potential problems regarding the development or administration of patient care .9. Identify and assess any changes in patient conditions/needs and report to charge nurse/supervisor.
A review of the facility provided, Job Description Unit Manager RN not dated, included but was not limited to Job Summary: Monitors staff to ensure all facility policies and procedures are followed. Acts as a liaison between resident, families, other departments, and outside services to meet resident needs. Essential Generic Job Functions: 4. Works with interdisciplinary team to ensure quality services are provided. 11. Accountable for 24-hour resident care provided on assigned unit.
NJAC 8:39-11.2(e), 17.1(c), 27.1(a)
Based on observation, interview, record review and review of other pertinent documentation, it was determined that the facility failed to ensure: 1.) a resident who required enteral nutrition (EN) support via a tube feeding (liquid nutrition provided directly via a tube into the stomach) and sustained a 17 % weight weight loss over eight days was re-weighed per facility policy, and 2.) conduct a nutrition assessment upon admission and assess and report a weight gain of 8.9 pounds (lbs). This deficient practice was identified for (Residents #239 and #114) 2 of 7 residents reviewed for nutrition/hydration and tube feedings. The deficient practice was evidenced as follows:
1) On 07/19/22 at 11:07 AM, the surveyor observed Resident #239 in bed, with eyes closed, appeared thin, and EN support was being infused at 65 ML (milliliters) per hour via a pump.
On 07/20/22 at 12:55 PM, the surveyor reviewed the medical record for Resident #239, which revealed the following:
The Resident Face Sheet revealed diagnoses that included, but were not limited to, Type 2 Diabetes Mellitus with foot ulcer, Dysphagia following other cerebrovascular disease, and Unspecified severe protein-calorie malnutrition. Review of the Nursing Progress admission Note dated 07/9/2022 at 3:45 AM, revealed the resident was NPO and had a pegtube with a continuous feeding (received nothing by mouth and received continues nutrition via a tube into the stomach) and the usual body weight was 145 lbs. There were no current weights documented. A Medical Progress Note dated 07/15/2022 at 3:17 PM and signed by a Nurse Practitioner, revealed a current weight of 150 lbs, to monitor routine weights, and document, and no recent significant weight loss. Review of a Nutrition Assessment completed on 07/10/22 by the Registered Dietitian (RD), indicated Resident #239's weight was 150 lbs. A review of the Care Plan Activity Report for Resident #239 revealed a Focus area of: Enteral Nutrition Support/Risk for Aspiration. Intervention: Monitor weights as per MD (physician) order. A review of the weight record for Resident #239 dated 07/18/22, revealed a weight of 123.8 lbs. There was no additional weights documented in the medical record (this weight indicated a 23.2 lbs (17%) weight loss from 07/10/22 through 07/18/22.
On 07/21/22 at 10:03 AM, the surveyor interviewed the RD, who stated she was covering for the RD who completed Resident #239's nutrition assessment. The surveyor inquired to the RD regarding the nutrition assessment process. The RD stated weights would be completed upon admission and daily for two or three days, to check for accuracy of weights, and that would be dome for everyone. The RD reviewed Resident #239's Nutrition Assessment and the surveyor inquired to the RD regarding Resident #239's weight history. The RD stated the July 18 th weight was 123.8 lb and stated the 150 lbs weight was documented on the Nursing Shift assessment dated [DATE] at 8:43 AM. The RD confirmed that there were only the 150 lbs and 123.8 lbs weights available since the resident had been re-admitted the RD was unable to locate any additional Nutrition Notes for the resident. The RD stated she was made aware of the weight loss on 7/20/21 in the afternoon (two days after the weight loss was identified), and stated the resident was on her to-do list and would follow-up with the resident as soon as possible.
On 07/21/22 at 10:29 AM, the surveyor interviewed the Unit Manager, Registered Nurse, Assistant Director of Nursing (UM/RN/ADON) regarding the weight process. The UM/RN/ADON stated that residents should be weighted upon admission, then daily for three days and weekly after. The UM/RN/ADON was unable to locate any additional weights for Resident #239 in the weight book and on the Certified Nurse Aide (CNA) assignment sheet. The UM/RN/ADON stated Resident #239 weighed 150 lbs per review of a 07/16/22 nursing note. The UM/RN stated we should reweigh the resident and if the CNA weighed the resident, they should have notified the nurse right away of the weight.
On 07/21/22 at 10:45 AM, the UM/RN/ADON provided the surveyor with a copy of the Weight Loss Or Gain, Significant Unplanned Policy, Initital Date: December 1999, from a policy binder located at the C-Wing nursing station.
On 07/21/22 at 11:53 AM, the UM/RN/ADON was observed exiting Resident #239's room. The UM/RN/ADON stated Resident #239 was weighed and the weight was 126.6 lbs (This was a 2 pound weight increase over three days).
On 07/22/22 at 10:55 AM, the surveyor reviewed the RD progress notes which revealed that the RD completed a consultation related to Resident #239's (approximate) 21 lb weight loss since readmission. The progress note indicated, per documented wt [weight] of 123.8# [pound] on 7/18/22. Reweigh of 126.6# on 7/21/22 confirmed wt [weight] loss.
A review of the Dietary note, dated 07/21/22, revealed that a dietary consult was ordered for calorie increase recommendations related to weight loss. The consult documentated that Resident #239 had a 21 lb weight loss after readmission. The consult recommended an increase in the EN to provide additional calories and to continue to weigh the resident twice a week. This recommendation was discussed with the resident representative and was implemented.
On 07/21/22 at 1:23 PM, the LHNA stated the facility was working on the draft policy for the weights. The LNHA presented a draft policy and stated that the policy was not done. The LNHA further stated that the policy the facility had was the policy that was used.
On 07/26/22 at 10:07 AM, during an interview with the surveyor, the DON stated the staff should have reweighed the resident and informed the physician and family. The DON further stated that regarding resident weight loss, the RD was usually in the building Monday through Friday, and stated it should have been done sooner regarding the reweight.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
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 documents, it was determined that the facility ...
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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 documents, it was determined that the facility failed to ensure that a resident was properly positioned while the resident received enteral nutrition support ([NAME]) via a gastric tube (a form of nutrition that is delivered into the digestive system via a tube as a liquid) for 1 of 4 residents reviewed for tube feeding (Resident #239). This deficient practice was evidenced by the following:
On 07/19/22 at 11:07 AM during the initial tour, the surveyor observed Resident #239 in bed with [NAME] being administered at 65 ML (milliliters) per hour via a feeding pump and the resident appeared thin.
07/20/22 at 12:55 PM, the surveyor reviewed Resident #239's medical record. The Resident Face Sheet indicated that Resident #239 was admitted with diagnoses that included, but were not limited to, dysphasia (swallowing difficulty), cerebrovascular disease, chronic kidney disease and diabetes mellitus (DM). The Physician Order Activity Detail Report revealed an order, dated 07/11/22 at 1:34 PM, for Diet: NPO (nothing by mouth), and an order, dated 07/10/22 at 10:47 AM, for Infuse Glucerna 1.5, 1300 ml at 65 ml per hour via pump. Up at 6 am and down at 2 am (next day) or until total volume 1300 ml infused. Document downtime and amount infused. Schedule: Every Day at 2:00 am-4:00 am. The resident's Care Plan (CP) had a focus of Nutrition-Enteral Nutrition Support/Risk of Aspiration, effective 07/10/22. The interventions on the CP indicated that the head of bed was to be kept at 30-45 degrees during the feeding and one hour after.
On 07/21/22 at 8:28 AM, the surveyor entered Resident #239's room and observed that the resident was being administered [NAME] through a feeding pump. The resident's head of bed was not observed to be at a 30 degree angle and the air mattress that the resident was lying on appeared to be deflated. Resident #239 appeared to be sunken into the bed. Resident #239's bilateral feet appeared elevated and the surveyor did not hear any alarms sounding while inside the resident's room, from either the bed or the feeding pump, and did not hear any sound coming from the bed.
On 07/21/22 at 8:34 AM, the surveyor exited the room and interviewed the Licensed Practical Nurse (LPN #1) assigned to Resident #239. LPN #1 stated she worked for an agency and was she was just here today. LPN #1 stated that Resident #239's tube feeding was running when she had started working that day.
On 07/21/22 at 8:40 AM, LPN #1 accompanied the surveyor to Resident #239's room and observed the resident had both legs elevated, the bed was sunken in, and the head of bed did not appear to be at a 30 degree angle. LPN #1 confirmed that the resident was being administered [NAME] at that time via a feeding pump. The surveyor inquired to LPN #1 regarding what degree the head of bed should be when a tube feeding was being infused. LPN #1 stated that the head of bed should be up 30 degrees when a tube feeding was infusing. LPN #1 and the surveyor both observed that the resident's head of bed was not elevated to 30 degrees, the resident's bilateral legs were elevated and the mattress on the bed was sunk in. The surveyor then inquired to LPN #1 if that was acceptable and LPN #1 stated asked No, I would not have [the resident] like this. LPN #1 then stated that it didn't look like the air mattress was functioning, because the head of the bed was too low. LPN #1 confirmed that the resident's air mattress was not turned on, and she then proceeded to push the button that inflated the air mattress and stated there it goes and the air mattress then started to inflate. LPN #1 then confirmed that the mattress was now working properly and admitted that it was a concern if the resident was in that position with the head of the bed less then 30 degrees, with the bed deflated and feet elevated and LPN #1 stated the resident could have aspirated (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the windpipe.) She then stated that the Certified Nursing Assistants (CNAs) must have performed care for the resident but that no one had told her that the air mattress was deflated, or that the residents head of bed was below 30 degrees with both feet raised. She also stated that it was not on the shift-to-shift report that the resident was like that and LPN #1 then proceeded to elevate the residents head to 30 degrees and elevated the bed to the proper position.
On 07/21/22 at 9:26 AM, the surveyor interviewed the Director of Nursing (DON). The surveyor asked the DON what position should a resident be in while being administered a tube feeding. The DON stated that a resident's head of bed should be at a 30 degrees when being administered [NAME]. The surveyor inquired as to why the head of bed should be at 30 degrees and the DON stated, to prevent aspiration and vomiting. The DON also admitted that it was a concern that Resident #239 was positioned with the head of bed less than 30 degrees, feet elevated and bed deflated, because of the potential risk of aspiration and skin breakdown. The DON then stated he would get the policy for resident on tube feedings and check the skin integrity also.
On 07/21/22 at 9:37 AM, the DON provided a copy of the tube feeding policy to the surveyor and confirmed that the head of bed should be elevated at a 30 degree angle.
On 07/21/22 at 10:45 AM, the surveyor observed a maintenance employee (ME) exiting Resident 239's room and the surveyor interviewed the ME at that time regarding Resident #239's bed. The ME #1 stated the air mattress needed a controller and then it would not deflate.
On 07/26/22 at 1:35 PM, the surveyor interviewed the Plant Operations Manager who confirmed that the bed motor was bad, and that was why Resident #239 had his/her head down and feet were up. He stated that he was not aware of this prior to the surveyor bringing it to the nurses attention on 07/21/22. He stated that the staff could have called him at any time, because they keep spare motors at the facility.
On 07/28/22 at 9:30 AM, the surveyor entered Resident #239's room and observed the [NAME] was being administered at 80 ml per hour via a feeding pump, the resident's bilateral legs appeared elevated.
On 07/28/22 at 9:39 AM, the surveyor entered Resident #239's room with the assigned LPN (LPN #2). LPN #2 observed Resident #239's elevated legs and stated they were too high. LPN #2 proceeded to use the bed controller and lower the resident's legs. LPN #2 stated the elevated legs could compress the stomach and affect the digestion of the tube feeding. LPN #2 stated the legs were not like that before the Nurse Aide (CNA) completed the resident's morning care and there was no order for the legs to be elevated and she would educate the CNA.
The facility policy dated 05/2022 and titled, Tube Feeding (Enteral Nutrition) and Medication Administration for Adults indicated that the purpose for this policy was to provide safe protocols regarding enteral nutrition practices in the skilled nursing facility. The enteral nutrition is nutrition provided through the gastrointestinal tract via a tube or catheter that delivers nutrients distal to the oral cavity. The policy specifically indicated: 7. Elevated head of bed (HOB) to at least 30 degrees and preferably 45 degrees, 11. Maintain the head of bed at 30-45 degrees.
NJAC 8:39-27.1(a)
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, facility documentation review and clinical record review, it was determined that the facility failed to provide oxygen therapy consistent with physician orders and inf...
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Based on observation, interview, facility documentation review and clinical record review, it was determined that the facility failed to provide oxygen therapy consistent with physician orders and infection control measures. This deficient practice was identified for 1 of 2 residents reviewed for oxygen therapy, Resident #89 and was evidenced by the following:
On 07/19/22 at 9:45 AM during the initial tour of the facility, the surveyor observed (B Wing) and Resident #89 sitting in a chair next to the bed receiving oxygen at a flow rate of 1.5 liter per nasal cannula (NC) by way of a concentrator. The Oxygen [O2] tubing was observed on the floor and not labeled or dated. There was no signage at the door to alert of Oxygen being in use.
On 07/19/22 at 11:57 AM, the surveyor observed Resident #89 sitting on the bed eating lunch, their O2 tubing noted on the floor.
On 07/19/22 at 1:15 PM, the surveyor observed Resident #89 sitting in the chair in the room. The surveyor observed the O2 setting at 1.5 liters delivery via NC.
On 07/20/22 at 9:07 AM, the surveyor observed Resident #89 in his/her room, awake and alert. There was no signage posted to reflect that Oxygen was in use. The O2 tubing was on the floor. The O2 Concentrator was set to deliver O2 at a flow rate of 2 liters via NC.
On 07/20/22 at 10:40 PM, the surveyor briefly reviewed the Resident #89's current medical record which revealed that Resident #89 was admitted to the facility with diagnoses which included but not limited to Malignant Neoplasm of rectum, Transient cerebral ischemic attack, Unspecified asthma and Airway disease.
Further review of the clinical record revealed a Physician Order Sheet (POS) dated 05/21/22 timed 03:25 PM that contained the following order: Apply O2 [Oxygen] at 3 liters nasal cannula continuously.
The most recent quarterly Minimum Data Set (MDS, an assessment tool) with an (Assessment Reference Date) ARD of 06/01/2022, coded Resident #89 as having a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition.
On 07/20/22 at 11:26 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1 assigned to the B Wing. The LPN verified on the electronic record that the order was for Resident #89 to receive O2 at a flow rate of 3 liters via nasal cannula. The surveyor entered Resident #89's room with LPN #1 and we both observed that the concentrator setting was for O2 to be delivered at 2 liters via NC and the O2 tubing was noted on the floor. LPN #1 stated that he verified the order and that Resident #89 was ordered 3 liters of O2 not 2 liters as was set on the concentrator. LPN #1 then went to the room and adjusted the O2 flow rate from 2 liters to 3 liters to reflect the physician order.
On 07/20/22 at 11:29 AM, LPN #1 acknowledged that the physician orders must be followed. The nurse added that the tubing should not be on the floor for infection control prevention because the floor was contaminated.
On 07/21/22 at 7:34 AM, the surveyor observed Resident #89 sitting in a chair next to the bed. The O2 tubing was observed lying on the floor. The O2 concentrator was set to deliver 2 liters of O2 via NC.
