Voorhees Pediatric Facility
For profit - Limited Liability company
122 Beds
MILLENNIUM HEALTH SYSTEMS
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#302 of 344 in NJ
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Families considering Voorhees Pediatric Facility should be aware that it has a Trust Grade of F, indicating a poor rating with significant concerns. It ranks #302 out of 344 facilities in New Jersey, placing it in the bottom half, and #16 out of 20 in Camden County, where only a few alternatives are better. The facility is worsening, with reported issues increasing from 7 in 2024 to 11 in 2025. Staffing is a relative strength, rated 3/5, with a turnover of 30% that is below the state average, but the overall health inspection rating is just 1/5, which is poor. Concerningly, the facility has incurred $285,780 in fines, which is higher than 98% of New Jersey facilities, suggesting ongoing compliance problems. Specific incidents include a critical failure to ensure that all residents using wheelchairs were safely secured, leading to a resident suffering accidental asphyxiation. Additionally, the facility neglected to implement safety measures for wheelchair users, increasing the risk of similar accidents. While the facility has good RN coverage, which is crucial for catching potential issues, the combination of high fines and serious health inspection failures raises significant red flags for families considering this nursing home.
- Trust Score
- F
- In New Jersey
- #302/344
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 30% annual turnover. Excellent stability, 18 points below New Jersey's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $285,780 in fines. Lower than most New Jersey facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 121 minutes of Registered Nurse (RN) attention daily — more than 97% of New Jersey nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 13%
Review needed
7 → 11 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 11 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (30%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (30%)
18 points below New Jersey average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below New Jersey average (3.2)
Below average - review inspection findings carefully
Federal Fines: $285,780
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: MILLENNIUM HEALTH SYSTEMS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 30 deficiencies on record
3 life-threatening 1 actual harm
May 2025
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview it was determined that the facility failed to ensure a) the required ambient air temperature (between 71-81 degrees Farenheight) was maintained in all resident areas, a...
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Based on observation, interview it was determined that the facility failed to ensure a) the required ambient air temperature (between 71-81 degrees Farenheight) was maintained in all resident areas, and the shower room with an adjacent storage area was maintained in a clean and sanitary manner. The deficient practice was identified for 1 of 2 shower areas on the B-Wing Unit, for the 6 bed Annex Unit and was evidenced by the following:
On 5/18/25 at 7:29 PM, during a tour of the B-Wing Unit shower room the surveyor observed what appeared to be a brown feces covered washcloth wrapped around the bath sprayer nozzle which was below the bath stretcher that was on top of the bath. The surveyor showed the Registered Nurse Supervisor (RNS) who stated, she was not sure what happened. The surveyor then entered the attached store room and a tub of urine cups was stored directly on the floor and what appeared to be a mop or broom handle was stored inside the tub. The RNS stated someone must have dropped them (urine cups) there.
On 05/21/25 at 9:54 AM, the surveyor entered the Annex Unit and felt a noticeable chill in the air temperature. The surveyor interviewed a Respiritory Therapist (RT # 2) at that time regarding the air temperature in the Annex and RT #2 stated sometimes its colder in here. The surveyor observed that temperature reading on the thermostat behind the nursing desk was 73 degrees Farenheight (F). The six bed unit contained six residents (Resident # 41, #66, #84, #103, #108 and one Unsampled Resident (UR #1) at that time. The surveyor observed Resident #103 was in room and staff was talking to resident behind the curtain.
On 05/21/25 at 10:30 AM, two surveyors registered an ambient (environmental) temperature at the nursing desk of 68.8 F, although the wall thermostat registered 73 F. The surveyors observed the temperature in Resident # 103's room registered an ambient temperature of 68.3 F while the resident was in bed, and the Packaged Terminal Air Conditioner (PTAC) unit in the room was set to 61 F and was not running at that time. At that time, the Maintenance Director (MD) was present and the surveyor asked why was the PTAC temperature set to 61 F. The MD stated, anyone can touch it, you can come in here and lower it to anything. When asked if the room temperature felt cold, the MD stated, it is cold in here, and it is cold outside.
