Part B 2. The surveyor interviewed Resident #98 on 5/30/25 at 10:58 AM. The resident was seated in a wheelchair at the bedside. The resident stated they were currently receiving chemotherapy. The resident stated they were experiencing generalized weakness and weakness of the left leg resulting in difficulty with ambulation. The resident stated they use the call bell device to request assistance getting from the bed to the wheelchair, for toileting, and for dressing. The resident stated the call bell response can be very slow. The resident described an incident which had occurred the previous week. The resident had propelled their wheelchair into the bathroom unassisted. The resident transferred themself onto the toilet and had a bowel movement. The resident rang the call bell for assistance with cleaning themself. The resident waited for one half hour, received no response, and stood up from the toilet and used the wheelchair as a rolling walker pushing the wheelchair in front of themself and ambulated to the bedside. The resident attempted to place a pillow case on the wheelchair cushion so that they could sit down without soiling the seat. The wheelchair moved and the resident fell onto their knees. The resident rang the call bell and waited 45 minutes for the Certified Nursing Assistant (CNA) to respond. There were no injuries as a result of the incident. A review of the electronic medical record revealed the following information. The resident was admitted for short term rehabilitation with diagnosis including, but not limited to, polyneuropathy (nerve ending degeneration); diffuse large B cell lymphoma; chemotherapy induced pancytopenia (low levels of red and white blood cells); anemia; protein calorie malnutrition. The 5/2/25 admission Miniumum Data Set assessment tool (MDS) indicated the resident had no cognitive deficits; was dependent on staff for toileting hygiene, was dependent on staff for standing from a sitting position, transferring to and from a bed and wheelchair, and getting on and off the toilet. The MDS indicated the resident used an indwelling urinary catheter and was frequently incontinent of bowel. The fall care plan, initiated 4/25/25 and revised 5/29/25, indicated the resident was at risk for falls due to impaired balance and poor coordination. The resident was noted to have had a fall on 5/24/25 without injury. Fall precaution interventions included, but were not limited to, reinforce the need to call for assistance and remind the resident to lock the wheelchair prior to transfers. The electronic medical record progress notes did not contain any reference to the 5/24/25 fall incident. The surveyor interviewed the resident's CNA on 6/02/25 at 10:45 AM. She stated the resident needs stand by assistance of one person. She stated his left leg is weak and sometimes gives out without warning and you have to be there to support him if that happens. The surveyor discussed concerns of the slow call bell response and the subsequent resident's fall with the Licensed Nursing Home Administrator and the Director of Nursing on 6/2/25 at 3:00 PM. No further information was provided to the surveyor. Based on observation, interviews, record review, and review of other pertinent documentation, it was determined that the facility failed to ensure a cognitively impaired resident, who had a diagnosis of Alzheimer's Disease, and dysphagia (difficulty swallowing) with a history of aspiration (when material such as food or drink enters the airway or lungs), received the appropriate physician ordered moderately thick (honey thickened; liquids thickened with an agent for a honey-like consistency) liquid consistency. This deficient practice was observed for 1 of 4 residents reviewed for accidents and accident prevention (Resident #62). During a lunch observation on 5/30/25 at 12:25 PM, Surveyor #1 and #2, observed the Activity Aide (AA) deliver a cup of liquid to Resident #62 in the North dining room. Surveyor #1 and #2 observed the AA pour a pre-thickened nectar consistency beverage into the cup of liquid. The resident immediately began drinking the liquid and started to cough. Surveyor #1 and #2 approached Resident #62 and reviewed the resident's meal ticket. At that time, Surveyor #1 called the Licensed Practical Nurse (LPN) over to check the resident's meal ticket. The LPN then verified the resident's meal ticket which indicated that the resident was on honey thickened liquids (HTL) and should have received only HTL to prevent choking. The LPN stated that the resident's green dot on the wristband indicated the resident had an order for HTL and confirmed that the liquid in Resident #62's cup had not been thickened to Honey Thick (HT) consistency. An interview on 5/30/25, with the Speech Language Pathologist (SLP) confirmed that giving Resident #62 liquids that were not HT consistency could cause aspiration pneumonia. The facility's failure to ensure cognitively impaired residents received and consumed liquids in the appropriate form as prescribed by a physician, posed the likelihood of aspiration which could result in serious harm, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 5/30/25 at 12:25 PM, when Resident #62 was observed coughing after being served the incorrect liquid consistency. The facility's administration was notified of the IJ on 5/30/25 at 3:58 PM. The facility submitted an acceptable written Removal Plan on 6/2/25 at 12:02 PM. The survey team verified the implementation of the Removal Plan through observation and interview during the continuation of the on-site survey on 6/2/25. The facility further failed to ensure staff provided adequate supervision for a resident at risk of falls resulting in a fall for Resident #98, and failed to ensure safety interventions for fall prevention were in place for a resident at risk for falls, Resident #62 for 2 of 2 residents reviewed for falls. The evidence was as follows: PART A A review of the facility's Dysphagia Management Program (Formerly Think Green/ Think Blue) policy, dated revised 1/3/25, indicated: Policy: Patients will have their diet and hydration managed safely and effectively, meeting their individual nutritional and hydration needs . Purpose: The Dysphagia Management Program (DMP) is designed to raise awareness of staff regarding patients with swallowing problems requiring alternate liquid consistencies. The DMP is a clinical system adopted by the center for the care of an individual at risk for aspiration and choking .Patients assessed by the interdisciplinary team receive therapeutic diets as ordered by a physician to assist in the management of the identified swallowing problems . Process: The Director of Nursing will complete the DMP Identifier form which will adopt a color to identify patients in the DMP. Use of a color-coded wristband and color code on the meal tray card is mandatory for this program. The Nurse receiving the physician order starts the identification system for any individual on thickened liquids (Moderately thick, mildly thick) or NPO (nothing by mouth.) Thickening Liquids: Commercially prepared thickened liquids will be purchased and used when possible. Some liquids will not be available pre-thickened by the manufacturer. A further review of the facility's DMP policy indicated: Commercially prepared thickened liquids will be purchased and used when possible. Some liquids will not be available pre-thickened by the manufacturer and will need to be thickened using bulk thickener by trained staff with demonstrated competency using the product. Diet and Liquid Consistency Orders: Diet and liquid consistencies are adopted from the International Dysphagia Diet Standardization Initiative (IDDSI) Guidelines as follows: Pureed (PU4) Moderately thick liquid (MO3) Dining with thickened liquids: Liquids will be delivered pre-thickened from the food and nutrition services department. Liquids may be thickened by the Speech Language Pathologist at bedside for a speech evaluation or for home education. Staff Education: Staff will be introduced to the dysphagia management program and International Dysphagia Diet Standardization Initiative (IDDSI) terminology during orientation and on an ongoing basis. A review of the facility's Identification System policy undated, indicated: Policy: A system has been developed to provide identification to staff of specific individualized patient/resident needs while maintaining confidentiality. Identification of specific needs will be indicated on the patient's/resident's wrist band, medical chart, room, door, or bedside with designated colored dots or specific symbolic stickers. Patients assessed by the interdisciplinary team receive therapeutic diets as ordered by a physician to assist in the management of the identified swallowing problems . Identification as follows: Red Dot=Diabetic Green Dot=Thickened Liquid (N-Nectar Thick/ H-Honey Thick) Blue Dot= Fluid Restriction Orange Dot= Nothing by Mouth (NPO) . During a lunch observation on 5/30/25 at 12:25 PM, Surveyor #1 and #2, observed the AA deliver a cup of liquid to Resident #62 in the North dining room. Surveyor #1 and #2 observed the AA pour a pre-thickened nectar consistency beverage into the cup of liquid. The resident immediately began drinking the liquid and started to cough. Surveyor #1 and #2 approached Resident #62 and reviewed the resident's meal ticket. The surveyors observed that Resident #62's meal ticket on their tray indicated moderate thick liquids and was highlighted with a green marker. At that time, Surveyor #1 called the Licensed Practical Nurse (LPN) over to check the resident's meal