During an interview with the surveyor, Resident #89 at 7:35 AM revealed that he/she was not made aware that the O2 tubing could not be on the floor. He/she also acknowledged that he/she never changed or touched the O2 setting.
On 07/21/22 at 7:36 AM, during an interview with the surveyor, the 11:00 PM-07:00 AM nurse (LPN #2) revealed that she did not check the O2 setting during her shift. She also stated she was unsure of the physician's order and it Could be 2 or 3 liters. The surveyor accompanied LPN #2 to the room where we both observed the concentrator set to deliver O2 at a flow rate of 2 liters via the NC. LPN #2 left the room and did not adjust the flow rate to depict the physician's order.
On 07/22/22 at 9:08 AM, the surveyor observed Resident #89 sitting in the room eating breakfast. The O2 tubing was on the floor. The concentrator was set to deliver O2 at a flow rate of 3 liters via the NC.
On 07/26/22 at 9:30 AM, the surveyor observed Resident #89 standing in the room and was short of breath (SOB). The surveyor could not read the gauge for the setting on the concentrator. The surveyor alerted the LPN/UM [Unit Manager] who was at the medication cart in the hallway. The LPN/UM entered the room and verified that the O2 concentrator was turned off. The LPN/ UM turned on the concentrator and set the O2 flow rate for 3 liters via NC as ordered by the physician.
On 07/26/22 at 9:35 AM, during a follow up interview with the surveyor, the LPN/UM stated that she did not get report from the 11:00 PM-07:00 AM nurse. She added that the LPN/UM in training received report and she did not checked the O2 setting. She added that sometimes if the resident was being assisted to the chair, staff would turn the concentrator in the room off and used the portable oxygen tank attached to the wheelchair. She could not provide the rationale for why the concentrator had been turned off.
On 07/26/22 at 9:40 AM, during an interview with the surveyor, the LPN/UM in training revealed that she did not check the O2 setting after receiving report nor did a walking round with the 11:00 PM- 07:00 AM nurse. She added that she was not aware that the O2 concentrator was turned off.
On 07/26/22 at 12:46 PM, during an interview with the surveyor, the Certified Nursing Assistant (CNA) who cared for Resident #89 revealed that Resident #89 can assist with care, had no behaviors, and had a colostomy bag cared for by the nurse. The CNA added that Resident #89 was also receiving O2 and that the nurses were responsible for the O2 setting. She indicated that she did not touched the O2 concentrator.
On 07/27/22 at 8:38 AM, the surveyor observed Resident #89 sitting on the bed eating breakfast. The O2 tubing was on the floor, not labeled or dated, and the concentrator had been set to deliver O2 at a flow rate of 3 liters via the NC.
During the pre-exit conference on 08/02/22 at 1:30 PM, the Licensed Nursing Home Administrator (LNHA), the Assistant (LNHA), the Director of Nursing (DON), and the Regional nurse were informed of the findings. No further information was provided. The regional nurse told the survey team that the nurse who worked on the 11:00 PM- 07:00 AM shift was an agency nurse and she would be educated.
A review of the facility's policy titled, Oxygen Therapy last revised September 2008, read in part.
The purpose of oxygen therapy is to administer oxygen in cases where insufficient oxygen is carried to the tissues by the blood.
Oxygen therapy is administered only as ordered by a physician or as an emergency measure until an order can be obtained. The physician's order will specify the rate of oxygen flow.
Rules: Smoking in the resident's room is prohibited while oxygen is in use.
Make sure oxygen flow rate and concentration remain as ordered by the physician.
Under procedure for administering oxygen the following were noted:
1. label humidifier and tubing with date.
2. Place Oxygen in use sign on outside of the room, if an oxygen tank is being used.
3. Apply face mask and nasal cannula as ordered.
Under guidelines for administering Oxygen it is stated, Oxygen tubing changed every 7 days. Date when changed.
NJAC 8:39-11.2 (b) 27.1 (a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview and the review of the medical record and other facility documentation, it was determined that the facility failed to provide a gradual dose reduction (GDR) of psychoact...
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Based on observation, interview and the review of the medical record and other facility documentation, it was determined that the facility failed to provide a gradual dose reduction (GDR) of psychoactive medication in the absence of behaviors and ensure the appropriate use and monitoring of psychotropic medications for 1 of 5 (Resident #81) residents reviewed for psychoactive medications and was evidenced by the following:
On 07/19/2022 at 10:00 AM during tour, the surveyor observed Resident #81 in bed with the head of bed up, non-verbal with eyes half open. The resident was not tracking (scanning) the surveyor with his/her eyes and had a blank gaze in his/her eyes. The surveyor was unable to interview the resident due to severe cognitive impairment. The resident was observed with a tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe (trachea)) and a tube feeding (a means of providing nutrition by way of a feeding tube inserted into the gastrointestinal tract) was hanging on a pole next to the resident's bed. The surveyor also observed that a urinary drainage bag (bag that collects urine) was hanging on the bottom of the bed.
The Resident Face Sheet reflected that Resident # 81 was admitted to the facility with the diagnoses that included and was not limited to; persistent vegetative state (a condition in which a medical patient is completely unresponsive to psychological and physical stimuli and displays no sign of higher brain function, being kept alive only by medical intervention), chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and ruptured brain aneurysm (bleeding on the brain from a ruptured blood vessel). The significant change Minimum Data Set (MDS) an assessment tool dated 06/13/2022, indicated that Resident #81 required total care with all aspect of activities of daily living (ADLs) and had severe cognitive impairment. The MDS did not reflect that the resident exhibited any behaviors.
On 07/19/2022 at 11:18 AM, the surveyor reviewed the Medication Administration Record (MAR) which revealed that Resident # 81 was on the following psychoactive medication:
Fluoxetine (Prozac) 20 mg (milligrams)/5 mL (milliliters) (4 mg/mL) oral solution Dispensed: fluoxetine 20 mg/5 mL (4 mg/mL) oral solution give 2.5 milliliters (10 mg) by g-tube route once daily in the morning.
Start Date: 05/22/2022 03:01 pm. The medication Fluoxetine is classified as an antidepressant medication.
The surveyor reviewed the original standing physician's order dated 04/16/2021 for Fluoxetine 10 mg give one capsule via g-tube once daily.
The Physician's Order Sheet (POS) dated 07/08/2022 had an order for Fluoxetine 20 mg/5 ml oral solution, give 2.5 milliliters (10 mg) by g-tube route one daily in the morning for the diagnoses of Major Depressive Disorder.
The Care Plan (CP) dated 02/03/22 reflected a focus:
Resident was on an antidepressant prior to admission. Resident currently in persistent vegetative state and medication will be reviewed regularly for indication by psychiatrist.
The CP goals indicated that the resident would utilize the lowest needed dose of medication to effectively manage the disease process. There was no behaviors documented on the CP.
The CP meeting note dated 05/10/2021, indicated that there were questions regarding alertness, responsiveness, and stimulation and that the resident was not able to follow commands.
The CP meeting note date 05/20/2021, indicated that the resident was in a vegetative state and was not responding to stimulation, not exhibiting a response, and not tracking with eyes.
The CP meeting notes dated 08/19/2021, 12/01/2021, 02/17/2022, 06/02/2022 and 06/15/2022 reflected that the resident was in a persistent vegetative state.
The surveyor did not find any documentation in the clinical medical record on what specific behaviors Resident #81 was exhibiting or that the facility was monitoring the antidepressant medication for side effects or effectiveness.
The admission Checklist dated 04/15/22 indicated that there was a consult ordered for physiatrist, however the surveyor could not find a physician's order for a psychiatric consult or documentation that the resident was evaluated by a psychiatrist.
On 07/20/22 at 11:38 AM, the surveyor reviewed the Pharmacy Consultant Review (PCR) which reflected that the pharmacy consultant (PC) reviews the residents' medications monthly. The PCR sheets revealed the following:
On 09/09/2021 the PC documented the resident was receiving Prozac for Post-Traumatic Stress Disorder (PTSD) and that this medication was not approved by the Food and Drug Administration for PTSD and for the physician to please document the rational at the bottom of the form. The surveyor could not find any documentation from the physician for the rational on the form or in the clinical medical record.
The PCR dated 03/02/22 reflected a recommendation from the PC to consider a trial decrease in the resident's Fluoxetine 10 mg daily and that changes to this dose was not attempted since August of 2021. The physician documented that the half life of Fluoxetine was unavailable to skip the dose without exacerbation of symptoms however there is no documentation in the resident's medical records to indicate what symptoms or behaviors the resident was exhibiting.
On 07/20/22 at 01:02 PM, the surveyor interviewed a Licensed Practical Nurse (LPN#1) on the A-wing who stated that she was familiar with Resident #81 and that the resident was nonverbal, did not respond to verbal stimuli, required complete care and was on hospice. LPN #1 stated that Prozac was an antidepressant and she stated that she does not know why the resident is on the antidepressant medication as the resident did not exhibit any behaviors.
On 07/20/22 at 01:07 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) for the A-wing who stated that Resident #81 was in a vegetative state (not responsive), had a trach, required total care and was on hospice services. The LPN/UM added that the resident did not exhibit any behaviors but that the resident made facial grimaces at times. The LPN/UM explained that when a resident was on an antidepressant medication, the medication was reviewed quarterly by the psychiatrist or the attending physician. The LPN/UM could not find any clinical documentation in the medical record that the resident was evaluated by a psychiatrist or why the resident was on the medication Fluoxetine. The LPN/UM also stated that when a resident was on any type of psychoactive medications such as an antidepressant, that the facility would do a monthly psychotropic summary. The LPN/UM could not provide the surveyor with any documentation that a monthly psychotropic summary was done for the use of Fluoxetine for Resident #81. The LPN/UM could not find that a gradual dose reduction was attempted.
On 07/20/22 at 01:41 PM, the surveyor interviewed Licensed Practical Nurse (LPN#2) who stated that when any resident was on an antipsychotic, anxiolytic or an antidepressant that a monthly psychotropic summary was scheduled on the MAR and that the nurses were responsible to document what the psychotropic medication was being used for, behaviors that the resident was exhibiting and if the resident had any improvement or decline with the use of the medication.
On 07/21/22 at 08:45 AM, the surveyor interviewed the Director of Nursing (DON) on what the facility process was when a resident was on psychoactive medication and what the nurses were responsible to document in the clinical record related to the use of this classification of medication. The DON explained that the nurses were responsible to document the resident's behaviors and the reason for the need of the psychoactive medication including a monthly psychoactive medication summary. He explained that the monthly psychoactive summary was a cumulative note regarding behaviors and side effects and effectiveness of medication. The DON stated that Resident #81 was diagnosed as being in a persistent vegetative state. He stated that he was not sure why resident #81 was on the medication Prozac or why Resident #81 was not seen by a psychiatrist. He stated that when a resident was admitted to the facility on a psychotropic medication that the resident was usually seen by the psychiatrist to assure that the medication was still needed. The DON stated that the resident should have been seen by a psychiatrist and there should have been documentation of what behaviors were being exhibited and that the medication should be monitored. The DON also stated that a gradual dose reduction (GDR) was done two times and year. The DON could not provide the surveyor with any documentation as to why Resident # 81 was on an antidepressant medication, what behaviors the resident was exhibiting, if the resident was evaluated by a psychiatrist or why a GDR was not attempted since the resident had been on the medication since 04/16/2021. The DON provided the surveyor with documentation that Resident # 81 had been on Fluoxetine (Prozac) 10 mg once daily since 04/16/2021.
On 07/25/22 at 10:00 AM, the surveyor conducted a telephone interview with Resident #81's physician who stated that the resident had a hemorrhagic stroke, required full care with activities of daily living (ADLs) and was dependent upon the staff to provide all of his/her needs. The physician stated that the term vegetative state was just a term used when there was no evidence that the resident was improving. He stated that the resident did not exhibit behaviors and was on the medication because he/she had a past history of depression prior to his/her current condition of being in a vegetative state. He stated that the nurses could monitor the medications effectiveness by taking the residents vital signs. The physician was unable to give the surveyor specifics on what depressive behaviors the resident exhibited or explain to the surveyor as to why the resident was being given an antidepressant medication in the absence of behaviors or communication. The physician stated that the resident grimaced at times but could not explain if this was a indication that the resident was depressed. The physician could also not provide a reason as to why there was not clinical documentation in the resident's medical record on a rational as to why a GDR was not attempted since the resident had been on the medication since 04/16/2021.
On 07/25/22 at 10:54 AM, the surveyor conducted a telephone interview with hospice Manager of Clinical Practice (MCP) and the hospice DON who both agreed that the resident had a hemorrhagic CVA with several comorbidities, was lethargic and unresponsive. We usually review the medications to determine if there was a need for the meds. The MCP stated that she did not have any information documented on the hospice clinical records on what behaviors the resident was exhibiting indicating that the resident was depressed. MCP stated that if a resident was on a psychoactive medication, they would make sure that the resident was seen by a psychiatrist. The MCP could not find documentation that this resident was evaluated by a psychiatrist for the use of Fluoxetine. The MCP stated that the registered nurse that comes into the facility had a conversation with the family and that the family wanted to continue all medications.
On 07/25/22 at 01:18 PM, the surveyor telephone interviewed the Pharmacy Consultant (PC) who could not provide any information regarding psychotropic use for Resident #81.
On 08/03/22 at 09:35 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) stated that he would investigate the process regarding psychoactive medication usage and did not have any additional information.
The facility policy dated 03/2022 and titled, Unnecessary Drugs-Psychotropics. Purpose: the policy indicated that the facility would ensure that each resident's entire drug/medication is managed and monitored to promote or maintain the resident's highest practical. Mental, physical, and psychological well-being. The policy indicated that based on a comprehensive assessment of a resident the facility must ensure the following:
1.)
Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.
2.)
Residents who use psychotropic drugs receive a gradual dose reduction, behavior interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
3.)
Use of psychotropic medication for each resident will be evaluated for appropriate indication and diagnoses.
4.)
Residents using psychotropic medications will be monitored for efficacy and adverse consequences.
5.)
Psychoactive medication orders will be routinely re-evaluated to determine whether prolonged or indefinite use is indicated.
6.)
Resident prescribed psychotropic medications will receive dose tapers or GDR's unless clinically contraindicated with the goal of seeking an appropriate dose and duration and minimizing the risk of adverse consequences.
7.)
Residents admitted on or initiated on a psychotropic medication will have an initial progress note entered into their medical record.
8.)
Residents on a psychotropic medication will be evaluated by their primary physician/psychiatrist for pharmacological necessity of medication as necessary.
9.)
Residents will be monitored for effectiveness and potential adverse consequences related to psychotropic medication use.
10.)
A Psychoactive Drug Monitoring Summary progress note will be completed monthly.
11.)
A GDR will be attempted for all psychotropic medication based on CMS state operations manual requirements.
N.J.A.C. 8:39-29.3(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, interview, and review of other pertinent facility documentation it was determined that the facility failed to consistently a.) serve foods at temperatures preferred by residents ...
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Based on observation, interview, and review of other pertinent facility documentation it was determined that the facility failed to consistently a.) serve foods at temperatures preferred by residents for 5 of 6 residents at the Resident Council Meeting that complained of undesirable food temperatures. b.) serve hot and cold foods at acceptable temperatures, and c.) follow the facilities policy for Food holding.