On 5/21/25 at 10:45, the surveyor reviewed the National Weather Service weather which revealed the outside temperature at the facility location was 55 F with rainy conditions, and 49 F forecasted for the evening.
On 05/23/25 at 1:54 PM, the survey team reviewed responses to the above concerns from the Liscensced Nursing Home Administrator (LNHA) and Director of Nursing, the LNHA stated moving forward the MD will monitor the temperatures in the resident rooms.
NJAC 8:39-5.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
REPEAT DEFICIENCY
Based on interview, medical record review and review of other facility documents, it was determined that the facility failed to complete a thorough investigation of an injury of unkn...
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REPEAT DEFICIENCY
Based on interview, medical record review and review of other facility documents, it was determined that the facility failed to complete a thorough investigation of an injury of unknown origin, and to rule out abuse. This deficient practice was identified for 1 of 4 residents reviewed for abuse, Resident #37 and was evidenced by the following:
On 5/22/25 at 10:08 AM, the surveyor reviewed the electronic medical record for Resident #37.
According to the admission Record, Resident #37 was admitted to the facility with diagnoses which included, but were not limited to; Spastic quadriplegic cerebral palsy (is a severe type that is characterized by paralysis of both arms and both legs, with muscle stiffness), Contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility) and Septo-optic dysplasia of brain (is a disorder of early brain and eye development).
A review of Resident #37's Quarterly Minimum Data Set (an assessment tool used to facilitate the management of care) dated 03/27/25, reflected that the resident's Brief Interview for Mental Status (BIMS) interview was not conducted because resident was rarely/never understood. The MDS did not indicate that Resident #37 had physical behavioral symptoms directed towards others or self. Further review of the MDS indicated resident had functional limitation in range of motion/impairment on both sides in their both upper and lower extremities.
A review of the Progress Notes (PN) revealed the following:
The PN revealed a Communication - with family/NOK/POA [next of kin/power of attorney] note dated 3/31/25 at 4:51 PM, which revealed: Spoke with [family] regarding exam of left arm upon return from [name redacted] school. Assessed with Director of Nursing (DON) present, to be examined by medical.
The PN revealed a [name redacted] General Note dated 3/31/25 at 5:35 PM, which revealed: On assessment with DON present, 2 circular bruises noted right exterior elbow, skin intact, no swelling, no discomfort when touched top bruise faded, second blue and purple in color. Will place on medical list to re-assessed.
Further review of the PN revealed a communication - with family/NOK/POA note dated 3/31/25 at 4:32 PM which revealed: received call from [family], stated [name redacted] school called regarding bruise left upper leg. Nursing supervisor made aware.
On 5/23/25 at 9:55 AM, the surveyor reviewed an incident report dated 3/31/25 at 4:51 completed by the Registered Nurse (RN) and checked off other for location of incident. Under section Procedure related incidents checked off other: Bruising related to blood draw 3/27/2025. Under Miscellaneous- Additional information: Report of bruising from [name redacted] school- per [family]- discussed bruise with [family]- verbalized understanding and acknowledged blood work- stated told school to call me first so they could inform them that they were aware of bruises. Signed off by Immediate supervisor, Nurse Manager, and the DON. There were no statements attached to the incident report.
On 5/23/25 at 9:22 AM, during an interview with the surveyor, the day shift Nursing Supervisor (NS) stated if she observed a resident with bruises, she would fill out incident report and investigate how did the resident get bruises. The NS further stated she would go back 3 days to complete her investigations. The NS stated the process to complete an investigation was to get staff statements.
On 5/23/25 at 10:23 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The surveyor presented above mentioned concerns regarding the investigation having no conclusion or and there were no statements. The DON stated Resident #37 had blood drawn and that was how Resident #37 got bruises on their arms. The surveyor requested for additional information including blood test report or any statements that were obtained.
On 5/23/25 at 1:42 PM, In the presence of the survey team, the DON stated everything was in the Progress Notes, and confirmed that that there were no statements obtained regarding the investigation of Resident #37's bruises. The DON acknowledged that the facility wanted to ensure that injuries of unknown origin were investigated to rule out abuse. The DON could not provide any further information.