ticket. The LPN then verified the resident's meal ticket which indicated that the resident was on HTL and should have received only HTL to prevent choking. The LPN showed the surveyors that the resident had a green dot with an H on their wristband which indicated the resident had an order for HTL. The LPN confirmed that the liquid in Resident #62's cup had not been thickened to HT consistency. On 5/30/25 at 12:42 PM, during an interview with the surveyors, the AA stated that the resident requested an additional beverage, so the AA obtained a cup of tea from the food truck. The AA confirmed that it was a cup of tea that had not been pre-thickened from the kitchen, so she poured a small amount of nectar pre thickened liquid into the tea. The AA stated that she was not aware of what Resident #62's diet was, but that the resident's family member told her that the beverage needed to be thickened. The AA confirmed that she should have called the kitchen to send the appropriate HT beverage for the resident and that she should not have thickened it herself. The surveyor asked the AA what the green highlight on the resident's meal ticket indicated and what the green dot/H on the wristband that Resident #62 was wearing indicated. The AA did not respond. On 5/30/25 at 12:45 PM, Surveyor #2 observed the Speech Language Pathologist (SLP) evaluate the liquid Resident #62 had consumed. The SLP stirred the liquid with the straw and stated she had to get a spoon from the nurse. The SLP used a spoon to assess the liquid and stated, this is not honey thick. The SLP confirmed that moderately thick liquids were considered honey thick. On that same date, at that time, during an interview with Surveyor #1 and #2, the SLP confirmed that giving the resident liquids that were not moderate consistency could cause aspiration pneumonia. The SLP stated that the AA should not have served the incorrect liquid consistency. She further stated that the kitchen staff and nurses usually thicken the liquids and that she also did bedside pharyngeal swallow assessments where she altered the consistencies of the beverages to assess the resident's ability to swallow and tolerate foods and beverages. On 5/30/25 at 1:00 PM, during an interview with Surveyor #1, the Nurse Practitioner, who stated that she worked with the pulmonary physician, confirmed that the resident had a physician's order for moderately thick liquids and should be provided with HTL only. The NP stated that she assessed the resident who had clear lungs, no wheezing and oxygen saturation (the percentage of hemoglobin in the blood that is carrying oxygen) between 94-96%. The NP stated that she ordered a chest x-ray for tomorrow morning (5/31/25), to monitor the resident for possible aspiration pneumonia. On 5/30/25 at 1:42 PM, during an interview with Surveyor #1 and #2 the Director of Nursing (DON) stated that the AA should have followed the facility's policy which would be to have the kitchen staff add thickener to the beverage before serving it to the resident. On 5/30/25 at 2:26 PM, during an interview with Surveyor #1, the Food Service Director (FSD) who prepared Resident #62's lunch meal and beverages, stated that the dietary staff thickens the coffee and hot tea in the kitchen and then sends it on the food truck. The FSD further stated that milk, juices and water were pre thickened by the vendor. The FSD confirmed that extra thin liquid hot beverages were sent up in the food trucks during meal service. The FSD stated that if Resident #62 requested additional beverages, the staff should have obtained them from the kitchen. At that same time, Resident #62's family member who was seated next to the resident, stated that the resident was supposed to be on HTL and that they didn't thicken it enough. The surveyor reviewed the medical record for Resident #62. According to the admission Record, Resident #62 had diagnoses which included but were not limited to; pneumonitis due to inhalation of food and vomit (aspiration pneumonia), dysphagia, Alzheimer's Disease, and pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest). A review of the admission Respiratory Care Evaluation, dated 5/24/25, reflected Resident 62's primary diagnoses included but were not limited to; pneumonitis due to inhalation of food and vomitus (aspiration pneumonia) and pleural effusion (a buildup of fluid between the tissues that line the lungs and chest.) A review of the Speech Language Pathologist (SLP) Speech Evaluation and Plan of Treatment dated 5/26/25, reflected the patient presented with oropharyngeal phase dysphagia (swallowing disorder that affects the oral and pharyngeal phases making it difficult to move food from the mouth into the throat and esophagus) characterized by prolonged bolus formation, oral transport time and post swallow