The deficient practice was observed in 1 of 1 test trays on 1 of 4 units (B-Wing) and was evidenced by the following:
On 07/26/22 at 10:31 AM, the surveyor conducted the Resident Council Meeting with six (6) alert and oriented residents in which 5 of 6 unsampled residents at the meeting complained that the food did not always get delivered fast enough to the residents, so sometimes the food was cold. They stated that the food was delivered on time from the kitchen, but then once the food truck was on the unit, the nurses and certified nursing assistants do not pass them out quickly enough so that the food temps were not palpable.
On 08/02/22 at 11:39 AM, two surveyors observed that test trays were being prepared in the kitchen. The two surveyors observed that a plate was retrieved from a plate warmer and placed on a heated tray warmer and the food was placed on the plate. One test tray was a regular consistency diet, and the other test tray was a puree diet. Both food trays contained one hot dog, stewed tomatoes and macaroni and cheese. There was also a milk placed on the tray as well as a 4-ounce carton of cranberry juice.
On 08/02/22 at 11:40 AM, the two surveyors observed the test tray being put into the insulated food truck that would be delivered to the B-wing Unit.
On 08/02/22 at 11:41 AM, the surveyors observed the food truck containing the test trays leaving the kitchen to be delivered to the B- wing Unit.
On 08/02/22 at 11:43 AM, the surveyor interviewed the Food Service Director (FSD) who stated that acceptable hot foods temperatures were served over 140 degrees and acceptable cold foods were served below 40 degrees.
On 08/02/22 at 11:44 AM, the surveyors observed the food trays delivered to the B-wing Unit.
On 08/02/22 at 11:45 AM, the Certified Nursing Assistant (CNA) stated that the trays for residents requiring assistance with feeding remain on the insulated food cart until the residents were ready to be fed by the staff. The surveyor then observed the CNA take a tray off the food cart.
On 08/02/22 at 11:52 AM, the surveyors observed the Licensed Practical Nurse Unit Manger (LPN/UM) take the last tray off the food truck.
On 08/02/22 at 11:53 AM, the surveyor along with the FSD took the temperatures of the test tray and the temperatures were as follows:
The regular textured meal temperatures were taken and the results were as followed:
Stewed tomatoes were 136.2 degrees according to the surveyor's thermometer and 131.5 according to the FSD thermometer. The FSD stated that the temperature of the stewed tomatoes was too cold.
The hot dog's temperature was taken and according to the surveyor the temperature of the hot dog was 135.6 degrees and the FSD thermometer read the hot dog at 133 degrees. The FSD stated that the hot dog's temperature was too cold.
The surveyor took the temperature of the 4-ounce carton of milk and a 4-ounce carton of cranberry juice along with the FSD and the surveyor got a temperature of 53.9 degrees for the milk and 52.2 degrees for the cranberry juice and the FSD obtained a temperature of 53.9 for the milk and a temperature of 51.6 for the cranberry juice. The FSD stated that the milk and cranberry juice were too warm.
On 08/02/22 at 11:56 AM, the surveyors interviewed the FSD who stated that the food temperatures were off' because it took too long for the staff to pass the food trays out to the residents that required to be fed.
The undated facility policy titled, Food Holding indicated that the purpose of the facility policy was to ensure that all hot foods and cold foods are held at the proper temperature to prevent food born illness. The policy indicated that all hot food must be held at or above 140 degrees and all cold foods must be held between 32 degrees and 41 degrees.
NJAC 8:39-4.1
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected most or all residents
b) On 07/19/22 at 9:57 AM, Surveyor #2 conducted an initial tour on A wing and observed Resident #101 sitting in the day room with other residents. Resident #101 was at a table alone. There were birth...
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b) On 07/19/22 at 9:57 AM, Surveyor #2 conducted an initial tour on A wing and observed Resident #101 sitting in the day room with other residents. Resident #101 was at a table alone. There were birthday balloons tied to the back of the wheelchair. Surveyor #2 observed that there was no staff interaction observed with the residents. There were music videos playing on the television (TV). The surveyor observed the activity calendar that was posted on the wall in the hallway on the unit. The activities listed for 7/19/22 included: Ice Cream Day, AM Activities, Chronical & Coffee Delivery, Interesting Ice Cream Facts around the world, Ice Cream Detective, Afternoon Highlights and Strolling Ice Cream Cart. There were no times listed for the activities.
On 07/20/22 at 11:23 AM, Surveyor #2 observed Resident #101 in the A wing day room at a table alone and was facing the TV. There were other residents present in the room. There was music videos playing on the TV and the residents did not appear to be watching the TV.
On 07/21/22 at 9:42 AM, Surveyor #2 observed Resident #101 sitting in a wheelchair inside the A wing day room. The resident's eyes were closed and the resident appeared to be sleeping. At 9:50 AM, Surveyor #2 observed the nurse transport the resident in the wheelchair to the resident's room and then administered medications. At 9:56 AM, the nurse returned Resident #101 to the day room and placed them at a table facing the TV. At that time, there were nine residents in the day room. There were music videos on the television. The residents did not appear to be watching the TV. A Certified Nursing Assistant (CNA) was sitting in the corner of the room coloring with one of the residents. The other residents did not have coloring material in front of them. Surveyor #2 continually observed the residents in the A wing Day room, and Resident #101 from 9:42 AM through 10:32 AM from a clear unobstructed view through the window of the day room. The surveyor did not observe the CNA who was sitting in the day room, engage or interact with any of the other residents, or Resident #101.
On 07/21/22 at 10:18 AM, Surveyor #2 observed an Activity Staff (AS) #1 transport a resident, in a wheelchair, from the A wing day room to the main recreation room (MRR). Surveyor #2 did not observe AS#1 ask resident #101, or any of the other residents in the room if they wanted to attend the activity.
On 07/21/22 at 10:28 AM, Surveyor #2 interviewed the Provisional Nursing Assistant (PNA), who was sitting in the day room with the residents. She stated that her duty was to observe the residents to make sure that no one would fall. She stated that the residents in the day room were all assessed as being high fall risks. She stated resident #101 was a fall risk, and was also usually in the day room.
On 07/21/22 at 10:32 AM, Surveyor #2 observed five residents in the MRR attending a singing activity and singing along with the music, Proud to be an American. The MRR was a large room with several empty tables. Review of the July 2022 Activity Calendar located in the hallway across from the MRR, had documented for 7/21/22: AM Activities, Chronical & Coffee Delivery, ADMIT categories, Afternoon Highlights, Entertainment in the MRR. There were no times noted for the listed events.
On 07/21/22 at 10:45 AM, Surveyor #2 interviewed the Licensed Practical Nurse (LPN#1) from A wing who stated that the residents in the A wing day room were fall risks and that there was always a CNA or AS in the room with them to redirect the residents as needed. When the surveyor asked how she knew what time the activities were that were listed on the Activity calendar, she stated she did not know the schedule, however, activities staff would know.
Surveyor #2 reviewed the electronic medical record for Resident #101 which revealed the following:
According to the admission Record, Resident #101 was admitted to the facility with diagnoses that included but were not limited to, Dementia and anxiety.
According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 06/14/2022, Resident #101 had a Brief Interview for Mental Status (BIMS) score of 2/15, which indicated that Resident #101 had a severely impaired cognition. The MDS documentation indicated that Resident #101 required extensive staff assistance for Activities of Daily Living (ADLS).
Review of the Care Plan dated 10/12/2020 revealed Focus Activities: .exhibits a preference of own room and pursues leisure activities watching TV in room .would benefit from encouragement, redirection and reminders from staff to promote participation. Staff will encourage to attend and participate in activities with peers. Staff will redirect as needed with a need for decreased stimulation.
Review of the Initial Recreation Assessment form created on 9/2/2020 revealed Activity Interests-Past and Current included: Arts/Crafts, Exercise, Music, Spiritual/religious activities, trips/shopping, walking/wheeling outdoors, talking/conversing, parties/socials, special event/entertainment, animals, and some/what watching TV. In the past interest was cooking and reading/writing. The preferred activity setting: own room.
On 07/21/22 at 12:35 PM, Surveyor#2 observed Resident #101 in A wing day room eating lunch. At 1:47 PM, the resident was observed in the A wing day room. The television was on playing music videos. There was no staff interaction observed.
On 07/22/22 at 9:17 AM, Surveyor#2 observed Resident #101 sitting in the wheelchair in the hallway outside of the resident's room with a bed side table (BST) in front of the resident. There was nothing on the BST.
On 07/22/22 at 9:24 AM, Surveyor#2 interviewed CNA#1 who stated that before the current COVID-19 outbreak, the CNAs took turns monitoring the day room to make sure the residents did not fall. He stated that the residents were now sitting in the hallway so everyone could see them because they were high fall risks.
On 07/22/22 at 10:57 AM, Surveyor#2 observed Resident #101 sitting in the wheelchair near the doorway of the resident's room. There was no music or TV on. No staff interaction with the resident was observed.
During an interview with the survey team on 07/26/22 at 11:31 AM, AS #3 stated that the residents were provided with the Daily Chronical (DC). For residents that cannot read the DC, she could not identify what would be done.
During an interview with the survey team on 07/26/22 at 12:08 PM, AS#1 stated that the AM activity listed daily on the Activity Calendar included passing out the DC and providing coffee. When asked by the survey team, how do you determine which residents attended activities, she stated I asked the resident if they want to attend but if a resident is confined to their room, we asked nursing if they could attend the activity. She further stated that if the resident was a high fall risk, they must be seated at a table in the recreation room. When the survey team asked AS#1 about the times not being listed on the Activity Calendar, she stated that afternoon highlights that were listed daily on the calendar were for the A wing day room. AS#1 could not provide a time for the activity.
On 07/27/22 at 10:03 AM, Surveyor #2 observed Resident #101 sitting in a wheelchair in the hallway outside of the resident's room with an empty bed side table (BST) in front of the resident. At that time, Surveyor #2 interviewed Resident #101's assigned CNA #2. CNA #2 stated that Resident #101 was in the hallway because of being a fall risk. She stated that the resident was usually in day room but due to the current COVID-19 outbreak, the resident stayed in the hallway so the resident could be observed by staff and redirected as needed. CNA#2 stated that Resident #101 liked activities such as coloring and loved to listen to music. At 10:16, CNA#2 provided Resident #101 with markers and a picture to color. CNA#2 showed the resident what to do with the markers but Resident #101 did not use them.
On 07/27/22 at 10:17 AM, the surveyor observed AS#2 provide a cup of coffee to Resident #101 in the hallway. Resident #101 sipped the coffee. No other interaction from AS#2 was observed at that time.
On 07/27/22 at 10:25 AM, Surveyor #2 interviewed LPN#2, who was assigned to Resident #101. LPN#2 stated that the resident was a fall risk and was usually in the dayroom but was currently sitting in the hallway due to the recent COVID-19 outbreak. LPN#2 stated that Resident #101 liked to watch movies. She stated we can offer the residents things to color, snacks, coffee, tea, or hot chocolate. LPN#2 stated when the fall risk residents were in the A wing day room they could watch TV but due to the recent COVID-19 outbreak the A wing day room was closed.
On 07/27/22 at 10:40 AM, Surveyor #2 interviewed the Unit Manger/Licensed Practical Nurse (UM/LPN) #1 who stated that Resident #101 was usually in the day room because the resident was a line of sight due to being a fall risk. She stated that they used the day room because of the windows and residents could be observed by everyone. She stated that residents could be given crayons to color a picture.
On 07/27/22 at 10:56 AM, Surveyor #2 observed Resident #101 in a wheelchair in the hallway with an empty BST. The resident's eyes were closed. The resident appeared to be sleeping. At 12:36 PM, the resident was observed sitting in the hallway with an empty lunch tray on the BST.
On 07/27/22 at 1:16 PM, Surveyor #2 interviewed the Acting Director of Recreation/Occupational Therapist (ADR/OT) who stated that she updated the resident's care plan goals at the care plan meetings to make sure they were up to date with the resident's needs. The ADR/OT stated that she thought her staff had access to the care plans. At 2:07 PM, the ADR/OT confirmed that the activity staff did not have access to the resident's activity care plans. When the surveyor asked why the calendar listed activities without time, the ADR/OT stated that it had been this way and stated that the times were removed since COVID-19. She stated that activities are usually held at 10:00 AM and 2:00 PM on the units.
On 07/28/22 at 1:05 PM, Surveyor #2 interviewed AS #2 who stated that every morning the recreation staff delivered coffee and the DC to residents. She stated because of COVID-19 they have not been allowed to have gatherings, except for bingo. AS#2 stated that room visits were completed daily with residents at 10:00 AM and 2:00 PM. When the surveyor asked how much time was spent in the rooms, she stated sometimes it was quick and it would depend on what the resident needed. AS #2 stated that sometimes residents were sleeping, or they would want to talk. When the surveyor asked if activities were important, she stated to keep the resident's mind going, to keep them engaged and prevent depression. AS#2 stated that Resident #101 loved coffee, to talk on the phone, and to listen to music.
On 08/02/22 at 10:22 AM, Surveyor #2 interviewed the Registered Nurse Educator (RNE) who stated that her role was to educate nurses on policy & procedures on the activities of this building. She stated that the residents in A Wing Day room were a very high risk for falls. She further stated, We put them together in the day room so that they can be observed to keep from falling. Staff should interact with them or give them a book or drawing to make sure that they have something in front of them to keep them from getting bored.
c) On 07/19/22 at 11:07 AM, Surveyor #3 observed Resident #239 in bed with eyes closed. The room was not personalized.
On 07/20/22 at 12:55 PM, the surveyor reviewed Resident #239's medical record. The Resident Face Sheet indicated that Resident #239 was admitted with diagnoses that included, but was not limited to, dysphasia (swallowing difficulty), cerebrovascular disease, chronic kidney disease and diabetes mellitus (DM). The Physician Order Activity Detail Report revealed an order, dated 07/08/22 at 7:43 PM, for Therapeutic Recreation as Tolerated. The Care Plan (CP) was reviewed. The CP included the following Focus areas: ADL function-impaired, Discharge Planning, Fall and Fall Related Injury Prevention, Nutrition, Skin Integrity, Risk for Acute Pain, Anticoagulation Therapy, Bed Rails, Body Image Disturbance R/T (related to) Loss of Body Part, Bowel Evacuation, Cardiac Disease- Heart Failure of Myocardial Infarction and Hypertension, Diabetes Mellitus, Dysphagia-Impaired Swallowing, Risk for COVID-19 Infection, Neurological Diseases - Seizure Disorder and CVA, Surgical Wound, Palliative Care. There was no Activity CP to ensure the staff were aware of Resident #239's activity preferences.
On 07/21/22 at 8:28 AM, Surveyor #3 observed Resident #239 in bed, bilateral feet were elevated. The resident had his/her eyes open and did not respond when spoken to. The room was not personalized, there were no activity calendars in the room and the resident was not engaged in an activity.
On 07/26/22 at 11:13 AM, Surveyor # 3 interviewed the Occupational Therapist/AD, in the presence of the survey team, regarding her role as the Activity Director. The OT/AD stated she was currently functioning as an occupational therapist and had a modified case load.