A review of the facility's policy titled, Abuse and Neglect, last revised 11/23 revealed the following: The facility shall promptly report all suspected cases of abuse or neglect in compliance with New Jersey Law and Regulation. All reports of abuse, neglect or exploitation shall be considered allegations until the matter is substantiated. The facility has an obligation to protect the welfare and to fully investigate and correct any circumstances upon that welfare. The approach should be as proactive as possible. As such, all new employees shall review this information at least annually. Procedure: Any allegation of abuse from any source shall be investigated and every effort shall be made to prevent recurrence. The report shall be made to the administrator /DON or after business hours to the Supervisor on duty. The Supervisor shall in turn report the incident to the Administrator, designee and if an investigation is necessary, take immediate steps to address the situation including:
Securing medical attention for the alleged victim .
NJAC 8:39-4.1(a)(5)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 documents it was determined that the facility failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure a system was in place to ensure devices used to prevent contractures were consistently applied per physician order. The deficient practice occurred for 1 of 6 residents reviewed for positioning (Resident #84) and was evidenced by the following:
On 5/18/25 at 8:00 PM, the surveyor observed Resident #84 in bed sleeping with both hands visibly contracted and there was no device inside both hands. There were two posters on the wall above Resident #84's bed detailing the use of Resident #84's right and left hand roll (a device used to prevent the hands from closing into the palms).
On 5/19/25 at 9:30 AM, the surveyor reviewed the medical record for Resident #84 which revealed the following:
- The admission Record revealed the resident had diagnoses which included, but were not limited to; Localization-related (Focal)(Partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus, Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, Spastic quadriplegic cerebral palsy.
- A Care Plan Focus for alteration in muscle tone and/or joint stability related to their diagnosis, initiated 6/7/24. A Goal, initiated 6/7/24 to remain free from complications related to the use of specialized positioning equipment, including but not limited to, skin integrity issues or progression of contratures. Interventions included: OT (Occupational Therapy) to monitor specialized equipment PRN [as needed] and quarterly for the IDT [Interdisciplinary Team], initiated 6/7/24. Another Intervention revealed will utilize L (orange) and R (blue) hand rolls for 3 hours, two times each 12 hour nursing shift with a minimum of 1 hour break between wearing periods, date initiated 6/7/24.
-A physician order dated 6/7/24 at 1900 [7:00 PM] for Orthotics: R (Right) (blue) wrist roll, R blue hand roll, and L (Left) (orange) hand roll to be worn for 3 hours, two times each 12 hour nursing shift with a minimum of 1 hour break between wearing periods, every shift for Contracture.
The Treatment Administration Record (TAR) revealed the above order with an area only to indicate Day/ Night and staff initials. There were no times specified to ensure that the hand rolls would be worn two times each 12 hour period for for 3 hours with the ordered 1 hour break between wearing.
The Quarterly Minimum Data Set, dated [DATE] revealed the resident had impairment on both sides related to range of motion and was dependent on staff for all care.
On 05/21/25 at 10:05 AM, the surveyor asked the Registered Nurse (RN #1) providing care to Resident #84 if the resident was wearing their handrolls. Both the surveyor and RN #1 observed Resident #84 in bed, and the signs behind the resident's bed regarding the directions for the right and left handroll. RN #1 stated, I don't see them, and the surveyor asked are they supposed to be there? RN #1 responded yes.
On 05/21/25 at 12:34 PM, the surveyor interviewed the Occupational Therapy Supervisor (OTS), and asked what the handrolls were used for. The OTS stated they used orthotics to keep fingers open and help to prevent contractures.
On 05/21/25 at 12:40 PM, both the OTS and the surveyor went to Resident #84's room, the sheets were now removed from the bed, and the blue and orange handrolls were on the nightstand. The surveyor asked how did they ensure the orders were carried out for the specific amount of time since it was not specific in the TAR. The OTS stated, they were not responsible for putting specific times into the TAR, and stated that was a nursing function.
