**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/7/25 at 9:08 AM, the surveyor observed Resident #3 in bed and watching television. The surveyor attempted an interview but the resident declined. A review of Resident #3's medical records revealed: A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but not limited to; metabolic encephalopathy (a brain dysfunction that occurs when there's an imbalance of chemicals in the blood, usually due to an underlying medical condition), congestive heart failure (chronic condition in which the heart does not pump blood as well as it should), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and unspecified intestinal obstruction (blockage in the small or large intestine that prevents food and liquid from passing through). A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. A review of the weights revealed: 9/23/24: 138.0 lbs. 10/23/24: 120.0 lbs. (18 lbs or 13.4% significant weight loss in a month) 11/19/24: 122.6 lbs. 12/9/24: 118.6 lbs. 1/2/25: 117.8 lbs. A review of the resident's admission Nutritional assessment dated [DATE], included that RD #1 identified that the resident was 138 lbs. and the resident's ideal body weight was 80-98 lbs and the BMI was 32 (obese). The resident was on a NAS, fat-controlled diet. The RD identified the resident reported having a poor appetite. A review of the Nutritional assessment dated [DATE] at 1:24 PM, revealed that the resident's current weight was 119 pounds, and that weight loss was expected with the resident was on a diuretic (Lasix). The resident's BMI was 27.6 and was overweight. The RD recommended a therapeutic diet and to continue monitoring the resident's nutritional status. There was no Nutrition/Dietary Note to address the 18 lbs weight loss on 10/23/24, or a reweigh. On 1/9/24 at 1:00 PM, the surveyor interviewed RD #1, who stated Resident #3 had multiple hospitalizations and comorbidities including congestive heart failure that contributed to their weight loss. RD #1 stated that she saw the resident after their re-admission on [DATE], and she was waiting for the resident to be weighed; that the weight loss could have happened during the resident's hospitalization. RD #1 acknowledged that the resident had a significant weight loss on 10/23/24, and that the resident should have been re-weighed, and that she should have written a Nutrition Note to address the 18 lbs or 13.4% weight loss. The RD stated that the resident's weight was now stable, and that she was monitoring the resident's weight. On 1/9/24 at 1:30 PM, the surveyor discussed the above concerns with the LNHA, DON, and the RDON. No further information was provided. A review of the facility's Weight Assessment and Intervention Policy with a last revised date of October 2024, include: Policy Statement: The multidisciplinary team [MDT] will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation: Weight Assessment 1. The nursing staff will measure the resident's weight on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted, weights will be measure monthly thereafter. 2. Weights will be recorded in the Weights and Vitals tab in the EMR. 3. Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will immediately notify the RD. 4. The RD will respond within 24 hours of receipt of notification. 5. The RD will review the unit's weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change have been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months-7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months-10% weight loss is significant; greater than 10% is severe. Analysis: 1. Assessment information shall be analyzed by the MDT and conclusions made regarding the: a. The resident's target weight range including rationale if different from ideal body weight. b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake. c. Relationship of current medical condition or clinical situation and recent fluctuations in weight. d. Whether and to what extent weight stabilization or improvement can be anticipated. 2. The physician and the MDT will identify conditions and medication that may be causing anorexia, weight loss or increasing the risk of weight loss. Care Planning 1. Care planning for weight loss or impaired nutrition will be an MDT effort. 2. Individualized CP should address to the extent possible: a. The identified causes of weight loss. b. Goals and benchmarks for improvement. c. Time frames and parameters for monitoring and reassessment. NJAC 8:39 - 11.2(e)(1)(f), 17.1(c), 17.2(c)(d), 27.1(a) Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) identify, assess, and implement interventions for a resident (Resident #35) with an unplanned significant weight loss of 7 pounds (lbs) or 5.1% in one month and 25.2 lbs or 25.71% significant weight loss in six months from 4/12/24 through 10/7/24, b.) identify, assess, and implement interventions for a resident (Resident #92) with a significant weight loss of 14 lbs. or 10.03% in one month for 48 days; c.) identify, assess, and implement interventions for a resident (Resident #3) with a significant weight loss of 18 lbs. or 13.4% in one month; d.) obtain, record, and monitor weights in accordance with physician's orders; e.) obtain re-weights to verify a significant weight change; and f.) monitor the effectiveness of interventions for a resident with a significant weight loss. The deficient practice was identified in 3 of 7 residents (Residents #3, #35, and #92) reviewed for nutrition. This deficient practice was evidenced by the following: 1. On 1/6/25 at 12:06 PM, the surveyor observed Resident #35 lying in bed, who was alert and