The OT/AD stated she had not received specialized training in activities and was involved with the restorative program (assist with helping residents maintain physical function and limit deterioration). She stated that a new Director was supposed to start in August, however, she had been in the role from September 2021 to January 2022 and from June 2022 to present. She stated the activity staff completed the Activity Calendars and stated, I don't sign off on the calendar, and the activity staff were responsible for completing the activity assessments.
On 07/26/22 at 11:31 AM, Surveyor #3 interviewed Activity Staff #3, in the presence of the survey team, regarding her job functions. AS #3 stated she went to the floors, completed one- to- one resident visits, delivered mail, passed out beverages, entertainment. Surveyor #3 inquired as to how AS #3 knew what the residents liked to do. She stated that she knew that the alert ones mostly liked arts and crafts, and for the dementia residents we do coloring, balloon toss, sensory activities, sensory blocks, and puzzles. Surveyor #3 asked who would complete the activity assessments on the residents to determine what activity they liked. She stated that was on one of her computers. Surveyor #3 asked who assigned the activity staff their assignments and AS #3 stated, well, we don't have our own boss and stated two of the other activity staff would determine that. Surveyor #3 asked AS #3 if she every spoke to families about the residents. She stated she never talked to the families. She stated, she used to work in the evenings, but the schedule has changed since COVID and there was no evening bingo because of COVID. Surveyor #3 asked AS #3 if she utilized the activity assessments to determine what types of activities resident's like and what activities would be provided. She stated she never looked at the activity assessment and stated we provided a daily chronical, or a newspaper daily, coloring and trivia. She stated we could read the chronical to them and read the date and year to the people in the room, and they had a radio that they put in the ventilator unit to play music for people.
On 07/26/22 12:08 PM, Surveyor # 4, in the presence of the survey team, interviewed AS #1, who stated she had worked at the facility for 22 years as a recreation assistant (activity staff). AS #1 stated we tried to address each resident's needs, read the assessments, and established relationships with the residents. The AS #1 stated the LHNA and AA were overseeing the Activity Department at present, and the LHNA was new. She stated they currently provided the LHNA and AA with the Activity Calendar for review and the OT/AD was not involved with the process. The AS #1 stated there were things that the AS wanted to do, and there were something's that they wanted to do and they had to wait on because of management. The AS #1 provided an example regarding the snacks the residents had requested for happy hour. She stated she would hand the list over to the Food Service Director (FS). The surveyor inquired if the FSD would respond back and she stated, I don't know how it works, maybe it went to the upper management. She stated she was unaware who was responsible or how to follow-up with resident food complaints, since the FSD would inform her that he would take care of the complaints. The surveyor inquired to AS #1 how it would be determined who would attend an activity. She stated that she would ask nursing, since they could not go room to room and they tried to do one on one resident room visits, but sometimes they could not do it. She stated they would call family for residents who were unable to speak. When asked where the documentation would be to confirm that she had contacted a resident's family, she stated that it was not documented anywhere, and she was not aware that she would have to document it. The surveyors inquired about the facility having any resident trips. She stated we haven't because of COVID and the former LHNA told them, no outside trips would be allowed because the van was too small. She stated that the activity staff did not complete the MDS section for the residents. The surveyor inquired if weekend activities were conducted. The AS #1 stated that there were scheduled independent resident activities for the weekend, which may include a packet of word games. The surveyor asked the AS #1 to review the July 2022 Activity Calendar dated 21 and to explain what ADMIT Categories was as listed on the calendar and was untimed. She stated that she did not know what that activity was.
Surveyor #3 reviewed the July 2022 Activity Calendar for the following Saturdays which revealed the following activities 07/07/22, Int'l [international] Joke Day, AM Activities, Chronical & Coffee Delivery, Grins & Groans, Searching for Laughter, Afternoon Highlights, Funny Letters of Complaints (All untimed), 07/09/22, AM Activities, Afternoon Highlights, Chronical & Coffee Delivery, Anything Goes Exercise, It's Puzzling, Afternoon Highlights, Group Up (All untimed).
Surveyor #3 requested the resume for the OT/AD and it was provided on 07/27/22 at 1:15 PM, by the LHNA. The resume revealed the OT/AD did not have any documented work experience or training in activities or therapeutic recreation. The OT/AD was the Interim Director of Recreation from September 2021 through January 2022 and from June 2022 to current: Lead and oversee the personnel and facilitates organization of the recreation department.
On 07/27/22 2:07 PM, Surveyor #3, in the presence of the survey team interviewed the Occupational Therapist/ Activity Director (OT/AD) about her job function as the Activity Director. The AD/OT stated she completed the activity care plans and added interventions on the care plans. She stated she did not speak to resident families often, did not reach out to contact resident families, and would base her activity interventions for the CP on what the activity staff did with the resident. The AD/OT stated she did not provide oversight for the activity program assessments, and she did not complete any of the activity assessments. The AD/OT confirmed that she never reviewed activity assessments that were completed by the activity staff. and stated she had attended to the interdisciplinary meetings and completed activity care plans. The AD/OT also confirmed that there were no activities scheduled with other departments and stated they it should be. The AD/OT was not involved with budgeting, since everything was directed to the prior LHNA. The AD/OT stated there used to be activities planned outside and she was not sure about that now. She stated Surveyor #3 inquired to the AD/OT about what her role was to lead and oversee the personnel and facilitates organization of the recreation department. She stated the activity staff created the activity calendars, and that she just completed care plans and went to the interdisciplinary meetings.
On 07/28/22 at 8:26 AM, Surveyor #3 toured the B-Wing and observed a large July activity calendar affixed to the wall in hallway. The activities listed for the 28 th were: Star of the Month, [redacted], AM Activities, Chronical & Coffee Delivery, [redacted] Packet, Afternoon Highlights, Perfect Puzzles, all were un-times. The Lower portion of the calendar revealed, all activities are subject to change, Religious/Spiritual needs met throughout the month (no specifics indicated), Calendar subject to change per State, Dept. of Health, CDC guidelines and CMS Regulations, Independent Leisure & Materials Provided, In-room Exercise Encouraged, Video Chat/Phone Assistance Available, Heart to Heart Moments & Sensory Stimulation offered daily, Mail delivered daily
On 07/28/22 at 8:30 AM, Surveyor #3 interviewed the B-Wing nurse unit Manager (UM). The UM stated she had been the UM since March 2022. Surveyor #3 inquired about the resident activity program and what activities were provided for the residents. The UM stated that activity staff would come around and usually pass around the Chronical (a one-page document with facts) and offer coffee. She stated that since she had been employed at the facility, the B-Wing Day room had not been used for unit activities. Surveyor #3 inquired to the UM if there were times for the activities listed on the calendar. The UM looked at the activity calendar posted to the wall and stated, no it does not. The UM stated that to her knowledge the calendar has never had times listed. Surveyor #3 had observed a large outside courtyard with access from the B-Wing dayroom. Surveyor #3 inquired to the UM if residents were ever taken outside to use the courtyard. The UM stated if residents could go outside on their own, they were allowed to; and if a resident would ask, nursing would try to take them if they had time. Surveyor #3 inquired if a resident was unable to ask to go outside, would they be provided outside time, and she stated that she could not say they would be taken outside. Surveyor #3 inquired if the residents had ever gone on trips. The UM stated they used to go to the dollar store, but no trips anymore.
On 07/28/22 at 9:39 AM, Surveyor #3 entered Resident #239's room with a Licensed Practical Nurse (LPN). The resident was in bed, with eyes open and did not respond to the nurse. The room was not personalized, the resident was not engaged in an activity, no music was playing, and there was no activity calendar posted in the room.
On 07/28/22 at 9:48 AM, Surveyor #3 interviewed the LPN in the hallway outside of the day room. Surveyor #3 interviewed the LPN about the activities provided to the C- wing residents. The LPN stated there used to be activity calendars in each room. The LPN, who stated she had worked at the facility for 16 years, proceeded to point to an empty white board affixed outside of the C-Wing day room. She stated there used to be an activity calendar posted there (on the white board). The LPN stated activities would offer coffee to residents, and the rehabilitation residents on C-Wing did not mingle with the residents downstairs. The LPN stated that the activity staff would do what they can.
On 07/28/22 at 9:59 AM, Surveyor #3 interviewed AS #2 regarding her job functions. The AS #2 stated she would complete activity assessments for the C-Wing residents when they were admitted , since the residents were mostly sub-acute (short term rehabilitation) residents. AS #2 stated she was responsible for mostly all of the resident activity assessments. AS #2 stated she began completing the activity assessments for the residents as the activity staff diminished. She stated that the assessment was supposed to be completed within 5 days, and that she was unable to complete all the assessments timely because she would be pulled to work on the units. Surveyor #3 inquired to AS #2 regarding an activity assessment and activity care plan for Resident #239. The AS #2 stated that she really did not know what Resident #239 liked to do, because she did not spend a lot of time on C-Wing. The AS # stated, like I said, we are real thin. The AS #2 stated I am not allowed to complete resident CP and she stated she had no access to them on the computer. Surveyor #3 inquired to AS #2 if there was a Care Plan for Resident #239's activity interests and she reviewed the CP in the presence of Surveyor #3. The AS #2 could not locate a Care Plan for activities for Resident #239. The AS #2 reviewed the activity assessment for Resident #239 that was completed February 28, 2022. She stated that the assessment indicated that family was not contacted and had been unable to be reached for preferences related to activities and she had used information from the resident's medical record to complete the assessment.
On 0728/22 at 10:13, Surveyor #3 was provided with the most recent completed admission MDS for Resident #239, dated 05/25/22. The MDS revealed the resident was rarely/never understood, has moderately impaired decision-making ability and has an impaired memory. Activity preferences section of the MDS indicated that it was very important for the resident to listen to music the resident likes and be around pets.
Surveyor #3 reviewed Resident #239's Progress Notes (PN), dated 07/09/22 at 3:45 AM through 07/27/22 at 1:01 PM. There were no Activity PN observed. A Social Service PN dated 07/26/22 at 1:27 PM revealed the Social Worker had a telephone call with the family member.
On 07/28/22 at 11:22 AM, Surveyor #3 interviewed the LHNA, who stated he had been at the facility for less than one month and that the OT/AD was overseeing the Activity Department. The LHNA stated, that to his knowledge and per the system put into place by the former LHNA, the OT/AD was completing the activity assessments, completing the MDS, CP's and met with the residents. Surveyor #3 inquired to the LHNA what the role of the Activity Director should entail and the LHNA stated that the Activity Director should complete resident assessments, complete the MDS and develop an Activity Calendar that meets the needs of the residents, keeps the residents engaged and fulfilled.
A review of the facility provided policy, Activities and Social Events with an effective date 08/2021, revealed Policy: All residents have the right to choose the types of activities and social events in which they wish to participate. Procedure: 1. Residents are encouraged to choose the types of activities and social events in which they prefer to participate; 2. When developing the residents' activity and social care plan, the resident should be given an opportunity to choose when, where, and how he or she will participate in activities and social events. Activities, social events and schedules are developed in conjunction with the resident's interests, activities, at or away from the facility, are encouraged to do so, 6. Daily activities, including those on weekends and holidays, are provided as well as scheduled religious and social activities .
A review of the facility provided policy, Care Plan Policy, Effective 07/2022 revealed Purpose: To develop and implement a care plan for each resident/patient that includes the interventions needed to provide effective and person-entered care of the resident/patient that meet professional standards of quality of care. The Care Plan will be consistent with the resident/patient rights that include measurable objectives and time frames to meet a resident's/patient's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Scope: All clinical departments and resident/patient care areas of nursing and rehabilitation facilities.
NJAC 8:39-7.3(a); 4.1(a)24, 28
Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to: a.) provide a meaningful and individualized activity programs to enhance the life of severely cognitively impaired residents (Resident #18 and Resident #101), and b.) ensure activities, social events and schedules were developed in conjunction with resident interests and needs. This deficient practice occurred for 3 of 3 residents reviewed for activities (Resident #18, Resident #101, and Resident #239), on 3 of 4 resident care units (Unit A, B & C), and for 6 of 6 residents who attended a resident council meeting. The deficient practice was evidenced by the following:
Refer to 680F
On 07/26/22 at 10:30 AM, the surveyor conducted a resident meeting with six alert and oriented residents. Resident (R1) stated that the facility has not had a Director of Recreation for about six months, and it had affected the residents. R #1 stated that the residents had felt that they were not getting enough activities, and there were no activities during the weekend. R #1 stated we just sit here. R #1 stated there was not much offered during the week, and once a week we might do a craft. R1 stated that there were no outside trips since the pandemic began (approximately a two-year time span). R #1 stated the resident council was concerned and wanted to know what the facility was providing to ensure the confused residents received activities since the alert and oriented residents were not being provided with resident activities. R#1 stated the facility did not offer any activities in the evening. Six of Six residents in attendance agreed with R #1's statements. Another resident, (R #2) stated that he/she could not remember the nursing staff member's name, however, stated that he/she had been told by nursing staff to find things keep him/herself busy, and that was what R #2 had tried to do.
a. On 07/24/22, the surveyor reviewed Resident #18's electronic medical record (EMR). Resident #18's diagnoses included, Dysphagia, hemiplegia, vascular dementia without behavioral disturbances, hemiparesis following other cerebrovascular disease, pressure ulcers of sacral region.
The admission Minimum Data Set (MDS) an assessment tool used to prioritize care, dated 01/08/22, revealed that Resident #18 had a BIMS of 3 out of 15. This score was indicative of severely impaired cognition. Resident #18 was dependent upon staff to anticipate and assist with all activities of daily living (ADL).
The resident care plan dated 06/14/22 had a focus for Activities: Limited participation. The goal was for Resident #18 to receive 1:1 visits, sensory stimulation to maintain current level of socialization within the next 90 days. Interventions included, Provides social /emotional support. Communicate with Interdisciplinary team any changes in mood and behavior.
The surveyor observed Resident #18 on 07/19/22 at 11:47 AM, and noted that Resident #18 was laying on their backside facing the wall. The television on the wall was turned off and the wall was bare with no visual items on the wall to look at when he/she was awake.
An observation on 07/20/22 at 9:45 AM, revealed Resident #18 laying on the bed, the head of the bed was elevated and Resident #18 was able to respond to the surveyor's greeting. Resident #18 was looking at the bare wall and the television was turned off.
Further review of Resident #18's EMR revealed that section F of the MDS which referred to Preferences for Customary Routine and Activities was not completed.
On 07/28/22 at 9:04 AM, an interview with the Activity staff assigned to conduct activities on the B-Wing revealed that Resident #18's Initial Rec[TRUNCATED]
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected most or all residents
Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the activities program was directed by a qualified therapeutic rec...
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Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the activities program was directed by a qualified therapeutic recreation specialist or activity professional. The deficient practice was evidenced by the following:
Refer to 679F
On 07/26/22 at 10:30 AM, the surveyor conducted a resident meeting with six alert and oriented residents. Resident (R1) stated that the facility has not had a Director of Recreation for about six months, and it had affected the residents. R #1 stated that the residents had felt that they were not getting enough activities, and there were no activities during the weekend. R #1 stated we just sit here. R #1 stated there was not much offered during the week, and once a week we might do a craft. R1 stated that there were no outside trips since the pandemic began (approximately a two-year time span). R #1 stated the resident council was concerned and wanted to know what the facility was providing to ensure the confused residents received activities since the alert and oriented residents were not being provided with resident activities. R#1 stated the facility did not offer any activities in the evening. Six of Six residents in attendance agreed with R #1's statements. Another resident, (R #2) stated that he/she could not remember the nursing staff member's name, however, stated that he/she had been told by nursing staff to find things keep him/herself busy, and that was what R #2 had tried to do.