On 05/23/25 at 1:53 PM, during the exit conference held with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA). The DON stated, he would look into it and he acknowledged that there was no specific times documented in the TAR to ensure the handrolls were worn per physician order.
The Hand Rolls policy, Dated, 11/00 revealed: Purpose: Patients who required preventive measure and/or positioning devices will be provided with these devices in order to prevent contractures or problems associated with contractures. These measure or devices will be provided in accordance with an order from a physician, nursing, occupational therapy, and/or physical therapy.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REPEAT DEFICIENCY
Based on observation, interview and record review, it was determined that the facility failed to ensure that n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REPEAT DEFICIENCY
Based on observation, interview and record review, it was determined that the facility failed to ensure that nurses administer all prescribed medications according to the physician's order. This deficient practice occurred to 1 of 7 residents (Resident #85) observed during the medication pass observation and was evidenced by the following:
On 5/21/25/25 at 9:45 AM, during the medication administration observation the Licensed Practical Nurse (LPN ) informed the surveyor that Resident #85's Propanolol dose was not available. The surveyor inquired regarding the facility's protocol to reorder medications. The LPN informed the surveyor that the medication should be reordered before reaching the remaining 8 doses on the Bingo cart or remaining 3 doses left in multidose bottle. The LPN stated that she had not been on the medication cart and could not comment when the medication was reordered.
On 5/21/25 at 10:15 AM, the surveyor reviewed the medical record which revealed: Resident #85 had diagnoses which included, but were not limited to; Chronic respiratory failure, persistent vegetative state, essential hypertension and tachycardia.
According to the Quarterly Minimum Data Set Assessment (MDS) dated [DATE] Resident #85 was severely cognitively impaired. Resident #85 was totally dependent on staff for care.
On 05/22/25 at 1:45 PM, during the reconciliation of physicians orders in the medical record, it was noted that Resident #85 had an order for Propanolol Solution (heart medication and also used for anxiety) 20 milligrams (mg)/5 milliliter (ml). The order was to give 0.7 ml via Gastrostomy tube every 8 hours for dysautonomia, spasticity. The medication was to be held if Systolic blood pressure was less than 70 and heart rate less than 70. On 5/19/25 the blood pressure was not entered on the medication administration record.
A review of the Medication Administration Record (MAR) for April 2025 reflected that five doses of Propanolol had not been administered on 4/25/25 at 10:00 PM; 4/26/25 at 6:00 AM and 2:00 PM; 5/19/25 at 10:00 PM, and 5/20/25 at 6:00 AM. There was no blood pressure and heart rate entered on the days the medication was missing.
On 5/20/25 at 11:30 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN #7) who confirmed that the Propanolol was not administered because the pharmacy did not send the medication. A review of the Progress notes failed to indicate that the physician was made aware of the omission and that Resident #85 was being monitored for any adverse effects.
On 5/23/25 at 10:15 AM the facility was made aware of the above concerns. No additional information was provided.
A review of the facility's policy titled, Medication Ordering and receiving from pharmacy revealed the following: Medications and related products are received from pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt.
NJAC 8:39-29.3(a)(4)(5)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
REPEAT DEFICIENCY
Based on observation, interview and record review it was determined that the facility failed to properly label, dispose and store medication in 1 of 2 medication storage areas. The d...
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REPEAT DEFICIENCY
Based on observation, interview and record review it was determined that the facility failed to properly label, dispose and store medication in 1 of 2 medication storage areas. The deficient practice was evidenced by the following:
On 5/20/25 at 10:45 AM, the surveyor inspected the Unit 2 Medication Room in the presence of the Registered Nurse Unit Manager (RN #7) found a bottle of iron liquid with an expiration date of 2/2025. RN #7 informed the surveyor that the Nursing Supervisor checked the storage room daily and could not provide the rationale for the expired medication to be among other medications.
On 5/20/25 at 11:00 AM, the surveyor inspected the Unit 2 Medication Cart #1 in the presence of the Licensed Practical Nurse (LPN#3) and noted a vial of Lantus Insulin that was opened and not dated. LPN #3 stated that all insulin vials and Pen should be dated upon opening. LPN #3 added that the 7:00 PM-7:00 AM used the Lantus Insulin and should have been dated.