verbally responsive to the surveyor's greeting. The resident stated, I'm hungry. The surveyor observed the lunch meal trays had just arrived on the unit, and Resident #35 received their lunch tray which was set up by the nursing staff. On 1/7/25 at 11:13 AM, the surveyor observed Resident #35 lying in bed with an opened health shake (a nutrition supplemental drink) that was within the resident's reach. Resident #35 stated to the surveyor I'm hungry. At that time, the Hospitality Aide entered the room, spoke with the resident, and went to get assistance for the resident. On 1/8/25 at 9:30 AM, the surveyor reviewed the electronic medical records (EMR) of Resident #35. A review of the admission Record (AR; an admission summary) reflected the resident was admitted to the facility with diagnoses that included but were not limited to; osteoporosis (a condition in which bones become weak and brittle), hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), unspecified psychosis (group of symptoms that affect a person's mind and cause them to lose touch with reality), fracture of the humerus (long bone of the upper arm) and compression fracture of the thoracic vertebrae (a bone in the spine breaks and collapses). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/4/24, reflected a Brief Interview Mental Status (BIMS) score of 6 out of 15, which indicated the resident had severe cognitive impairment. A review of Section K (Swallowing/Nutritional Status) revealed the resident was 73 lbs. and was coded for having a weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a physician prescribed weight loss regimen. A review of Resident #35's weights revealed: 4/12/24: 98.0 lbs. 5/3/24: 93.0 lbs. (7 lbs loss or a 5.1% significant weight loss in one month) 6/25/24: 96.0 lbs. 10/7/24: 72.8 lbs. (25.2 lbs loss or a 25.71% significant weight loss six months) 10/15/24: 73.0 lbs. 10/29/24: 73.0 lbs. 12/9/24: 66.2 Lbs. 12/19/24: 73.2 lbs. 12/23/24: 71.2 lbs. 12/30/24: 71.2 lbs. There were no documented weights for Resident #35 for July 2024, August 2024, September 2024, and November 2024, and there were no corresponding notes or orders in the medical record as to why the resident's weights were not obtained. The resident had a significant weight loss of 23.2 lbs or 24.7% in three months (6/25/24 to 10/7/24) with no documentation of the resident's weight loss until it reached 23.2 lbs. A review of Progress Notes (PN) revealed: A Nutrition/Dietary Note dated 5/24/24, written by the Registered Dietician (RD #1), documented the resident was noted with weight loss and had edema (swelling caused by fluid buildup in the body's tissues) upon admission. RD #1 indicated that the resident was on a diuretic medication (helps increase urine production, helping the body get rid of excess fluid and salt) and weight loss may be expected. An Interdisciplinary Care Plan (IDCP) Note dated 7/9/24, written by RD #1, documented a quarterly nutrition assessment that cultural foods were provided. The resident's weight was stable since admission, and the resident's intake was 75-100%. The RD indicated to continue the current diet for the resident and to monitor nutritional intake. An IDCP Note dated effective 10/4/24, written by RD #1, included the resident's weight on 4/12/24, was 98 lbs. and the resident's current weight on 10/7/24, was 72.8 lbs. RD #1 documented that she spoke with the Resident's Representative (RR #1) about the weight loss, who indicated the resident had a history of variable intake at meals, very small portion sizes with meals, and that weight loss was noted with legs look smaller. RD #1 indicated that Resident #35 had edema upon admission, a diuretic medication (med) was in use, and the team was made aware of the weight loss. RD #1 recommended a three-day calorie count, weekly weights for four weeks, a magic cup (a calorically dense frozen supplement) at lunch, and a health shake twice a day at 10:00 AM and 2:00 PM. A Nurse Practitioner (NP) PN dated 10/10/24, documented the resident had severe weight loss. The note indicated a calorie count for three days, weekly weights for four weeks, and laboratory tests were ordered for the next day. A Nutrition/Dietary Note dated 10/15/24, documented the results of the three-day calorie count that the resident was eating between 25-75% of meals and referred to a NP note regarding the resident's weight loss. The note included the RD recommended to continue fortified foods, monitor weekly weights and the resident's nutritional status. A review of Physician's Orders (PO) for Resident #35 included: A PO dated 4/11/24, for a no-added salt (NAS) diet, regular consistency texture, and thin liquids. A PO dated 4/13/24, for hydrochlorothiazide (a diuretic) oral tablet (tab) 25 milligram (mg); give one tab by mouth one time a day for hypertension. The order was discontinued (d/c) on 11/14/24. A PO dated 10/8/24, to give a four ounce (4 oz) health shake two times a day for supplement and record the percentage consumed. A PO dated 10/8/24, to give magic cup one time a day for supplement and record the percentage consumed. A PO dated 10/8/24, for a three-day calorie count every shift for three days and to ensure calorie count paper was completed after each meal or snack, including supplements. A PO dated 10/8/24, with a start date of 10/15/24, and an end date of 11/12/24, to document the resident's weights weekly for four weeks every day shift every Tuesday. These interventions were implemented after the resident lost 25.2 lbs. since admission to the facility. A review of the October and November 2024 electronic Medication