On 07/26/22 at 11:13 AM, the surveyor interviewed the Occupational Therapist/Activity Director (AD/OD), in the presence of the survey team, regarding her role as the Activity Director. The OT/AD stated she was currently functioning as an occupational therapist and had a modified case load.
The OT/AD stated she had not received specialized training in activities and was involved with the restorative program (assist with helping residents maintain physical function and limit deterioration). She stated that a new Director was supposed to start in August, however, she had been in the role from September 2021 to January 2022 and from June 2022 to present. She stated the activity staff completed the Activity Calendars and stated, I don't sign off on the calendar, and the activity staff were responsible for completing the activity assessments.
On 07/26/22 at 11:31 AM, the surveyor interviewed AS #3, in the presence of the survey team, regarding her job functions. AS #3 stated she went to the floors, completed one- to- one resident visits, delivered mail, passed out beverages, entertainment. The surveyor inquired as to how AS #3 knew what the residents liked to do. She stated that she knew that the alert ones mostly liked arts and crafts, and for the dementia residents we do coloring, balloon toss, sensory activities, sensory blocks, and puzzles. The srveyor asked who would complete the activity assessments on the residents to determine what activity they liked. She stated that was on one of her computers. The surveyor asked who assigned the activity staff their assignments and AS #3 stated, well, we don't have our own boss and stated two of the other activity staff would determine that. The surveyor asked AS #3 if she every spoke to families about the residents. She stated she never talked to the families. She stated, she used to work in the evenings, but the schedule has changed since COVID and there was no evening bingo because of COVID. The surveyor asked AS #3 if she utilized the activity assessments to determine what types of activities resident's like and what activities would be provided. She stated she never looked at the activity assessment and stated we provided a daily chronical, or a newspaper daily, coloring and trivia. She stated we could read the chronicle to them and read the date and year to the people in the room, and they had a radio that they put in the ventilator unit to play music for people.
On 07/26/22 12:08 PM, a surveyor, in the presence of the survey team, interviewed AS #1, who stated she had worked at the facility for 22 years as a recreation assistant (activity staff). AS #1 stated we tried to address each resident's needs, read the assessments, and established relationships with the residents. The AS #1 stated the LHNA and AA were overseeing the Activity Department at present, and the LHNA was new. She stated they currently provided the LHNA and AA with the Activity Calendar for review and the OT/AD was not involved with the process. The AS #1 stated there were things that the AS wanted to do, and there were something that they wanted to do and they had to wait on because of management. The AS #1 provided an example regarding the snacks the residents had requested for happy hour. She stated she would hand the list over to the Food Service Director (FS). The surveyor inquired if the FSD would respond back and she stated, I don't know how it works, maybe it went to the upper management. She stated she was unaware who was responsible or how to follow-up with resident food complaints, since the FSD would inform her that he would take care of the complaints. The surveyor inquired to AS #1 how it would be determined who would attend an activity. She stated that she would ask nursing, since they could not go room to room and they tried to do one on one resident room visits, but sometimes they could not do it. She stated they would call family for residents who were unable to speak. When asked where the documentation would be to confirm that she had contacted a resident's family, she stated that it was not documented anywhere, and she was not aware that she would have to document it. The surveyors inquired about the facility having any resident trips. She stated we haven't because of COVID and the former LHNA told them, no outside trips would be allowed because the van was too small. She stated that the activity staff did not complete the MDS section for the residents. The surveyor inquired if weekend activities were conducted. The AS #1 stated that there were scheduled independent resident activities for the weekend, which may include a packet of word games. The surveyor asked the AS #1 to review the July 2022 Activity Calendar dated 21 and to explain what ADMIT Categories was as listed on the calendar and was untimed. She stated that she did not know what that activity was.
The surveyor requested the resume for the OT/AD which was provided on 07/27/22 at 1:15, by the LHNA. The resume revealed the OT/AD did not have any documented work experience or training in activities or therapeutic recreation. The OT/AD was the Interim Director of Recreation from September 2021 through January 2022 and from June 2022 to current: Lead and oversee the personnel and facilitates organization of the recreation department.
On 07/27/22 at 1:15 PM, the Licence Nursing Home Administrator (LHNA) provided the surveyor with the unsigned/undated Recreation Director Job Description, with a grayed out DRAFT typed over the document. The document revealed. Job Summary: The Recreation Director provides an ongoing program of activities designed to meet, in accordance with a comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. Essential Generic Job Functions: 1. Assess resident needs and develops resident activity goals for the care plan, 2. Encourages resident participation in activities and document outcomes, 3. Reviews goals and progress notes, 4. Provides a plan of activities appropriate to the needs of the residents including but not limited to group social activities, indoor and outdoor activities community activities, and spiritual programs, 6. Coordinates the activities program with other departments in the facility, 7. Recruits, trains, and supervises volunteers, 8. Properly documents MDS (Resident assessment tool), 9. Participates with administrator in developing a budget, 10. Fosters family and community support for the activity program, 11. Contributes to facility efforts to maintain and improve quality of care through participation in care plan meetings. Contacts: 1. Regular contact with residents, resident's family/significant others and visitors .Knowledge, Education and Skills Required: 1. Education: Minimum: High school diploma or equivalent and satisfactory completion of a training course for activity directors approved by the Department of Health & Human Services .
On 07/27/22 at 2:07 PM, The surveyor, in the presence of the survey team, conducted an additional interview with the Occupational Therapist/Activity Director (OT/AD) about her job functions as the Activity Director. The AD/OT stated she completed the activity care plans and added interventions on the care plans. She stated she did not speak to resident families often, did not reach out to contact resident families, and would base her activity interventions for the CP on what the activity staff did with the resident. The AD/OT stated she did not provide oversight for the activity program assessments, and she did not complete any of the activity assessments. The AD/OT confirmed that she never reviewed activity assessments that were completed by the activity staff. and stated she had attended to the interdisciplinary meetings and completed activity care plans. The AD/OT also confirmed that there were no activities scheduled with other departments and stated they it should be. The AD/OT was not involved with budgeting, since everything was directed to the prior LHNA. The AD/OT stated there used to be activities planned outside and she was not sure about that now. The surveyor inquired to the AD/OT about what her role was to lead and oversee the personnel and facilitates organization of the recreation department. She stated the activity staff created the activity calendars, and that she just completed care plans and went to the interdisciplinary meetings (The AD/OT failed to meet all of the the requirements for the facility Recreation Director Summary of Duties, which included: Assess resident needs and develops resident activity goals for the care plan, 2. Encourages resident participation in activities and document outcomes, Reviews goals and progress notes, Provides a plan of activities appropriate to the needs of the residents including but not limited to group social activities, indoor and outdoor activities community activities, and spiritual programs, Coordinates the activities program with other departments in the facility, Recruits, trains, and supervises volunteers, Properly documents MDS (Resident assessment tool), Participates with administrator in developing a budget).
On 07/28/22 at 8:26 AM, the surveyor toured the B-Wing and observed a large July activity calendar affixed to the wall in hallway. The activities listed for the 28th were: Star of the Month, [redacted], AM Activities, Chronicle & Coffee Delivery, [redacted] Packet, Afternoon Highlights, Perfect Puzzles, all were un-times. The Lower portion of the calendar revealed, all activities are subject to change, Religious/Spiritual needs met throughout the month (no specifics indicated), Calendar subject to change per State, Dept. of Health, CDC guidelines and CMS Regulations, Independent Leisure & Materials Provided, In-room Exercise Encouraged, Video Chat/Phone Assistance Available, Heart to Heart Moments & Sensory Stimulation offered daily, Mail delivered daily
On 07/28/22 at 8:30 AM, the surveyor interviewed the B-Wing nurse unit Manager (UM). The UM stated she had been the UM since March 2022. The surveyor inquired about the resident activity program and what activities were provided for the residents. The UM stated that activity staff would come around and usually pass around the Chronicle (a one-page document with facts) and offer coffee. She stated that since she had been employed at the facility, the B-Wing Day room had not been used for unit activities. The surveyor inquired to the UM if there were times for the activities listed on the calendar. The UM looked at the activity calendar posted to the wall and stated, no it does not. The UM stated that to her knowledge the calendar has never had times listed. Surveyor #3 had observed a large outside courtyard with access from the B-Wing dayroom. The surveyor inquired to the UM if residents were ever taken outside to use the courtyard. The UM stated if residents could go outside on their own, they were allowed to; and if a resident would ask, nursing would try to take them if they had time. Surveyor #3 inquired if a resident was unable to ask to go outside, would they be provided outside time, and she stated that she could not say they would be taken outside. The surveyor inquired if the residents had ever gone on trips. The UM stated they used to go to the store, but no trips anymore.
On 07/28/22 at 9:48 AM, the surveyor interviewed the LPN in the hallway outside of the day room. The surveyor interviewed the LPN about the activities provided to the C-Wing residents. The LPN stated there used to be activity calendars in each room. The LPN, who stated she had worked at the facility for 16 years, proceeded to point to an empty white board affixed outside of the C-Wing day room. She stated there used to be an activity calendar posted there (on the white board). The LPN stated activities would offer coffee to residents, and the rehabilitation residents on C-Wing did not mingle with the residents downstairs. The LPN stated that the activity staff would do what they can.
On 07/28/22 at 9:59 AM, the surveyor interviewed AS #2 regarding her job functions. The AS #2 stated she would complete activity assessments for the C-Wing residents when they were admitted , since the residents were mostly sub-acute (short term rehabilitation) residents. AS #2 stated she was responsible for mostly all of the resident activity assessments. AS #2 stated she began completing the activity assessments for the residents as the activity staff diminished. She stated that the assessment was supposed to be completed within 5 days, and that she was unable to complete all the assessments timely because she would be pulled to work on the units. The surveyor inquired to AS #2 regarding an activity assessment and activity care plan for Resident #239. The AS #2 stated that she really did not know what Resident #239 liked to do, because she did not spend a lot of time on C-Wing. The AS # stated, like I said, we are real thin. The AS #2 stated I am not allowed to complete resident CP and she stated she had no access to them on the computer.
On 07/28/22 at 11:22 AM, the surveyor interviewed the LHNA, who stated he had been at the facility for less than one month and that the OT/AD was overseeing the Activity Department. The LHNA stated, that to his knowledge and per the system put into place by the former LHNA, the OT/AD was completing the activity assessments, completing the MDS, CP's and met with the residents. The surveyor inquired to the LHNA what the role of the Activity Director should entail and the LHNA stated that the Activity Director should complete resident assessments, complete the MDS and develop an Activity Calendar that meets the needs of the residents, keeps the residents engaged and fulfilled.
A review of the facility's policy, Activities and Social Events with an effective date 08/2021 revealed Policy: All residents have the right to choose the types of activities and social events in which they wish to participate. Procedure: 1. Residents are encouraged to choose the types of activities and social events in which they prefer to participate; 2. When developing the residents' activity and social care plan, the resident should be given an opportunity to choose when, where, and how he or she will participate in activities and social events. Activities, social events and schedules are developed in conjunction with the resident's interests, activities, at or away from the facility, are encouraged to do so. 6. Daily activities, including those on weekends and holidays, are provided as well as scheduled religious and social activities .
NJAC 8:39-7.3(a); 4.1(a)24, 28
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected most or all residents
Based on interviews, the resident council meeting, review of medical records and other pertinent facility documentation it was determined that the facility was not consistently offering nighttime snac...
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Based on interviews, the resident council meeting, review of medical records and other pertinent facility documentation it was determined that the facility was not consistently offering nighttime snacks to all residents on a nightly basis. This deficient practice was identified for 9 of 47 unsampled residents on 1 of 4 units (A-wing) and was evidenced by the following.
On 07/26/22 at 10:31 AM, the surveyor conducted the Resident Council Meeting with six (6) alert and oriented residents. The residents at the resident council meeting were all in agreement that snacks were not consistently being offered at night.
On 07/29/22 at 10:01 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) on the A-Wing who stated that she worked 12 hour shifts, usually 7:00 AM to 7:00 PM and had seen that trays of snacks were delivered approximately 7:00 PM in the evening right before she was ready to leave for the night. However, she added that she was not in the facility when snacks were being handed out to the residents so she was not sure who was offered snacks at night. She stated that snacks that were labeled with resident's names were delivered to residents and are signed out in the Medication Administration Record (MAR) that the resident received the snack and how much was consumed. She was not sure what the process was for the other residents on the unit or if the other residents were offered snacks or not.
On 07/29/22 at 10:02 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) #1 who was currently on orientation on B-Wing who stated that resident snacks were delivered to each individual unit from the kitchen and that the nursing staff on the units were not required to sign any particular form that they received them. She stated that the residents that have assigned snacks or physician ordered snacks were provided with the snack and it was signed out in the MAR that the resident received them. She then added that residents that are not assigned snacks and do not have a name on the snack she was not sure if residents were offered because she did not work at night. The current LPN/UM #2 on B-wing stated that she doesn't work at night so she didn't know if all the residents were offered snacks at night, but was sure that if a resident requested a snack that the nurse would call the kitchen and get the resident a snack of choice.
On 07/29/22 at 11:00 AM, the surveyor interviewed the facility's Registered Dietician (RD) who stated that she had been employed since March 2022. The RD stated that residents with weight loss issues, potential weight issues or diabetics were ordered snacks by the physician which were signed out by the nurse in the MAR that the resident received the snack and how much snack the resident consumed. These snacks were recommended by the dietician and were ordered by the physician. The RD stated that all residents should be offered snacks at night, not just the residents that had physician ordered snacks. She added that she did not know why some residenst had an order on the MAR to offer snacks and some do not. She stated that she would get the surveyor the facility policy and the information.
The surveyor reviewed the Physician Orders (PO), MAR and Treatment Administration Record (TAR) for 47 unsampled residents on the A-wing and determined that 9 unsampled residents did not have documentation on the MAR, TAR or PO that they were offered a nighttime snack. The surveyor reviewed the 47 unsampled residents MAR which revealed that 38 residents had an order on the MAR which read to offer a nighttime snack and 9 residents did not have a order on the MAR to offer the resident a nighttime snack.
On 07/29/2022, the Food Service Director (FSD) provided the surveyor with a facility policy dated 10/2021 titled, Nightly Snack Policy. The purpose of the policy was to ensure that all patients/residents are offered nutritious snacks at bedtime and there is more than 14 hours between the dinner and breakfast meals. The policy specified that if there was more than 14 hours between a substantial evening meal and breakfast that a nourishing snack must be offered at bedtime following procedure:
-Upon admission add order to MAR/TAR for a nutritious snack to be offered nightly.
-Document performances.
-Distribute snack carts at approximately 07:00 PM.
-The policy indicated that snacks would be offered and/or served to each patient/resident at approximately 07:00 PM by dietary aid or nursing team and that each resident would be offered and served snacks depending on their diet and texture.
-The policy also indicated that snacks would be documented in the MAR/TAR which snack each resident selected and if they selected or declined the nutritious snack.