A review of the Manufacturer's Specifications for Lantus Insulin revealed the following: Lantus Insulin should be discarded 28 days of first use regardless of whether it's been refrigerated or stored at room temperature.
On 5/23/25 at 10:15 AM the facility was made aware of the above concerns. No additional information was provided.
A review of the facility's policy Delivery, Receipt and Storage, last revised 1/2025 revealed the following:Medication bottles are to be labeled with date and time opened. Medications are to be checked daily for expiration date. Any expired medications should be disposed of properly.
NJAC 8:39-29.4 (a) 8
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care, and personal hygiene care for 2 of 4 residents (Resident #82 and #58) reviewed for Activities of Daily Living (ADLs) on 1 of 2 resident units, (B Wing Unit). The deficient practice was evidenced by the following:
1. On 5/18/25 at 7:45 PM, the surveyor toured the B Wing Unit, and observed a strong feces and urine odor in the hallway. All the residents were observed in bed at that time.
On 5/18/25 at 8:29 PM, the surveyor observed Resident #82 in an enclosure bed (a complete bed system resembling a tent, designed to provide safety). The resident was facing the window. From a clear unobstructed view through the open door, the surveyor observed the resident's incontinence brief was bulging from the back. The surveyor then observed the resident was asleep, and there was no sheet to cover the bed. The Surveyor then observed 3 incontinence pads on the mattress underneath the resident.
On 5/18/25 at 9:15 PM, the surveyor escorted another surveyor to the room and we both observed Resident #82 in the same position with bulging incontinence brief, and the strong smell of urine and feces penetrated into the hallway.
On 05/19/25 at 8:30 AM, the surveyor returned to the B Wing Unit and observed the resident in the enclosure bed, was in the same position as observed on 5/18/25 at 8:29 PM, facing the window and the incontinence brief could be observed bulging from the back as observed on 05/18/25 at 9:15 PM.
On 05/19/25 at 10:37 AM, the surveyor observed Resident #82 in the enclosure bed in the same position as observed on 5/19/25 at 8:30 AM, and the resident was still sleeping.
On 05/19/25 at 11:05 AM, the surveyor reviewed the B Wing Unit's assignment sheet and located the Certified Nurse Aide (CNA #1 ) assigned to care for Resident #82. CNA #1 informed the surveyor that she would need another staff to assist with Resident #82. A Licensed Practical Nurse (LPN #1) entered the room to assist with the incontinence care. The incontinence pads and the bed were observed saturated with urine. Resident #82 was wearing two incontinence briefs. The resident's genital area was wrapped up in an infant brief which was also saturated with urine and feces. The larger sized incontinence brief was also saturated with urine and filled with a large amount of feces. CNA #1 turned the resident to the right side to facilitate the care. Resident #82 was observed covered with feces from the waist to the buttocks. CNA #1 used one pack of wipes and consistently wiped the embedded feces from Resident #82's backside and buttocks as the feces appeared caked on.
On 5/19/25 at 11:30 AM, the surveyor inquired regarding the protocol for incontinence care. The Registered Nurse (RN #6) informed the surveyor that all CNAs were responsible to provide incontinence care, and the nurses were to administer treatments and assist as needed.
On 5/19/25 at 1:10 PM, the surveyor interviewed Certified Nurse Aide (CNA #1) who was assigned to provide care to Resident #82. CNA #1 stated that the night shift was responsible to wash and dress Resident #82. CNA #1 stated she checked the resident this morning and Resident #82 was sleeping and confirmed that she had not yet provided incontinence care to Resident #82.
On 05/20/25 at 9:45 AM, the surveyor observed Resident #82 in the enclosure bed and the resident was asleep. The surveyor interviewed LPN #1 who assisted CNA #1 with the incontinence care. LPN#2 informed the surveyor that Resident #82 was a heavy wetter. LPN #1 added that they have an order to wrap the resident's genital area in an infant brief. The surveyor inquired regarding the rationale to wrap the resident's genital area in an infant brief. LPN #1 could not provide the rationale. The surveyor then inquired regarding the facility protocol for incontinence care.