Administration Record (eMAR) for the weekly weights for four weeks order entries revealed the following: The 10/22/24, entry was left blank. A review of the corresponding PN did not include the resident's weight or any documentation as to why the resident's weight was not obtained. The 11/5/24, entry was signed 9 by the nurse which indicated to Other/See PN. A review of the corresponding PN did not include a note regarding the resident's weight. The surveyor continued to review the PN which revealed the next documented note the RD wrote regarding the resident's significant weight loss was a Nutrition/Dietary Note dated 12/18/24. The note indicated it was for a follow-up for a 9% weight loss; that the resident weighed 72.8 lbs. on 10/7/24, and 66.2 lbs. on 12/9/24. RD #1 documented that weight loss persisted despite nutrition interventions and that weight loss may also be attributed to diuretic use. RD #1 indicated a re-weigh would be completed to confirm the weight. The RD did not include the missing weights from October and November, and did not assess the effectiveness of the interventions added on 10/8/24, which were implemented after the resident had a 25.71% significant weight loss since admission to the facility. There was no evidence that the RD continued to monitor the resident's nutritional status as documented in the 10/4/24, Nutrition/Dietary Note. A review of the Nutrition/Dietary Note dated 12/19/24, documented the weight committee met to review unplanned weight loss for Resident #35. The RD included the resident's weight on 12/19/24 was 73.2 lbs. The RD recommended to continue the current nutrition interventions which included super cereal ( a calorically dense cereal) at breakfast, a 4 oz health shake supplement twice a day, and a magic cup at lunch. The resident's nutritional status will continue to be monitored. A review of an IDCP Note dated 12/31/24, written by RD #2, indicated that cultural foods were provided and the resident's meal intake was between 25-75%. Weekly weights were ordered on 12/23/24. RD #2's recommendations included to continue current nutrition interventions and monitor nutritional status. An additional review of the Physician's Orders included a PO dated 12/18/24, with a start date of 12/23/24, for weekly weight every Monday. A review of the corresponding December 2024 and January 2025 electronic Treatment Administration Record (eTAR) revealed the following weights: 12/23/24: 71.2 lbs. 12/30/24: 71.2 lbs. 1/6/25: 71.2 lbs. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 4/11/24, that the resident was at risk for malnutrition and was revised on 10/8/24, to include actual weight loss and variable intake. Interventions included to monitor nutritional status initiated on 4/11/24; communicate with the [RR #1] initiated on 10/8/24; and to provide health shake and magic cup initiated on 10/8/24. On 1/8/25 at 10:37 AM, the surveyor interviewed the Registered Nurse (RN) assigned to care for Resident #35, who stated that the facility's protocol was for residents to be weighed once a month, and the weight was documented in the weights section of the EMR. The RN stated that if the resident had a PO for weights obtained more frequently, the weights were documented on the eMAR or eTAR and may also be included in the weights section. The RN further stated Resident #35 sometimes did not like to eat at mealtime; that they consumed approximately 45-50% of meals; and in between meals, they informed staff that they were hungry. On 1/8/25 at 10:56 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) regarding weights, who stated that the resident's weights were obtained at least monthly and more frequently if there was a PO. The RN/UM stated the nursing staff obtained monthly weights in the first seven days of the month. The RN/UM further explained that she or the assigned nurses informed the Certified Nurse Aides (CNA) which residents needed to be weighed that day, and the CNA informed the nurse or RN/UM of the residents' obtained weights that they documented in the weights section of the EMR. The RN/UM stated the list was given to the RD to review. The RN/UM stated if there was a significant weight discrepancy from the previous weight, the resident was reweighed to confirm accuracy. The RN/UM stated if the resident lost a significant amount of weight, the RD and Physician were notified for recommendations. The RN/UM stated if a weight could not be obtained for a resident, the nurses documented the reason why it was not completed. At that time, the surveyor and the RN/UM reviewed the weights for Resident #35, and the RN/UM confirmed there were no weights in July 2024, August 2024, September 2024, and November 2024. The RN/UM could not speak to why there were no weights for those months, and the RN/UM acknowledged there should have been documentation for why the resident's weights were not obtained. The RN/UM confirmed the resident had a significant weight loss that was attributed to a poor appetite and was a selective eater. On 1/8/25 at 11:18 AM, the surveyor interviewed RD #1 about the facility's weight protocol, who stated the weights for all residents were taken once a month unless otherwise indicated in a PO. RD #1 stated all weights were documented in the weights section of the EMR, and she ran a report daily to review the weights. RD #1 stated if there was a discrepancy in the weight or a significant weight loss, a new weight was obtained immediately. At that same time, the surveyor notified RD #1 of the concern for Resident #35's significant weight loss and the missing weekly weights on 10/22/24 and 11/5/24. RD #1 stated she would review the EMR and provide additional information. On 1/8/25 at 1:01 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), and the Director of Nursing (DON) of the concern for Resident #35's significant weight loss and missing weights identified for the resident. The LNHA stated they would review and provide further responses the next day. On 1/9/25 at 10:37 AM, the LNHA, the DON, RD #1, and the Medical Director (MD) met with the survey team. The MD stated that he examined the resident yesterday (1/8/25) as per facility request and the MD stated that the resident had dementia, non-compliance at home with care regimen, a history of hypothyroidism, and edema which the resident received a course of diuretics. The MD added that the resident was a picky eater, finicky with eating, and was observed eating that morning their super cereal at breakfast and two-thirds of eggs. The MD stated their current weight was probably their baseline and would recommend to lower blood pressure (BP) meds and thyroid meds. The surveyor asked why the BP and thyroid meds were not lowered prior to surveyor inquiry, and there was no response. At that time, the surveyor asked about the missing weights from July to September 2024, and the concern for the significant weight loss that was identified in October 2024 based on the weights. RD #1 acknowledged the resident's significant weight loss and the missed monthly weights. RD #1 stated that her assessments were not only based on the resident's weights, that she did rounds on the units to observe the resident and the nursing staff informed her if there were concerns with the resident's intake. The surveyor asked RD #1 if she had reviewed the four weekly weights requested in October 2024 for Resident #35 after the significant weight loss was identified, and RD #1 stated she reviewed the weights on 10/7, 10/15, and 10/28. The RD stated the resident's weights were stable and acknowledged there were some missing weights. Additionally, RD #1 stated a calorie count was completed, and the team discussed the resident being on a diuretic. There was no additional information provided by the facility. 2. On 1/6/25 at 12:30 PM, the surveyor observed Resident #92 lying on their bed with their eyes closed. The resident had a meal tray unopened on their bedside table. On 1/7/25 at 11:25 AM, the surveyor observed Resident #92 sitting up at the side of their bed with their breakfast tray on the bedside table in front of them. The resident was alert and did not respond to the surveyor's greeting. Resident #92 was eating eggs that were on their breakfast meal tray. On 1/9/25 at 9:20 AM, the surveyor reviewed the EMR of Resident #92. A review of the AR reflected Resident #92 was admitted to the facility with diagnoses that included but were not limited to; dementia, anxiety disorder, sleep disorder, gastroesophageal reflux disease (GERD), orthostatic hypotension (low BP while standing up from sitting or lying position), depression, and muscle weakness. A review of the most recent quarterly MDS dated [DATE], indicated a BIMS score of 9 out of 15, which indicated the resident had moderate cognitive impairment. A review of Section K revealed the resident was coded for having a weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a physician-prescribed weight loss regimen. The resident's weight was coded 126 lbs in the MDS. A review of Resident #92's weights revealed: 8/16/24: 139.6 lbs. 9/16/24: 139.6 lbs. 10/11/24: 125.6 lbs. (14 lbs loss or a 10.03% significant weight loss in one month) 11/18/24: 122 lbs. 12/4/24: 119 lbs. 12/8/24: 118.6 lbs. 12/12/24: 117.8 lbs. 12/18/24: 123 lbs. 12/25/24: 121 lbs. 1/6/25: 120 lbs. A review of PN revealed the following: A Nutritional assessment dated [DATE], written by RD #1, documented that RR #2 was present, the resident's food preferences were reviewed and per the resident's history, their weight had been stable. The resident's current weight was 139.6 lbs and their body mass index (BMI; calculation based on weight to height) was within normal limits. The note included recommendations to continue to monitor the resident's nutritional status and for the resident to continue a therapeutic diet of fat-controlled, regular texture, and thin liquid diet. A Nutrition/Dietary Note dated 11/5/24, written by RD #1, documented that the resident had a 10% weight loss with a weight of 139.6 lbs on 9/16/24, and a weight of 125.6 lbs on 10/11/24. RD #1 indicated recommendations were to follow up weight, liberalize therapeutic diet, super cereal at breakfast, and super mash (calorically dense mashed potatoes) at dinner. A review of the Physician's Orders did not include a PO for super cereal or super mash. A review of an IDCP Note dated 11/15/24, written by RD #1, indicated a weight follow-up was pending, weight loss notes, provided liberalized diet, and to continue to monitor. A review of a Nutrition/Dietary Note dated 11/28/24, written by RD #1, indicated a reweigh was pending and weight loss was reviewed with the IDCP team. The RD indicated recommendations for a 4 oz health shake to be given twice a day, a three-day calorie count, weekly weights for four weeks, liberalize therapeutic diet, super cereal at breakfast, and super mash at dinner. A review of the corresponding Physician's Orders included the following POs: A PO dated 4/11/24, for a regular diet, regular consistency texture, and thin liquids. A PO dated 11/5/24, to obtain weight one time only for one day. A PO dated 11/28/24, to give a 4 oz health shake two times a day for supplement mouth and record the percentage consumed. A