On 08/02/22 at 12:59 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that he was not familiar with the facility's policy on snacks and would investigate the concerns. The surveyor interviewed the Director of Nursing (DON) at the same time who stated that there were residents that had snacks ordered but was not familiar with the facility's policy on snacks.
On 08/03/22 at 09:42 AM, the LNHA admitted that the facility did not have a system in place for snacks and that the snacks system would be revamped, but at this point the facility would be assuring that all residents will be offered snacks at night.
NJAC 8:39-17.4(b)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interviews, and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is inten...
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Based on observation, interviews, and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) failed to maintain adequate infection control practices during food service in the kitchen.
This deficient practice was observed and evidenced by the following:
On 07/19/22 from 9:47 AM until 11:17 AM, the surveyor toured the kitchen in the presence of the Director of Dietary Services (DDS) and observed the following:
1. The DDS wearing a surgical mask with short facial hair observed on both cheeks and long white facial hair observed on his chin hanging out of the bottom of the surgical mask.
2. In walk-in refrigerator #3, there was one box filled with individual containers of cream cheese with no dates on the box and no dates on the containers. There was one black quarter container of individual cream cheese with no dates. There were six boxes of 720 count individual containers of butter with no dates on the boxes and no dates on the individual butters. The DDS acknowledged that there were no dates on the cream cheese nor on the butter and stated that they should have been dated when they were delivered. The DDS further stated that it was important to date the items to prevent expired items from being served to the residents.
3. In walk-in refrigerator #2, there were six sealed clear plastic bags that contained chopped celery with no label and no dates. The DDS acknowledged that the bags should have been dated and should have had a label.
4. In walk-in refrigerator #1, there was one box that contained two sealed 5 pound packages of ground beef marked use by 7/11/22, and two boxes that each contained four sealed 5 pound packages of ground beef marked use by 7/18/22. The DDS acknowledged that the ground beef should not be in the refrigerator and that it would be thrown away. The DDS further stated that it was important to not serve outdated food because you don't want to contaminate the residents with bacteria in bad food.
5. In the top convection oven, on the inside doors there was black greasy debris and black debris resting on the oven floor. In the bottom convection oven, on the inside doors there was black greasy debris and black debris resting on the oven floor. The DDS acknowledged that the debris should not be there and stated that it was important to keep the ovens clean so debris didn't get into food and for the prevention of cross contamination.
6. The standing mixer was covered with a plastic bag. The DDS removed the bag which revealed white debris and white dried drippings on the motor and the bowl, on the back of the machine and on the back shield. The DDS acknowledged the debris and told the cook to reclean the mixer. The DDS stated that it was important to keep the mixer clean to prevent cross contamination with bacteria and fresh food.
7. The stove top was observed with brown, white, and black debris and the back of the stove with white greasy drippings. The DDS acknowledged the debris and stated that the stove was not cleaned in days and that it should all have been wiped down and that the burners should have been placed in the dishwasher.
8. There was a large white covered bin that contained brown rice which was labeled rice with no dates. The DDS discarded the rice and acknowledged that the bin should have been dated to show how old the rice was.
9. The ice machine was filled with ice. There was black debris along the underside of the lid. The DDS acknowledged that the debris should not have been there and stated that it was from condensation.
10. On the clean rack were three large white cutting boards all with black smudges, brown smudges, and black marks. The DDS acknowledged that the marks should not have been on the cutting boards and that they should have been clean to prevent cross contamination.
11. In the freezer was one sealed resealable plastic bag with seven pieces of square breaded meat that the DDS identified as breaded cod with no label and no dates. There was one opened 10 pound box labeled Italian style chicken breast meat that contained: one opened, unsealed clear plastic bag that contained eight pieces of tan meat that were visible and exposed to air with no date, and one opened clear plastic bag wrapped in clear plastic that contained eight pieces of tan meat with no date. The DDS acknowledged that the food items should not have been stored that way and stated that it was important to wrap, label and date all the food correctly so everyone would know how old the food was, to prevent freezer burn, and to make sure the quality of the product was still good.
12. On a metal rack in the dry storage room there was one dented 6.38 pound can of stewed tomatoes, one dented 6.56 pound can of corn, and one dented 6.6 pound can of crushed tomatoes. The DDS acknowledged that the cans were dented and stated that they should have been on the dented can rack. The DDS removed the cans and stated that it was important to not use the dented cans because they could have caused botulism.
On 07/19/22 at 11:09 AM, the surveyor interviewed the DDS on the hairnet policy in the kitchen who stated that everyone had to wear a hairnet or a hat, and that all hair had to be covered. The DDS acknowledged that he was wearing a surgical mask and that his facial hair was not covered and stated that it was important to cover all hair so it didn't contaminate the food.
On 07/20/22 from 11:56 AM until 12:23 PM, the surveyor toured the kitchen in the presence of the DDS and observed the following:
1. Five staff members on the tray line that prepped and prepared trays for lunch. One dietary aide (DA#1) on the tray line who prepped the food trays with coffee and cream, removed and replaced covers from the plates, and placed trays on the food cart, was wearing a hairnet that covered the back of her hair with the front sides and top of her hair exposed. One DA#2 on the tray line who prepped the food trays at the prep refrigerator, placed milk, juice, and desserts on trays, was wearing a hairnet that covered the top of her hair and her ponytail with the back of her hair exposed.
2. On a metal prep table there was one box of 12 inch x 2000 foot roll of food service film that was open and exposed to air. The DDS stated that the film was for wrapping sandwiches once they were prepped and that it should have been covered so no debris would get into the food.
On 07/20/22 at 12:21 PM, the surveyor interviewed DA#1 who stated that hairnets were always to be worn in the kitchen and that she was wearing it correctly. DA#1 was then observed pulling the front of her hairnet down over the exposed hair on the top and sides of her head and stated, I fixed it. DA#1 then further stated that it was important to cover all hair with the hairnet so hair doesn't get into the food. DA#1 was then observed removing her gloves and handwashing at the sink for 28 seconds before donning new gloves.
On 07/20/22 at 12:23 PM, the surveyor interviewed DA#2 who stated that everyone was to wear a hairnet in the kitchen and that her hair was short and that was why it fell out of the hairnet and that she needed to put her hair inside the hairnet. DA#2 further stated that it was important to wear the hairnet correctly because some hair may land on the tray and that would be dirty because the resident could eat it.
On 07/25/22 from 9:58 AM until 10:12 AM, the surveyor toured the kitchen in the presence of the DDS and observed the following:
1. On a metal shelf in refrigerator #1 there was one 10.75 pound box of sealed packaged beef cubes that was dated that it was received 7/19/22, with no pulled or use by dates. The DDS stated he did not know when the beef cubes were pulled, did not answer when asked when they should be used by, then stated they were good for 7 days. There was one hotel pan covered with clear wrap that the DDS identified as baked ziti, with no label and no date. The DDS acknowledged that it should have been dated and told the cook to discard it. The DDS stated that the ziti should have had a tag with the date and that it would only be good for three days. On the bottom shelf of a metal rack was one box that was labeled and stamped that it was packaged on 7/6/22, that contained two sealed clear bags that contained 10 pounds boneless skinless chicken thighs in pink liquid that were in an opened blue plastic bag, with no pulled or use by dates. The DDS acknowledged the chicken was not labeled correctly and stated that he did not see a tag on the box and that he was unsure when the chicken was pulled. The DDS then removed the box from the refrigerator and disposed of it in the garbage. The DDS further stated that the box of chicken should have been labeled with the delivery date when it was received, and that it was important to label things correctly so everyone would know when to get rid of food before it spoiled.
On 07/25/22 at 10:12 AM, the surveyor observed the DDS wearing a surgical mask with long white hair exposed from his chin under the surgical mask. The DDS acknowledged he was not wearing a beard guard and stated that if he was in the kitchen he should have worn a beard guard. The DDS stated that it was important to cover all hair because hair would fall into people's food.
On 08/02/22 at 1:21 PM, the Team Coordinator presented the kitchen findings to the Licensed Nursing Home Administrator (LNHA).
On 08/03/22 at 10:09 AM, the surveyor interviewed the LNHA on the kitchen hairnet policy. The LNHA stated that everyone should have worn a hairnet in the kitchen and that if there was facial hair that a beard guard should have been worn. The LNHA acknowledged that the kitchen staff should have had all their hair covered for infection control so that no hair escaped into the food.
The surveyor reviewed the facility's undated policy, Hairnets and Gloves, which revealed, Policy: While in the kitchen all team members must wear proper head wear (hairnets, hats, beard restraints, etc) to restrain hair .Procedure: Step 1. Upon entering the kitchen all persons must put on a hairnet.
The surveyor reviewed the facility's undated policy, Refrigerated Storage, which revealed, Procedure: Step 1. All items in the refrigerator must be labeled properly. They must follow the Food Labeling Policy.
The surveyor reviewed the facility's undated policy, Frozen Storage, which revealed, Procedure: Step 1. All items in the freezer must be labeled in accordance with the Food Labeling Policy.
The surveyor reviewed the facility's policy, HMNR Dry Food Storage, revised 03/2018, which revealed, Procedure: Step 1. All items in dry storage must be labeled in accordance with the Food Labeling Policy.
The surveyor reviewed the facility's undated policy, Food Labeling, which revealed, Policy: All food must be labeled properly upon delivery and after preparation. If food is not properly labeled it will be discarded. Labeling Upon Delivery, Procedure: Step 1. Once any food products are received they must be dated and labeled immediately. 2. All items will be dated with the day it was received in the following fashion: MM/DD/YYYY. 3. If food is taken out of packaging that there is no label, they must be labeled what the product is. (Ground beef, chicken breast, parmesan cheese, etc.) 5. If applicable, the use by date must be labeled on the food item. Labeling After Food Preparation Delivery, Procedure: Step 1. After food preparation is complete and food will be stored for later cooking, reheating, or consumption items must be labeled with description, preparation date, and expiration date. All dates in the following fashion: MM/DD/YYYY. 6. Any items that are not labeled correctly must be discarded. 7. Any items that have past the date and time of expiration must be discarded.
The surveyor reviewed the facility's undated policy, Labeling Policy, which revealed **All food must be labeled & dated with name of product, the date opened & the expiration date** Fresh meat (beef, lamb, steak, pork) 3-5 days. Fresh poultry (chicken, turkey) 1-2 days.
The surveyor reviewed the facility's document, Refrigerator & Freezer Storage Chart, dated March 2018, which revealed, Raw Hamburger, Ground and Stew Meat: Hamburger and stew meats, refrigerator 1-2 days. Fresh Poultry: Chicken or turkey, whole or parts, refrigerator 1-2 days.
The surveyor reviewed the facility's undated policy, Cleaning and Sanitizing Food Contact Surfaces (Sample SOP), which revealed, Purpose: To prevent foodborne illness by ensuring that all food contact surfaces are properly cleaned and sanitized. Instructions: 4. If State or local requirements are based on the 2001 FDA Food Code, wash, rinse, and sanitize food contact surfaces of sinks, tables, equipment, utensils, thermometers, carts, and equipment: .Any time contamination occurs or is suspected.
The surveyor reviewed the facility's document, Prep Cook's Daily Task & Cleaning Log, dated 07/18/2022, which revealed, Prep cook's initials, next to Convi-Oven cleaned checked weekly, 8:00 am prep cook: check mark observed.
The surveyor reviewed the facility's policy, [redacted] Ice Infection Control, with a revision date of 08/2013, which revealed, Procedure: Step 2. Ice needs to be stored in a closed, sterilized, container.
No dented can policy provided.
NJAC 8:39 17.2(g)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility f...
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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 documents, it was determined that the facility failed to a.) ensure the implementation of surveillance techniques to minimize sources and transmission of COVID-19 virus (an acute disease in humans caused by a Coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) by not appropriately ensuring that residents were screened, in Phase 0 of reopening, in accordance with the requirements in the New Jersey Department of Health's (NJDOH) Executive Directive No. 20-026¹ and the Center for Disease Control and Prevention (CDC) guidance for 2 of 3 residents (Resident #89 and #436) reviewed; b.) perform proper hand hygiene and perform a wound treatment in a safe and sanitary manner to reduce the further spread of infection during a Candida Auris (an emerging fungus that presents a serious global health threat) Outbreak for 1 of 5 residents (Resident #19) reviewed for Transmission Based Precautions (TBP) ; and c.) ensure that the urinary catheter drainage bag was stored in a manner to prevent Urinary Tract Infection (UTI) for 1 of 5 residents (Resident #112) reviewed for urinary catheter care.
This deficient practice was evidenced by the following:
1. Reference: A review of NJDOH Executive Directive No. 20-026¹, updated 01/06/21, documented the following:
Under Phases per this Directive: Phase 0: Any facility with an active outbreak of COVID-19, as defined by the Communicable Disease Service (CDS) .
Under section IV. Required standards for services during each phase. 1. Phase 0 . iv. Facilities shall screen all residents, at minimum during every shift with questions and observations for signs or symptoms of COVID-19 and by monitoring vital signs. Vital signs recorded shall include heart rate, blood pressure, temperature and pulse oximetry.
Reference: A review of CDC's Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 02/02/22, documented the following:
Respond to a Newly Identified SARS-CoV-2-infected HCP or Resident. Because of the risk of unrecognized infection among residents, a single new case of SARS-CoV-2 infection in any HCP or a nursing home-onset SARS-CoV-2 infection in a resident should be evaluated as a potential outbreak .Consider increasing monitoring of all residents from daily to every shift, to more rapidly detect those with new symptoms.
On 07/26/22 at 02:01 PM, the surveyor requested the Licensed Nursing Home Administrator (LNHA) provide documented evidence for the facility's screening for COVID-19 for three residents.
On 07/27/22 at 8:45 AM, the surveyor reviewed the facility provided screening Progress Notes titled Nursing Shift Assessment (NSA). The NSA documented the resident's vital signs which included blood pressure, pulse, respiration, temperature and oxygen saturation. The NSA included a section New/Suspected/Known Infection which had listed under the following: Fever/Chills/Shivers, Cough or Shortness of Breath or Increased Sputum Production, Abdominal (Diarrhea/Nausea/Vomiting .) The surveyor then reviewed each resident's screening documents provided which included the following:
Resident #89 had a NSA done on 07/23/22 at 1:44 AM, 07/24/22 at 11:17 PM and 07/26/22 at 8:02 AM. There was not a NSA provided for 07/25/22. There was no documented evidence that the screening (NSA) was done every shift.
Resident #436 had a NSA done on 07/23/22 12:00 AM, 07/24/22 at 12:01 AM and 07/26/22 at 07:07 AM. There was not a NSA provided for 07/25/22. There was no documented evidence that the screening (NSA) was done every shift.
On 07/27/22 at 9:25 AM, during surveyor interview in the presence of the survey team, the LNHA stated that he was not the clinical person but that he believed that the screening was one time a day.
On 07/27/22 at 9:30 AM, during surveyor interview, the Licensed Practical Nurse (LPN) stated that a full set of vital signs would be done one time a day. She then stated that the blood pressure may be done more times if the resident was on a blood pressure medicine and that the oxygen saturation was done every couple hours by the Respiratory Therapist. She then added that the nurses worked 12 hr shifts.
On 07/27/22 at 9:55 AM, during surveyor interview, the Registered Nurse (RN) on B wing stated that the vital signs were obtained every day and that if anything was unusual then would ask all the questions.