residue placing patient at risk for aspiration. The patient's pharyngeal phase of swallow was positive for cough after they swallowed with thin liquids. The SLP determined that a dysphagia intervention was warranted and assessed the least restrictive diet that the patient could safely tolerate with no overt clinical signs or symptoms of aspiration. Recommendations included: moderately thickened liquids with a pureed diet. The recommendation was signed by the physician on 5/26/25. A review of the Physician's Order Summary Report, dated 5/29/25, included a diet order for, Pureed (PU4) Texture, Moderately Thick (MO3) consistency, fortified cereal. A review of the resident's individualized comprehensive care plan (ICCP) included a focus of, [Resident #62] has nutritional status as evidenced by therapeutic diet, swallowing difficulty, at risk for malnutrition initiated on 5/29/25. An intervention dated 5/29/25, included thickened liquids as ordered. A review of the Nurse Practitioner (NP) Progress Note dated 5/30/25 at 11:07 AM, reflected Resident #62 was previously admitted to the hospital due to a hypertensive emergency, with complaints of cough and difficulty of breathing. The chest x-ray was positive for pulmonary congestion and pneumonia and showed patchy air space disease on the right lower lobe lung field. Resident #62 was treated with antibiotics. A review of the of chest x-ray results dated 5/30/25 9:31 PM, reflected right lower lobe infiltrate, unchanged from prior chest x ray results. An acceptable Removal Plan was received on 6/2/25 at 12:02 PM, which indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice which included: NP assessed the resident, AA was removed from the facility until investigation was completed, the staff was educated on policies for dysphagia and aspiration risk, appropriate fluid consistency, following resident specific diet orders, the importance of adherence to diet orders, and to obtain from the kitchen any additional thickened beverage needed. The survey team verified the implementation on-site during the continuation of the survey on 6/2/25. NJAC 8:39-17.4(a)(1)(2); 27.1(a) 3. On 05/30/25 at 11:50 AM, the surveyor observed Resident #62 in his/her room in bed. The surveyor observed that there were no floor mats in place, and no functioning bed alarm on the bed. The surveyor observed a bed alarm on a shelf on the wall across from the foot of resident's bed. During an interview with Resident 62's family member who was seated at the resident's bedside stated that Resident 62's spouse expressed concern for the resident as he/she had a history of frequent falls. The family member stated that she had notified the social worker and admission staff of the resident's fall history and requested floor mats to be placed on each side of the bed as the resident had them in place during their last admission. A review of the admission Record reflected that Resident #62 was admitted to the facility with diagnoses that included but were not limited to; malfunctioning of the cystostomy (medical device inserted into the bladder to drain urine) pneumonitis r/t inhalation of food and vomit, and Alzheimer's disease. A review of Resident #62's Annual Minimum Data Set (MDS), an assessment tool dated 3/17/25 revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive impairment. Section GG indicated Resident #62 required staff assistance for activities of daily living and transfers. MDS indicated history of 2-3 falls in previous 6 months. A review of Resident #62's Fall risk evaluation dated 5/11/25 assessed Resident #62's as high risk for falls with a history of 1-2 falls in past 3 months. A review of Resident #62's Individualized Comprehensive Care Plan (CP) initiated on 3/10/23 reflected a focus area that indicated the Resident was at risk for falls due to impaired balance/poor coordination and medication side effects. The interventions included but were not limited to; bed alarm and fall mats on both sides of the bed. On 5/30/25 at 3:33 PM, the surveyor observed Resident #62 in bed, with no observed floor mats and no bed alarm on the bed. On that same date, at 3:34 PM, the surveyor accompanied by the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) assigned to Resident #62's care, entered the resident's room. The LPN and CNA confirmed that the there were no fall mats in place and there was no bed alarm in use, and both acknowledged the mats and bed alarm should have been in place for fall prevention. The surveyor requested the fall prevention/management policy and procedure but it was not provided. On 6/3/25 at 2:18 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator, Director of Nursing, Regional Nurse and Assistant Director of Nursing. No further information was provided by the facility. NJAC 8:39-17.4(a)(1)(2); 27.1(a)