PO dated 11/28/24, for three-day calorie count every shift for three days and to ensure calorie count paper was completed after each meal or snack, including supplements. A PO dated 11/28/24, for weekly weights for four weeks every day shift on Wednesday. The interventions that were implemented on 11/28/24, which to give a health shake twice a day, a three-day calorie count, and weekly weights for four weeks were added 48 days after the resident had a significant weight loss of 14 lbs. on 10/11/24. The resident also had continued weight loss with an additional 3.2 lbs. from 10/11/24 to 11/18/24. There was no PO for super cereal at breakfast or super mash at dinner. A review of a Nutrition/Dietary Note dated 12/2/24, written by RD #1, documented the results of a three-day calorie count indicated that the resident was meeting estimated nutritional needs. The RD recommended to continue current nutrition interventions, superfoods (cereal and mash), health shake supplements twice a day, and to continue to monitor weight trends. A review of a Nutrition/Dietary Note dated 12/18/24, written by RD #1, documented the resident had a weight gain with an improved weight status. The RD recommended to continue current nutrition interventions. A review of a Nutrition/Dietary Note dated 12/19/24, written by RD #1, documented a weight committee meeting took place to review the resident's unplanned weight loss. The resident had a weight gain with an improved weight status. The note indicated a message was left for RR #2. The RD recommended to continue the current nutrition interventions and to continue to monitor. A review of the November 2024 eMAR which revealed that on 11/5/24, the resident was documented with a weight of 125.6 lbs. A review of the December 2024 eMAR which revealed the following weights: 119 lbs on 12/4/24 117.8 lbs on 12/11/24 123 lbs on 12/18/24 121 lbs on 12/25/24 A review of the ICCP included a focus area dated 8/16/24, for the resident being at risk for malnutrition and revised on 11/5/24, to reflect an unplanned weight loss. Interventions included to: monitor nutritional status initiated on 8/16/24; regular diet initiated on 11/5/24, and health shake twice a day initiated on 11/28/24. The ICCP did not include super cereal at breakfast and super mash at dinner. On 1/9/25 at 11:39 AM, the surveyor interviewed RD #1 about Resident #92's 10% weight loss from September to October 2024 that was not documented as assessed until 11/5/24. RD #1 stated she would review her notes to provide a response to the surveyor's questions. The surveyor requested any documentation for any weight committee meetings for the resident. On 1/9/25 at 2:10 PM, RD #1 provided weight committee meeting sign-in sheets for 9/27/24 and 12/19/24. The sheet for 9/27/24, did not include Resident #92. A review of the untitled form dated 12/19/24, included the name, title, and signature of staff who attended the meeting and the name of the residents discussed in the meeting which included Resident #92. The meeting was attended by RD #1, a MDS staff, Director of Rehab, Assistant DON, LNHA, AA, Social Services, unit manager of 2 E unit, and the DON. RD #1 did not provide any weight committee meetings for October or November 2024, and provided no additional information regarding Resident #92's weight loss. On 1/9/25 at 12:50 PM, the surveyor informed the LNHA, DON, and the AA of the above concerns for Resident #92's significant weight loss between September to October 2024, and requested additional information. On 1/10/25 at 11:15 AM, the LNHA, DON, and AA met with the survey team. The LNHA stated there was no additional response or information regarding the concern for Resident #92.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#NJ00145520 Based on interview and record review, it was determined that the facility failed to a.) promptly notify the physician of a change in condition and provide timely service; b.) monitor and document the change of condition; c.) document the assessment of a Registered Nurse; and d.) ensure that staff were aware of the physician's written transfer order. This deficient practice was identified for 1 of 2 residents (Resident #223) reviewed for hospitalization, according to the standards of clinical practice. Resident #223 was hospitalized on [DATE] with a diagnosis of Stroke [Cerebrovascular Accident (CVA) occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients; This is a medical emergency, and prompt treatment is crucial]. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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. According to the Centers for Disease Control and Prevention (CDC), Stroke guidelines Page last reviewed: August 28, 2020, included Stroke Signs and Symptoms: During a stroke, every minute counts! Fast treatment can lessen the brain damage that stroke can cause. By knowing the signs and symptoms of stroke, you can take quick action and perhaps save a life-maybe even your own. Signs of Stroke in Men and Women sudden numbness or weakness in the face, arm, or leg, especially on one side of the body. Sudden confusion, trouble speaking, or difficulty understanding speech. Also, sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, loss of balance, or lack of coordination, sudden severe headache with no known cause. Call 9-1-1 right away if you or someone else has any of these symptoms. Acting F.A.S.T. Is Key for Stroke. Acting F.A.S.T. can help stroke patients get the treatments they desperately need. The stroke treatments that work best are available only if the stroke is recognized and diagnosed within 