On 07/27/22 at 11:23 AM, the surveyor requested from the LNHA any guidance that the facility was following for the screening for COVID-19 that they were performing one time a day. The surveyor then asked the LNHA if the facility was currently in an outbreak. The LNHA confirmed that facility was in an outbreak since April, 2022.
On 07/28/22 at 9:02 AM, the LNHA provided to the survey team the CDC guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes which was updated 02/02/22. The surveyor reviewed the document which the facility marked to indicate the guidance they were following in the following area: Evaluate Residents at least Daily .Actively monitor all residents upon admission and at least daily for fever (temperature =100.0°F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. The surveyor further reviewed the document which includes the following (if facility is in outbreak):
Respond to a Newly Identified SARS-CoV-2-infected HCP or Resident. Because of the risk of unrecognized infection among residents, a single new case of SARS-CoV-2 infection in any HCP or a nursing home-onset SARS-CoV-2 infection in a resident should be evaluated as a potential outbreak .Consider increasing monitoring of all residents from daily to every shift, to more rapidly detect those with new symptoms.
On 08/01/22 at 9:21 AM, during surveyor interview, the Infection Control Manager stated that when in an outbreak, residents should be screened, by taking vital signs and observing if they have any symptoms of COVID-19, every shift if they are not showing symptoms. She then stated that if a resident was in quarantine or had symptoms then the vital signs are obtained every four hours.
On 08/01/22 at 10:09 AM, the surveyor, in the presence of the survey team, told the LNHA the concern that the facility had not been screening the residents for COVID-19 every shift.
On 08/02/22 at 1:35 PM, the facility provided the surveyor with additional documentation that the residents vital signs were obtained more than once a day. The surveyor reviewed the documents which included the following:
Resident # 89's blood pressure was obtained multiple times a day from 07/22/22 to 08/01/22 except for when it was obtained one time a day on 07/27/22 and 07/30/22. Resident #89's oxygen saturation was obtained multiple times a day from 07/25/22 to 8/1/22. Resident #89's pulse was obtained multiple times a day from 7/22/22 to 8/1/22 except for when it was obtained one time a day on 07/27/22 and 07/30/22. Resident #89's temperature was obtained multiple times a day from 07/22/22 to 08/01/22 except for when it was obtained one time a day on 07/27/22 and 07/30/22.
Resident # 436's blood pressure, oxygen saturation and pulse were obtained multiple times a day from 07/28/22 to 07/31/22. Resident #436's temperature was taken one time on 07/19/22, one time on 07/21/22, two times on 07/22/22, one time on 07/23/22, was not taken on 07/24/22, one time on 07/25/22, two times on 07/26/22, was not taken on 07/27/22, two times on 07/28/22, was not taken on 07/29/22, one time on 07/30/22 and three times on 07/31/22.
The facility did not provide any additional documented evidence that the screening for signs and symptoms for COVID-19 were obtained more than one time a day.
On 08/2/22 at 1:35 PM, during surveyor interview in the presence of the survey team, the Director of Nursing (DON) confirmed that the NSA which included the screening for signs and symptoms of COVID-19 was documented one time a day and that it was not documented every shift.
A review of the facility provided policy titled, HMNR Post-Acute and ALF COVID-19-Pandemic Preparedness Infection Control Plan, with an updated date of 04/21/22, which included the following:
Screening of Resident/Patients LTC, Subacute, and Assisted Living (update 08/06/2021)
Facilities will screen all residents/patients, at a minimum set by current NJDOH advisory or Network/facility policy with questions/observations for signs or symptoms of COVID-19 and by monitoring vital signs. Vital signs recorded will include heart rate, blood pressure, respiratory rate-in addition, temperature and pulse oximetry. If any s/s [signs or symptoms] are noted, resident is to be immediately tested and considered a PUI until test results are received .8/6/2021 update-screening of residents/patients as above is required at a minimum daily.
b. On 07/19/2022 at 9:56 AM, during the initial tour of the facility, the surveyor observed that Resident #19's door was pulled closed and there was a Personal Protective Equipment (PPE - refers to protective clothing, gloves, facemasks and/or respirators and other equipment designed to protect the wearer from injury or the spread of infection) caddy that hung on the outside of the resident's door. A Stop Sign was secured on the door that cautioned of Enhanced Barrier Precautions Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting .Wound Care: any skin opening requiring a dressing. The surveyor interviewed Licensed Practical Nurse (LPN#1) who stated that the resident was on contact precautions for Candida Auris (CA). She further explained that according to signage posted on the resident's door, a gown and gloves were only required to be worn in the room for direct contact with the resident and were not required to speak with the resident without direct contact. The resident received care during that time and was not available for interview.
On 07/20/2022 at 11:06 AM, the surveyor observed Registered Nurse (RN #1) as she exited Resident #19's room and immediately performed hand hygiene with alcohol based hand rub (ABHR) that was readily available outside of the resident's room. When interviewed, she stated that the resident had a fungal infection, CA, on his/her toenails that was treated with Epsom salt and vinegar. She explained that the facility provided in-service training to the staff because there were additional residents who tested positive for CA. She stated that the resident's treatment was scheduled today at noon and she agreed to permit the surveyor to observe the treatment. She further stated that all of the resident's wound care supplies were required to be stored in his/her room due to infection control practices.
Review of Resident #19's Face Sheet revealed that the resident was readmitted to the facility in February of 2020 with diagnoses which included but were not limited to: Candidiasis of the skin and nails, nail disorder, and immobility syndrome (paraplegic, partial paralysis).
Review of Resident #19's Quarterly Minimum Data Set (MDS), an assessment tool dated 04/11/2022, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was fully cognitively intact. Further review of the MDS revealed that the resident was totally dependent and required assistance of two persons for bed mobility and transfers and required total dependence of one person for toileting and personal hygiene.
Review of Resident #19's Care Plan Activity Report (CPAR) revealed an entry dated 02/19/2021, titled, Infection: Candida Auris of the toe nail. The entry detailed that the resident completed treatment and went to Infectious Disease on 07/23/3021, and colonization was suspected with no further treatment recommended and resident would be kept on enhanced barrier precautions. Interventions included but were not limited to: Administer topical treatments as ordered, maintain appropriate infection control practices to include proper handwashing, refer to wound specialist as needed, assess, and address any predisposing factors as appropriate, and resident received treatment with Epsom salt and vinegar to the toenails which showed major improve [sic.], Will continue with current treatment. Additional interventions included: Maintain infection control practices through proper hand washing.
Review of Resident #19's Order Activity Detail Report (OADR) revealed the following order: Epsom Salt 100% crystals apply by topical route every other day. Soak gauze pads in two cups of white vinegar, one cup of Epsom salt, to toes and wrap x 20 MINS (minutes). Diagnosis: Dermatophytosis (skin, fungal disease), unspecified. Original order date: 12/06/2021.
On 07/20/2022 at 12:04 PM, the surveyor observed RN #1 who performed hand hygiene with ABHR before she donned a gown and gloves prior to entry to Resident #19's room. RN #1 prepared a printed copy of the resident's treatment order before the surveyor arrived to the unit and she stated that she planned to review it with the surveyor at the bedside prior to the treatment. RN #1 entered the resident's room accompanied by the surveyor and requested permission for the surveyor to view the treatment. When interviewed, the resident agreed and stated that he/she developed the fungal infection of the toenails during military service after his/her feet were submerged in water overseas.
Resident #19 had just finished eating lunch and he/she asked RN #1 to remove his/her clothing protector prior to beginning the treatment. RN #1 removed the clothing protector from the resident as requested. She proceeded to doff (remove) her gloves and gown and placed them in the trash can that was next to the resident's bed. She then went into the resident's bathroom and briefly (too brief to capture the time) and ran her hands under running water without soap application. She dried her hands on a paper towel, turned off the faucet with a second towel and donned another gown and gloves. The resident's phone rang, and RN #1 picked up the phone and answered it for the resident. RN #1 then proceeded to pull up the resident's blankets and exposed his/her feet.
Resident #19's treatment supplies were stored on top of an overbed table in the resident's room. RN #1 obtained two small plastic bags and lifted the resident's feet one at a time and placed a bag under each foot. She then obtained a bottle of normal saline solution (nss) and applied it to a 4 x 4 dressings that she used to cleanse the resident's toe nails bilaterally.
At 12:14 PM, RN #1 obtained a wash basin from the overbed table and took it into the resident's bathroom and rinsed the basin under running water. She then used a disposable washcloth to clean the inside of the basin prior to use.
At 12:15 PM, RN #1 doffed her gloves and washed her hands out of running water for seven seconds. She donned a new pair of gloves after.
At 12:16 PM, RN #1 poured two cups of vinegar and one cup of Epsom salt into the basin. She used an 8 ounce cup for measurement. She stated that the Nurse Practitioner who showed the nursing staff how to do the treatment stated, It was not an exact science. She then soaked 4 x 4 dressings in the solution that was in the basin. She removed the 4 x 4's from the mixture and applied two 4 x 4 dressing to the residents' toe nails bilaterally and then used silk tape to wrap around the 4 x 4 dressings to secure them in place.
At 12:24 PM, RN #1 rinsed the basin out in the resident's bathroom sink, dried it out with a paper towel, and put it inside a plastic bag and then proceeded to place it on top of the resident's overbed table that held his/her treatment supplies.
At 12:25 PM, RN #1 lifted the resident's feet and put each foot inside of a separate plastic bag.
At 12:26 PM, RN #1 doffed her gloves and rinsed her hands under running water without soap application for five seconds. She donned gloves after. Resident #19 observed the surveyor timing the hand washing observation on a stop watch and the resident stated, Sing happy birthday two times when you wash your hands, when she timed you.
At 12:28 PM, RN #1 pulled up the trash bag up that was nearly full inside of the trash can and doffed her gown and gloves inside of it. She then went into Resident #19's bathroom and washed her hands for 13 seconds.
At 12: 29 PM, RN #1 obtained a glove and held it in her right hand and failed to donn (put on) the glove as she used her ungloved hands to tie up the trash bag and remove it from the trash can.
At 12:31 PM, the surveyor accompanied RN #1 to the soiled utility room where she punched in a code with her ungloved index finger prior to entry and discarded the trash bag into a receptacle. RN #1 washed her hands in the soiled utility room for eight seconds. RN #1 then agreed to meet with the surveyor in twenty minutes for removal of Resident #19's dressing.
At 12:55 PM, the surveyor met RN #1 outside of Resident #19's room and observed her as she donned a gown and gloves and failed to tie the gown in the back to secure it. RN #1 leaned over the foot of the resident's bed and removed the plastic bags that were secured over top of the resident's feet. She proceeded to remove the silk tape that secured the dressings into place over top of the 4 x 4 dressings and discarded them into the trash can.
At 12:56 PM, RN #1 doffed her gloves and washed her hands for 9 seconds while she kept her gown on with the plastic loops in place that were secured over her thumbs bilaterally and prevented her from washing the full surface of both of her hands. She donned a new pair of gloves after.
At 12:57 PM, RN #1 doffed both her gown and gloves and placed them in the trash can. She then tied up the trash bag with her bare hands and carried it to the soiled utility room. RN #1 punched in a code to gain access to the room with her ungloved index finger and discarded the trash bag into a receptacle.
At 12:59 PM, the surveyor observed RN #1 as she washed her hands for 14 seconds before she exited the soiled utility room.
At 1:01 PM, the surveyor observed RN #1 as she signed out Resident #19's treatment orders in the computer.
At 1:02 PM, when interviewed, RN #1 stated that she was require to wash her hands for 15-20 seconds or sing happy birthday twice. RN #1 stated that she was required to turn on the faucet,wet her hands, apply soap,scrub her hands and scrub under her nails and wrists, then rinse her hands with her hands pointed downward into the sink, dry her hands with a paper towel, then turn off the faucet with a clean paper towel. RN #1 stated that she thought that she washed her hands for the appropriate length of time most times when the surveyor observed her. RN #1 stated that if there were ABHR in the resident room, there would have been a much less likelihood of her not washing her hands for the appropriate length of time.
RN #1 further stated that she thought that since Resident #19's feet were already in contact with his/her blankets before the treatment, that she was able to wear the same gloves that she used to answer the resident's phone and pull up the blanket to perform the treatment,because the feet were already considered dirty. She stated that she realized after she washed her hands that she had forgotten to doff her gown first. She stated that if she failed to secure her gown in place prior to treatment removal and her uniform may have become contaminated. She further stated that when she did not wash her hands for at least 20 seconds after she touched the resident's feet, she risked the spread of infection.
On 07/21/2022 at 10:23 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that the process to do a wound treatment was to: Wash your hands prior to entering the room. She then explained the hand washing process: Turn on faucet, wet hands, apply soap, lather with soap, clean under the finger nails and the wrists for 20-30 seconds to really clean them, then rinse, pat dry and discard the paper towels, use a clean towel to turn off the faucet. Next, donn gloves. Then begin to gather the required supplies. First, clean the table to be used to place equipment on with bleach wipes and allow it to sit and dry for two minutes (the time recommended by the manufacturer to kill germs), apply a drape to the table, wash your hands after and donn a gown and gloves. Place a drape beneath the area to be treated on the resident's bed to protect the bed linens. Remove the dressing if applicable and wash your hands again. During dressing removal, fold the soiled dressing into the trash, do not just drop it in. Wash your hands and use a clean towel to tie the bag and do not touch the bag with your hands. Once tied, wash your hands again and obtain a clean paper towel to carry the bag to the soiled utility room. When you approach the key pad on the soiled utility door, one hand is clean and should be used to punch in the security code into the key pad. She stated that she would not have used her bare hands to handle the trash bag. She clarified that RN #1 should have had her gloves on when she tied up the trash because if not, it was an infection control issue.
The LPN/UM further stated that the RN #1 should have cleaned off Resident #19's table and applied a drape to the table prior to the wound treatment to prevent infection. The LPN/UM stated that the spread of infection was a concern if RN #1 did not wash her hands for at least 20-30 seconds. The LPN/UM stated that if RN #1's gown was not secured prior to the treatment, there was a risk that the organism (CA) could have gotten onto her uniform and spread. The LPN/UM further stated that there was a risk of spread of infection if the trash bag that contained soiled dressings and PPE were mishandled and RN #1's hands were not washed for the appropriate length of time.
On 07/21/2022 at 11:39 AM, the surveyor interviewed the Director of Nursing (DON) who stated that he covered for the Infection Preventionist (IP) who was currently on vacation. He described the following process for a wound treatment: First, sanitize your hands prior to entry to the resident's room. He then described the process for hand washing: Turn the water on, wet your hands and apply soap and count for 20 seconds while all surfaces of the hands are scrubbed, then rinse the hands, obtain a paper towel to dry your hands and dispose of the towel after, then obtain another paper towel and turn the sink off and then throw the paper towel out. Next, assess the resident's pain level, medicate the resident if needed, wait and reassess the resident. Then, bring the bedside table close by. Perform hand hygiene and donn gloves. Clean the table with bleach wipes and allow for it to dry for two minutes. Once the table had dried, lay out a chux pad (disposable drape) on the table. Gather all needed supplies and place them on the drape in a clean manner.