On 05/20/25 at 9:46 AM, the surveyor interviewed LPN #2 regarding the protocol for incontinence care. LPN #2 stated, the protocol was to provide incontinence care every two hours but it was unrealistic based on staffing and who was assigned to the resident.
On 5/20/25 at 10:30 AM, the surveyor interviewed the Registered Nurse Nursing Supervisor (RN #5) regarding the concerns with incontinence care. RN #5 informed the surveyor that the staff who wrote the order to wrap Resident #82's genital area in an infant brief was no longer employed by the facility.
At that time the surveyor reviewed the medical record for Rsident #82 with RN #5 which revealed a Physician Order dated 3/11/24 for Resident #82 to have a condom catheter (a plastic sleeve over the genital area to collect urine) from 6:00 AM-6:00 PM. The Care Plan did not include the use of an infant brief.
Further review of the medical record revealed: Resident #82's admission Record (AR) revealed, Resident #82 was admitted to the facility with diagnoses which included but were not limited to; Spastic Quadriplegic Cerebral Palsy, other disorders of thee lungs, Symptomatic Epilepsy and Epileptic syndromes with complex partial seizures. The quarterly Minimum Data Set (MDS), an assessment tool dated 03/20/25, revealed that Resident #82 had severe cognitive impairment. Section GG of the MDS, which referred to ADLs revealed that Resident #82 was totally dependent on staff for care.
Review of the Care Plan for Resident #82, reflected there was no focus for ADLs. The care plan dated 3/11/24 and last revised 04/02/25 included a Focus Potential for skin breakdown, initiated 03/11/24. The goal was for Resident #82 to remain dry as much as possible to avoid skin breakdown. The intervention was for Resident #82 will use a [condom catheter] daily from 6:00 AM- 6:00 PM. Initiated 03/11/2024. The care plan did not indicate when staff were to provide incontinence care to the resident and the frequency for staff to turn and reposition the resident.
On 5/20/25 at 11:55 AM, the surveyor interviewed the Director of Nursing (DON) who stated that he was not aware that Resident #82 had an infant brief wrapped around their genital area and he stated was not aware of the order related to using an infant brief wrapped around the genitals.
On 05/23/25 at 12:43 PM, the surveyor went to the B Wing Unit, and again observed a strong urine odor in the hallway. The surveyor interviewed a random CNA (CNA #4) observed in the hallway regarding the odor. CNA #4 stated that she also noticed the odor and was about to locate the CNA (CNA #5) assigned to that hallway. The surveyor entered Resident #82's room and noted that the urine odor was pervasive in the room. The surveyor met CNA #5 in the hallway and asked to check Resident #82 for incontinence. The surveyor then observed, four days after the initial observation that occurred on 5/19/25 at 11:05 AM, that Residnet #82's bed was saturated with urine, and the incontinence brief was yellow stained and also saturated with urine. When inquired regarding the last time incontinence care was provided, CNA #5 stated, Not too sure, possibly around 9:00 AM or 10:00 AM. The surveyor then asked CNA #5 who assisted her with the resident's care and she stated, I checked the resident alone. I have ten residents to care for and [Resident #82] used to have an order for double briefs and it was discontinued.
2. On 05/18/25 at 8:46 PM, the surveyor observed Resident #58 on the B- Wing Unit in an enclosure bed. Resident #58 was was yelling and screaming. A strong feces odor was observed in the room. An interview with CNA (CNA #6) the same day at 9:15 PM, revealed that Resident #58 expressed behaviors, the enclosure bed was to maintain the resident safety.
On 05/20/25 at 2:20 PM, the surveyor returned to the B- Wing Unit and noted a strong feces odor in the B- Wing Unit hallway. The surveyor observed Resident #58 standing inside the enclosure bed. The Surveyor observed CNA #6 in the hallway and asked to assist to observe incontinence care. CNA #6 checked Resident #58 and the incontinence brief was heavily soiled with urine and feces. CNA #6 informed the surveyor that she had Resident #58 on her assignment but was not aware that the resident returned from school. Upon return from school the CNAs were supposed to be informed if the resident needed to be changed.