3 hours of the first symptoms. A review of the CDC Stroke Treatment Page last reviewed: May 25, 2021, included, If someone you know shows signs of stroke, call 9-1-1 right away. The key to stroke treatment and recovery is getting to the hospital quickly. Yet 1 in 3 stroke patients never calls 9-1-1. The emergency workers may take you to a specialized stroke center to ensure that you receive the quickest possible diagnosis and treatment. At the hospital, health professionals will ask about your medical history and about the time your symptoms started. Brain scans will show what type of stroke you had. If you get to the hospital within 3 hours of the first symptoms of an ischemic stroke, you may get a type of medicine called a thrombolytic (a clot-busting drug) to break up blood clots. Tissue plasminogen activator (TPA) is thrombolytic. TPA improves the chances of recovering from a stroke. Studies show that patients with ischemic strokes who receive TPA are more likely to recover fully or have less disability than patients who do not receive the drug. Patients treated with TPA are also less likely to need long-term care in a nursing home. Unfortunately, many stroke victims don't get to the hospital in time for TPA treatment. This is why it's so important to recognize the signs and symptoms of stroke right away and call 9-1-1. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included Parkinson's disease (progressive nervous system disorder that affects movement), depression, atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall), hypertension (elevated blood pressure), and seizures (are changes in the brain's electrical activity). A review of the electronic late entry Nursing Note (NN) dated 5/10/21 and timed at 19:24 documented by a Licensed Practical Nurse #1 (LPN#1) indicated, 1 PM-During rounds, was informed that resident is with [family member/RP] downstairs. 2 PM-Resident transferred to unit after [family member] visited. The [family member] left and [LPN #1] was informed by PT [physical therapy] that [family member] placed concern [about] the resident: VS taken: BP [blood pressure] 129/80 P [pulse] 77 RR [respiratory rate] 17 O2 [oxygen saturation] 96%, RA [room air] T [temperature] 97.9. Assessment done. RN [Registered Nurse] supervisor was called . [family member] was made aware that if any changes he would be informed .Will continue to monitor. A review of the medical records for Resident # 223 revealed that there was no assessment documented by the Registered Nurse/Supervisor #1 (RN/S #1) on 5/9/21. There was no documented evidence that the physician or the nurse practitioner was notified of the RP's concern with the resident's change in condition. A review of the 24-Hour Daily Report (24 HDR) provided by the Director of Nursing (DON) did not reveal a report or documentation on 5/9/21 regarding the RP's concern of a change in condition or that Resident # 223 would be monitored. A review of the Nursing schedule (Ns) provided by the Licensed Nursing Home Administrator (LNHA) dated 5/9/21 revealed that both LPN #1 and RN/S #1 worked the 7-3 and 3-11 shifts. The 5/9/21, Ns indicated that LPN #1 was scheduled to start the shift at 1:00 PM for the 7-3 shift. A review of the 5/10/21, Ns revealed that the Registered Nurse/Unit Manager (RN/UM) and LPN #2 worked the 7-3 shift, and LPN #1 and RN/S#2 worked the 3-11 shift. A review of the NN dated 5/10/21 timed at 17:38 and documented by the RN/UM indicated, 11-12 PM .NP [nurse practitioner] also examined resident as requested by resident's [family member]. 3:30 PM complete head-to-toe body assessment done by [name redacted] nurse NP, this writer, and shift supervisor . A review of the NN dated 5/10/21, timed at 19:29 and documented by LPN #1 indicated Received report regarding resident's [family member's] request. [name redacted] NP .ordered to send resident to [name redacted] ER [emergency room] for further evaluation. Altered mental status. [name redacted] NP discussed with [name redacted] NP .Resident left facility at 5:19 PM via [name redacted] transportation. A review of the 5/10/21 Discharge Minimum Data Set (DMDS), an assessment tool used to facilitate care management, indicated that Resident # 223 had an unplanned discharge to an acute hospital. The 5/10/21 DMDS also indicated that the cognitive skills for decision-making were moderately impaired. A review of the NP #1's handwritten Physician's Orders: Interim/Telephone dated 5/10/21, timed at 3:45 PM, included Send pt [patient] to [name redacted] ER [emergency room] for eval-slurred speech (dysarthria) . discussed with Np #2. A review of the 5/10/21, timed at 19:37 Individual Psychotherapy Progress Note (IPPN) by [name redacted]-LSW (Licensed Social Worker) indicated that the resident was seen for a face-to-face encounter. A review of the NP's #1 Acute/Reassessment (A/R) notes dated 5/10/21 included the History of Present Illness (HPI), which reflected that the [family member] called NP and reported that while visiting [Resident # 223] on 5/9 [Resident # 223] 'looked different,' he/she was 'drooling' and could not 'pin point what was going on with him/her.' Pt [patient] was elevated at bedside .Pt noted to be slower in responses and noted to have weaker grip on left side. [Family member] denied any previous hx [history] of stroke. Facetime with pt and [family member]-pt [patient] noted to be more slower while talking on facetime with [family member] .Pt [patient] to be evaluated further in ED [emergency department] per family request. On 6/28/21 at 8:27 AM, the surveyor interviewed NP #1, who stated that the RP called her