The DON further stated that the nurse was required to put a chux down on the bed beneath the resident's feet to protect the bed linens. Next, expose the resident's toes, apply the treatment and allow it to sit for 20 minutes as ordered. Then, remove the treatment by placing it on a chux and fold the chux in and around the soiled dressing to contain anything that may be contaminated. Then, dispose of the waste in the garbage. The DON stated that the resident should then be assessed for pain. Then, the nurse should have observed the resident's toes for assessment purposes. The DON stated that the garbage bag should have been tied up while the nurse was still in her full PPE. Then, she should have doffed her PPE and washed her hands for 20 seconds. After, obtain a clean paper towel to remove the garbage and place the bag in the red bag trash in the soiled utility room. The DON stated that the nurse should have washed her hands before she left the clean utility room for at least 20 seconds.
The DON further stated that the Department of Health (DOH) provided the facility with guidance regarding CA and specified that hand washing was the number one way to prevent infection. He stated that the problem was that RN #1 needed to be re-educated immediately because of poor handwashing, improper donning of PPE and numerous instances during Resident #19's treatment observation where she could have potentially spread CA. He stated that the facility needed to ensure that everyone understood the importance of proper hand washing, and prepping for a treatment in order to prevent the spread of infection.
The Licensed Nursing Home Administrator (LNHA) provided the surveyor with documented evidence that RN #1 had Wound Dressing Change Competencies completed on 06/15/2021 and 07/15/2021. On 06/27/2022 and 06/29/2022, RN #1 also participated in an educational program titled, Candida Auris, in which the course objectives were: understanding CA, Enhanced Barrier, and the importance of hand washing and hand hygiene and disinfecting environment and equipment used for patient care to prevent the spread of CA.
The surveyor reviewed the facility policy titled, Hand Washing/Hand Hygiene (Last Revised 03/2022) which revealed the following:
Hand washing and hand hygiene will be performed in accordance with the Center for Disease Control (CDC) guidelines.
Hands are a common transfer mechanism for potential pathogens from person to person or from a contaminated article to a person .
.Indications for hand washing/hand hygiene include, but are not limited to the following:
Before and after touching wounds, whether surgical, traumatic or associated with an invasive device
After touching inanimate sources that are likely to be contaminated with pathogenic microorganisms .
After removing gloves
Hand Washing Method: 1. Push up sleeves above the wrist prior to hand washing. 2. Stand well away from the sink in order to prevent getting splashed. 3. Turn on the water gently and adjust water temperature to a comfortable level. 4. Wet hands and wrists thoroughly. 5. Dispense soap. 6. Scrub each hand with the other, creating as much friction as possible by interlacing the fingers and moving the hands back and forth. 7. Scrub the hands for at least 20 seconds. 8. Rinse the hands thoroughly under running water, keeping the hands down below the level of the elbows. 9. Take care not to touch the surface of the sink, which is considered to be contaminated. 10. Dry the hands and wrists gently with a paper towel and discard into the wastebasket .11. Turn the faucet off with a new paper towel, as the faucet handles are considered to be contaminated. 12. Discard the paper towel into the wastebasket.
Review of RN #1's Wound Dressing Change Competency Checklist revealed the following:
Perform hand hygiene upon entering room.
Identified resident/patient using at least two identifiers.
.Prepared clean table and gathered all necessary supplies.
.Provided privacy.
Positioned resident/patient comfortably, draped to expose only wound site .
Placed disposable bag within reach, performed hand hygiene and put on clean gloves, applied necessary personal protective equipment (PPE) .
Removed dressing one layer at a time, observed appearance and drainage of dressing .
.Folded soiled dressing with drainage side in, removed gloves inside out, folded gloves over soiled dressing if appropriate, disposed of gloves and dressing in appropriate receptacle, covered wound with gauze, performed hand hygiene . Applied clean gloves.
.Clean wound: Used gauze with saline, antiseptic, or wound cleanser .
Disposed of gloves, performed hand hygiene. Applied clean gloves.
Applied treatment, then dressing as ordered .
Disposed of all treatment waste, removed PPE and disposed of it in appropriate receptacle.
Helped resident/patient to a comfortable position.
Performed hand hygiene upon leaving the room.
During the initial tour of the facility on 07/19/22 at 10:16 AM, the surveyor observed Resident #112 in bed. Resident #112 reported a delay in receiving care due to the facility being short of staff. The surveyor observed the Foley catheter drainage bag partly covered with a dignity bag. The Foley catheter drainage bag was touching the floor.
On 07/19/22 at 12:02 PM, the resident was observed in bed resting. The Foley catheter drainage bag was touching the floor and was only partly covered with the dignity bag.
On 07/20/22 at 9:05 AM, the surveyor entered the room and observed Resident #112 in bed. Resident #112 reported discomfort at the Suprapubic site. Resident #112's nurse was informed.
On 07/20/22 at 11:30 AM, the surveyor observed Resident #112 in bed. The Foley Catheter drainage bag was observed in the dignity bag and positioned above the floor.
On 07/21/22 at 7:05 AM, the surveyor observed the resident in bed and the resident acknowledged not feeling well. Resident #112 still reported discomfort at the Suprapubic site. The surveyor again observed the Foley catheter drainage bag and privacy bag placed directly on the floor.
On 07/21/22 at 7:15 AM, the surveyor accompanied the Licensed Practical Nurse (LPN) Unit Manager (UM) to the residents room where both observed the Foley catheter drainage bag and the dignity bag placed directly on the floor. Resident #112 occupied the bed by the door and visitors and staff in the hallway could easily visualize the catheter on the floor from the hallway. The Unit Manager stated, I saw the problem already. The Foley catheter should not be on the floor. The UM donned gloves and a PPE gown since the resident was on enhanced barrier precautions, entered the room and adjusted the Foley catheter on the bed frame.
The surveyor reviewed Resident #18's electronic clinical record on 07/21/22. According to the admission Face Sheet, Resident #112 was readmitted to the facility on [DATE] with diagnoses which included but not limited to Ulcerative colitis, diabetes mellitus and retention of urine.
The admission Minimum Data Set (MDS ) revealed that Resident # 112 was dependent upon staff for care. Resident #112 scored 15 on the Brief Interview for Mental Status (BIMS) which indicated intact cognition. The MDS reflected that Resident #112 had a Foley catheter/ suprapubic catheter in place (a urinary catheter placed through the lower abdomen directly into the urinary bladder).
A care area assessment (CAA) associated with the admission MDS dated [DATE], specified Resident #112 had a diagnosis of Urinary retention and Urinary infection. The resident was at risk for Urinary Tract Infections (UTI)s and injury related to suprapubic catheter.
A care plan dated 06/15/22 identified Resident #112 at risk for UTIs due to a history of urinary retention and the need for a suprapubic urinary catheter related to urinary retention. The care plan goal specified: Signs and symptoms of UTI will resolve within the course of antibiotic therapy. Interventions included, Maintain adequate hydration. Ensure proper perineal care, monitor labs as ordered, maintain appropriate infection control practices.
A review of Resident #112's medical record revealed the resident's last UTI was diagnosed and treated on 07/21/22.
On 07/21/22 at 9:45 AM, a follow up interview with the UM revealed that the Foley catheter drainage bag should not be on the floor because this wa[TRUNCATED]
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0625
(Tag F0625)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of the medical record and review of other pertinent facility documentation, it was determined that th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of the medical record and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy prior to transfer to the hospital for 3 of 3 residents (Resident #68, #81 and #436) reviewed for hospitalizations.
This deficient practice was evidence by the following:
1. On 07/26/22 at 10:26 AM, the surveyor reviewed Resident #68's medical record, which revealed that the resident was transferred to the hospital on [DATE]. The surveyor did not observe evidence of written notification of the facility's bed hold policy prior to or upon transfer to the hospital to the resident or the resident's representative.
A review of the July 2022 nurse's Progress Note (PN) indicated that the resident was transferred to the hospital on 7/15/22 due to acute kidney injury and hyperkalemia (high potassium levels in the blood) and was admitted to the hospital with acute renal (kidney) failure. A further review of the PN revealed a copy of Notice of Emergency Transfer provided to the PT {resident} and was faxed to NJ LTC (long-term care) Ombudsman. The PN did not reflect a post discharge note was completed to verify the bed hold policy and procedure.
On 07/29/22 at 09:25 AM, the Director of Nursing (DON) stated he was not sure of the bed hold policy and that the admission department handles it. The DON concluded he knew the bed hold policy was given as a part of the admission agreement.
On 07/29/22 at 09:27 AM, The admission Director (AD) stated the facility does not send out a written notification and that it was only signed during admission. The AD stated Medicaid has a 10-day bed hold policy and that a resident will still get their bed unless they need to quarantine. She further stated if the resident exceeded the 10-days she would call and speak with the resident or resident's representative. The AD emphasized that residents always went back to their rooms as this is their home. The AD acknowledged she was not aware of following up with a bed hold notification to the resident or resident's representative prior to or upon transfer to a hospital after the initial signed admission agreement.
On 07/29/22 at 09:52 AM, the AD provided the facility's notification of bed hold policy and showed the surveyor a highlighted Step 2 which revealed: Upon the discharge of a Medicaid resident, the social worker will verbally notify the resident where applicable and follow-up with a letter to the representative notifying of such. A copy of any notification is kept tint he {in the} Social Services office.
The surveyor reviewed the bed hold policy Resident #68 signed and dated 8/7/18.
A review of the Notice of Emergency Transfer was completed 7/15/22 which indicated, A copy of this notice must be provided to the resident/ resident representative, as well as to the Office of the Ombudsman
3. On 07/21/22 at 10:14 AM, the surveyor reviewed Resident #436's medical record, which revealed that the resident was transferred to the hospital on [DATE]. Further review revealed that Resident #436 returned to the facility on [DATE]. The surveyor did not observe evidence of written notification of the facility's bed hold policy prior to or upon the transfer to the hospital to the resident or the resident's representative.
On 07/21/22 at 12:05 PM, during surveyor interview, the AD stated that the facility did not mail out any notification about the bed hold prior to any hospitalization and that they would call the family. She then stated that the bed hold policy is provided in the admission agreement.
On 07/21/22 at 01:03 PM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) to provide the surveyor documented evidence of the written notification of the bed hold policy prior to the transfer to the hospital.
On 07/21/22 at 01:30 PM, the LNHA provided the surveyor with a document titled, Attachment C HMH Residential Care, Inc. Bedhold Policy which Resident #436 signed and was dated 8/27/2021. The LNHA did not provide any documented evidence of written notification of the bed hold policy prior to Resident #436's hospitalization on 06/28/22.
On 07/26/22 at 12:13 PM, during surveyor interview, the DON stated that the facility did not send out written notification to the family regarding bed hold policy when transferred to the hospital. He added that the facility provided the bed hold policy on admission.
On 08/2/22 at 01:29 PM, during surveyor interview in the presence of the survey team, the LNHA stated that the facility had not been providing written notification of the bed hold policy prior to hospitalization. He added that the bed hold policy had been provided on [initial] admission [to the facility].
On 08/3/22 at 09:54 AM, the LNHA acknowledged in the presence of the DON, [NAME] President (VP) of Nursing, Assistant LNHA and survey team that the facility did not complete the resident's bed hold policy notification prior to or upon transfer to the hospital.
A further review of the facility's Notification of Bed Hold dated effective 8/2021 reflected A discharged resident's bed will be held per Medicaid guidelines and the facility's admission policies and procedures Step 1. Residents receiving Medicaid benefit are entitles to a bed hold of 10 days if discharged to a general or psychiatric hospital .Step 4. If the resident is unable to return before the end of the 10 day period, the resident or representative can pay the daily private rate to hold the same bed until medically stable Step 5. The social worker or designee will follow-up with the resident or representative on a post discharge to verify bed hold policy and procedure.
N.J.A.C. 8:39-5.1 (a)
2.) The resident face sheet reflected that Resident # 81 was admitted to the facility with the diagnoses that included and was not limited to; persistent vegetative state (a condition in which a medical patient is completely unresponsive to psychological and physical stimuli and displays no sign of higher brain function, being kept alive only by medical intervention), chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and ruptured brain aneurysm (bleeding on the brain from a ruptured blood vessel). The significant change Minimum Data Set (MDS) an assessment tool dated 06/13/2022, indicated that Resident #81 required total care with all aspect of activities of daily living (ADLs) and had severe cognitive impairment.
On 07/19/22 at 11:03 AM, the surveyor reviewed Resident #81's clinical record and MDS and assessment tool which revealed that the resident was discharged from the facility on the following dates 12/14/2021, 04/05/2022 and 05/15/2022.
There was no documentation in the resident's clinical record regarding notification of family or representative regarding notification of bed hold policy prior to discharge from the facility.
On 07/29/22 at 08:39 AM, the surveyor interviewed the Director of Social Services (DSS) who stated that the AD notified families and discusses the bed hold policy with the residents, family, and representative during the admissions process. The DSS stated that there was a discrepancy in the policy for bed holds and that the Social Worker (SW) did not have any involvement with notification of the family or representative of resident bed holds on discharge.
On 07/29/22 at 08:47 AM, the AD stated that she goes over the admission agreement and the bed hold policy with families and residents that were alert and oriented during the admission process into the facility. She stated that when Medicaid residents were transferred to the hospital, they get a 10-day bed hold and that it was explained to them on admission. She stated that Long-Term Care residents or Medicaid residents or representatives were not given a second verbal notification or letter when the resident were transferred/ discharged to the hospital. The AD reviewed the policy titled, Bed Holds with the surveyor and stated that the SW did not have any involvement with the bed holds and that she was not aware that the policy indicated that the resident or the family had to be provided with written notification regarding bed holds.
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
- • No fines on record. Clean compliance history, better than most New Jersey facilities.
- • 41% turnover. Below New Jersey's 48% average. Good staff retention means consistent care.
Concerns
- • 36 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Complete Care At Bayshore Llc's CMS Rating?
CMS assigns COMPLETE CARE AT BAYSHORE LLC 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 Complete Care At Bayshore Llc Staffed?
CMS rates COMPLETE CARE AT BAYSHORE LLC's staffing level at 2 out of 5 stars, which is below 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 Complete Care At Bayshore Llc?
State health inspectors documented 36 deficiencies at COMPLETE CARE AT BAYSHORE LLC during 2022 to 2024. These included: 1 that caused actual resident harm, 33 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Complete Care At Bayshore Llc?
COMPLETE CARE AT BAYSHORE LLC 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 COMPLETE CARE, a chain that manages multiple nursing homes. With 232 certified beds and approximately 133 residents (about 57% occupancy), it is a large facility located in HOLMDEL, New Jersey.
How Does Complete Care At Bayshore Llc Compare to Other New Jersey Nursing Homes?
Compared to the 100 nursing homes in New Jersey, COMPLETE CARE AT BAYSHORE LLC'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 Complete Care At Bayshore Llc?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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?" These questions are particularly relevant given the below-average staffing rating.
Is Complete Care At Bayshore Llc Safe?
Based on CMS inspection data, COMPLETE CARE AT BAYSHORE LLC 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 Complete Care At Bayshore Llc Stick Around?
COMPLETE CARE AT BAYSHORE LLC 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 Complete Care At Bayshore Llc Ever Fined?
COMPLETE CARE AT BAYSHORE LLC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Complete Care At Bayshore Llc on Any Federal Watch List?
COMPLETE CARE AT BAYSHORE LLC 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.