On 05/21/25 at 9:09 AM, the surveyor interviewed the Registered Nurse in charge of the B- Wing Unit (RN #6). RN #6 stated that Resident #58 left for school at 8:30 AM, and returned at 12:30 PM every day. RN #6 added the staff at the school could also provide incontinence care but the CNAs were responsible to check on their residents upon return from school.
On 5/21/25 at 12:30 PM, the surveyor reviewed Resident #58's medical record which revealed the following:
Resident #58 was admitted to the facility with diagnoses which included but were to limited to: Pulmonary hypertension, paralysis of vocal cords, anxiety disorder and short stature (Child).
According to the Quarterly Minimum Data Set, dated [DATE], Resident #58 had memory problems and was assessed by the facility as being severely cognitively impaired. The MDS also indicated that Resident #58 was totally dependent on staff for all ADLs, and was always incontinent of urine and stool.
Review of the Care Plan for Resident #58 initiated on 01/16/25 and last revised 02/22/25, revealed the following: Focus: Resident #58 engages in noncompliance during nursing and ADLs. The goal was to: Limit reaction/attention to the behavior
Do not give the resident access to preferred items/ activities. There was no Care Plan to address incontinence care or the frequency for Incontinence care should be provided.
On 05/23/25 at 10:23 AM, the survey team interviewed the Director of Nursing and Licensed Nursing Home Administrator and presented the above concerns. The DON stated, RN #3 should not have left the med cart open. The survey team asked about the adequacy of the facility staffing and the LNHA stated, we meet the requirement and stated the acuity staffing hours requirement. When asked if the RTs were considered part of the staffing for resident care, the LNHA stated RTs were not nurses and confirmed that there was no process in place to cover the time the RTs were on break if there was only 1 nurse assigned and 1 RT for the Annex. The survey team asked if the facility looked at the CNA staff available for ADL care, and the LNHA stated, the facility was going to get a waiver (for CNA staffing) because they replaced CNAs with nurses, but our plan moving forward was to get more CNAs to help with changing residents and doing weights.
A review of the facility's policy titled, Routine Care: Incontinence Care/ Diapers Care effective 12/1997 and last revised 6/16 revealed the following: Purpose:
To assure the comfort and safety of the residents, prevent the transmission of infection. To assure an adequate supply of diapers if needed. General Information: Residents shall be checked every two hours for the presence of incontinence/wet or soiled diapers to facilitate immediate changing, thus decreasing the risk of skin breakdown.
NJAC 8:39 - 27.1(a)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete a performance review of Certified Nurse Aides (CNA) at least every ...
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Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete a performance review of Certified Nurse Aides (CNA) at least every 12 months. The deficient practice was identified for 4 of 5 Certified Nurse Aides reviewed under Sufficient and Competent Nurse Staffing task.
The deficient practice was evidenced by:
A review of the facility-provided CNA annual performance evaluations revealed that 4 of the 5 CNAs did not have an annual performance evaluation for 2024.
On 05/22/25 09:41 AM during an interview with the surveyor, the Liscensed Nursing Home Administrator (LNHA) confirmed there were no performance evaluations for 2024 for 4 out of 5 CNA's. The LNHA stated, I know we should have them, but we don't, the place fell apart. The LNHA stated they have had two Director of Nursing's and an interim DON in the past year. The LNHA had no further information to provide.
A review of an undated facility provided policy titled Employee Evaluation revealed: Each employee will have a written evaluation of their job performance within three months of employment and annually thereafter.
NJAC 8:39-43.17(b)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and document review it was determined that the facility failed to ensure a) appropriate Personal Protective Equipment was utilized while providing care to a resident wh...