on 5/10/21 and notified her about a change in the condition of Resident #223 during a visit with the resident on 5/9/21. NP #1 further stated that according to the RP, the resident showed signs and symptoms of facial drooping and was unable to open the right eye. NP #1 said that she did not receive a call from the facility on 5/9/21 regarding the RP's concerns. On that same date and time, NP #1 informed the surveyor that the resident was transferred to the hospital on 5/10/21, and the admitting diagnosis was a Stroke. Furthermore, NP #1 stated that further test on MRI (magnetic resonance imaging is a medical imaging technique often used for disease detection, diagnosis, and treatment monitoring) showed that the resident had a stroke. At that same time, NP #1 confirmed that she handwrote the 5/10/21 order timed at 3:45 PM to transfer the resident to the hospital for further evaluation due to slurred speech and discussed it with NP #2. NP #1 stated, it will not make any difference now because the hospital will ask when the symptoms of stroke started, and according to the RP, it began on 5/9/21. The surveyor asked NP #1 why the resident wasn't transferred to the hospital via 911 on 5/10/21 at 5:19 PM? The NP #1 stated, because the window period for stroke is within 3 hours. On 6/28/21 at 10:12 AM, the RN/UM informed the surveyors that as a standard of practice, if a staff member or responsible party reported a change in condition of the resident, then the LPN should have called the RN/S or the RN/UM to assess the resident because the assessment should be done by an RN. The RN/UM stated that the RN/S #1 should have assessed the resident on 5/9/21, called the physician, and documented her assessment and findings in the electronic medical records. On 6/28/21 at 10:48 AM, the surveyor, in the presence of the survey team, conducted a telephone interview with LPN #1 who stated she was the nurse assigned to Resident # 223 on 5/9/21, from 1:00 PM and the 3-11 shift, and on 5/10/21 during the 3-11 shift. LPN #1 stated that as a standard of practice, an LPN should call the RN/S or RN/UM if there is a report of change in condition because the RN was responsible for assessing the resident. She further stated that the RN would initiate a Situation-Background-Assessment-Recommendation (SBAR ), notify the physician, and document; [The SBAR allows for an easy and focused way to set expectations for what will be communicated and how between a member of the team, which is essential for developing teamwork and fostering a culture of patient safety in the electronic medical record as part of the RN's assessment]. LPN #1 further indicated that the nurse should have documented in the 24 HDR for another shift to continue monitoring the resident. She further acknowledged that she should have documented in the 24 HDR to communicate with the oncoming shift. On that same date and time, LPN #1 informed the surveyors that she remembered that the RP visited on 5/9/21 at 1:00 PM and had a concern regarding a change in the resident's condition. The RP asked the Restorative Certified Nursing Aide (RCNA) to have the nurse call the RP. LPN #1 stated that she informed RN/S#1 of the RP concerns. LPN #1 could not speak to why there was no report in the HDR on 5/9/21. When asked why there was no documented evidence of the change in condition reported by the RP until 5/10/21, timed at 7:24 PM. LPN #1 stated, I have no answer. LPN #1 further said, looking back now, I should have called the doctor on 5/9/21 to notify the physician that the RP had a concern with the resident's condition. LPN #1 informed the surveyors that the resident was admitted to the hospital with a diagnosis of stroke. She further stated that there should have been an SBAR in the electronic medical records on 5/9/21. On 6/28/21 at 11:08 AM, the [name redacted]-LSW (SCT/LSW) informed the surveyors that she's been coming to the facility as a Psychotherapist and writes her consultation reports electronically. The SCT/LSW stated that before she saw the resident on 5/10/21 at 1:30 PM, the facility Director of Social Services (DSS) asked her to check on the resident to see if there were any changes in condition because the RP called him and expressed concerns that the resident had a change in condition regarding the resident's speech and handgrip. On that same date and time, the SCT/LSW stated, since I've been seeing the resident for a while now, and I know the resident well. I can't remember what side of the arm was weak. The SCT/LSW stated, as per her observations, that the resident's speech was different, slower, and delayed, which was different for the resident. She further said that she informed NP #1 and RN/UM at that time, and that staff was aware of the RP's concerns since 5/9/21. The staff just wanted me to confirm the resident's changes since I knew the resident well. She stated, unless you take time to talk to the resident, you wouldn't be able to see the changes. The surveyor asked the SCT/LSW if she documented the resident's change of condition in her consult notes on 5/10/21? She stated, it should have been documented. On 6/28/21 at 11:20 AM, the RCNA informed the surveyors that on 5/9/21, he transported the resident to the visiting area and back to the unit. The RCNA stated that the resident was ok when he transported the resident to see the RP, and later, the RP called him because the RP observed changes in the resident. He further stated that he observed the resident was slow to respond and looked sleepy and was leaning to one side of the body, but he couldn't remember which side of the body. The RCNA stated that he brought the resident back to the unit, informed LPN #1 of the RP's concerns and that the RP wanted a call back regarding the resident's condition. On 6/28/21 at 11:32 AM, the surveyor, in the presence of the surveyor team, interviewed the DSS, who stated that he was unable to remember what the concerns of the RP were on 5/9/21 and could not speak of an incident or the RP's concerns. He further stated that there was no documented report regarding the 5/9/21 incident. On 6/28/21 at 1:08 PM, the surveyor conducted a telephone interview with the Registered Nurse (RN) in the presence of two other surveyors. The RN confirmed that he worked the 11-7 shift on 5/9/21. The RN stated that he remembered Resident # 223, and there were no reports or a shift to shift report to monitor the resident's condition. He said he was unaware that the resident's RP had concerns regarding the resident's condition on 5/9/21. On 6/28/21 at 2:18 PM, the survey team met with the LNHA, DON, Assistant Director of Nursing (ADON), Quality Assurance Performance Improvement Certified Specialist (QAPI/CS), Regional Nurse and discussed the above concerns. On 6/28/21 at 9:00 AM, 9:15 AM, and 10:00 AM, the surveyor, in the presence of the survey team, attempted to conduct a telephone interview with RN/S #1 but was unable to. On that same date, at 9:30 AM and 9:36 AM, the surveyor, in the presence of the survey team, attempted to conduct a telephone interview with NP#2 and the resident's primary care physician but was unable to. On 6/29/21 at 9:29 AM, the surveyor, in the presence of the survey team, interviewed LPN #2, who stated that Resident #223 was alert with some forgetfulness and confusion, able to make needs known to staff, and able to verbalize needs. LPN #2 confirmed that she worked the 7-3 shift on 5/10/21 and that there was an incident over the weekend that happened. I don't know what happened. She further stated, I know that was the priority at that time because the RN/UM and NP #1 were the ones taking care of the resident. The surveyor asked LPN #1 what the priority was at that time? LPN #1 stated, I don't know. On 6/29/21 at 9:37 AM, the surveyor, in the presence of another surveyor, interviewed the RN/UM, who confirmed that she worked the 7-3 shift on 5/10/21. She stated there were no reports about the resident from the medical record and no reports from the Staff about monitoring the resident's condition. The RN/UM noted that she was unaware that the RP had concerns on 5/9/21, not until NP #1 came into the facility on 5/10/21. The NP #1 informed her that the RP called the NP #1 with concerns of the resident, that the resident had a change in the condition of drooping and unable to speak. The RN/UM further stated that NP #1 and the RN/UM were able to assess the resident when the resident came back from an Orthopedic appointment in the afternoon. She further stated that the assessment was done with the RP via facetime. The RN/UM noted that the resident was fine at that time, except the resident was slow to respond than normal, and NP #1 ordered to transfer the resident to the hospital for further evaluation. On that same date and time, the RN/UM stated that she was not aware of NP #1's handwritten order dated 5/10/21 timed at 3:45 PM to transfer the resident to the hospital for slurred speech. She further stated that the resident should have been transferred to the hospital via 911 if the reason for the transfer was signs and symptoms of stroke, which was slurred speech, and stated, yes, I should have called 911. On 6/29/21 at 10:58 AM, the DON, in the presence of the ADON, informed the surveyors that the eInteract is the same as an SBAR. On that same date and time, the surveyor, in the presence of the DON, reviewed the electronic medical records for Resident # 223. There was no documented eInteract dated 5/9/21. A review of the staff statements provided by the DON on 6/29/21 at 1:38 PM reflected that the DSS had a typewritten statement which reflected that he received a call from the RP on 5/10/21, indicating that the RP visited on 5/9/21 and felt there were some changes with the resident. On 6/30/21 at 12:58 PM, the survey team met with the LNHA, Corporate [NAME] President of Nursing, DON, ADON, QAPI/CS. The DON informed the surveyors that she provided the staff statements to the surveyor. On 7/2/21 at 9:22 AM, during a post-survey telephone interview with RN/S#2, who confirmed that she worked the 3-11 shift on 5/10/21 but arrived at work around 3:30-4:00 PM. The RN/UM asked her to go with RN/UM and NP #1 to assess the resident. RN/S#2 stated that she could not remember the RN/UM and NP's names and why the resident was being assessed. RN/S#2 was unable to remember the admitting diagnosis of Resident # 223 on 5/10/21. She further stated that there was a concern on Sunday. I didn't work that day. She noted that the resident's family member was concerned that the resident had a stroke, and there were different stories about that day. She further stated that as a standard of practice, the RN/S should immediately assess the resident, call the doctor about the assessment and concern of the RP about signs and symptoms of stroke as reported, follow the physician's order, and document. She further stated that stroke is an emergency, even though you're not sure but there's a concern reported already, the nurse should call 911. A review of the facility's Change in a Resident's Condition or Status Policy that the DON provided with the last update of March 2021 included Our facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident . NJ 8:39-11.2 (b)