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Based on observation, interview and document review it was determined that the facility failed to ensure a) appropriate Personal Protective Equipment was utilized while providing care to a resident who required Enhanced Barrier Precautions (EBP), b) soiled linens were appropriately handled, and c) appropriate hand hygiene was performed per facility and Center for Disease Control Guidance. The deficient practice occurred on 1 of 3 resident units (The Annex) and was evidenced by the following:
On 05/21/25 at 9:54 AM, the surveyor entered the Annex Unit and observed Resident #103 was in the room, the curtain was pulled, and staff were heard talking to resident while providing care.
On 05/21/25 at 9:59 AM, the surveyor observed a sign posted outside of Resident #103's door that revealed 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 Ativities. Dressing, Bathing/Showereing, Transaferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting . At that time, the surveyor observed the curtain open, and a pile of linen was on the floor, while the Registered Nurse (RN #1) was observed kneeling on the floor in front of Resident #103 who was in a wheelchair, then RN #1 with her gloved hands, placed socks on the resident's feet. RN #1 was not wearing a gown and then picked up the soiled linen from the floor with her gloved hands and placed the linen into a bin in the hallway. RN #1 then re-entered Resident #103's room, removed the gloves, turned on the faucet, used the soap dispenser, and rubbed both hands under running water for 4 seconds.
05/21/25 10:00 AM, RN #1 exited the room and the surveyor interviewed her about what care she provided for Resident #103. RN #1 stated she washed the resident up every morning with care and the resident had a big poop and didn't like to be washed. The surveyor asked about putting linens on floor, and if what was observed was soiled? RN #1 stated Yes, they were soiled. The surveyor then asked if RN #1 wore a gown during care, and she stated No, I did not. The surveyor asked if Resident #103 required EBP and pointed to the sign next to the door. RN #1 looked at the sign and stated, no not for [Resident #103], the sign would have been on front of the door. RN #1 confirmed all the linens and soiled items were placed in the bin directly. The surveyor asked if was protocol to wash hands under running water and how should hands be washed. RN #1 stated, it was okay, to put the soap on the hands and put the hands under the water.
On 05/21/25 at 10:38 AM, the surveyor informed the facility Infection Preventionist Registered Nurse (IPRN) regarding the above observations and asked is it okay to change a resident and not wear a gown. The IPRN stated, no, you should be wearing a gown. The surveyor then asked if a feces soiled diaper could be placed on the floor with linen. The IPRN stated, No, your feet are tracking it all over the floor, it is disgusting and you should bag it, it should not be placed directly into the bin due to infection control. The surveyor informed the IPRN of the hand washing observation and inquired regarding the protocol for hand hygiene as the staff was observed washing their hands under running water. The IPRN confirmed that the staff should have had a gown on during incontinence care and acknowledged that 100% of the facility population was on EBP and RN #1 should have been wearing a gown when Resident #103 received incontinence care.
On 5/23/25 at 10:23 AM, the surveyor informed the Liscensed Nursing Home Administrator and Director of Nursing of the above findings.
On 5/23/25 at 12:36 the IPRN provided the surveyor with Tips for Meeting the Linen Requirements in Skillled Nursing Facilities which revealed: Tips: Carefully roll up soiled linen to prevent contamination of the air, surfaces, staff, and/or residents. Do not shake linen; Moving or shaking linens can aerosolize pathogens causing spread to others and contamination of the environment; Make sure contaminated laundry is gagged or contained at the point of collection (e.g. location where it was used) not in the entry way or hallway; This will reduce the risk spreading pathogens elsewhere in the facility to others; Place soiled linen into a clearly labeled, leak-proof container (e.g. bag) in the resident care area. Do not transport soiled linen by hand outside of the specific resident care area from where it was removed. Make sure all containers and bags are leak proof.
On 5/23/24 at 2:00 PM, during the facility exit, the facility provided no additional information.
The Handling Soiled Linen Policy, Revied 11/24 revealed: Procedure: 3. Linen should not be allowed to touch the uniform or floor and should be handheld as little as possible with minimum agitation to avoid contamination of air, surfaces, and persons. 4. Used or soiled linen shall be collected at the bedside and placed in a lined bag or designated lined receptacle. Bags will be stored on the clean linen carts. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom.
The Enhanced Barrier Precautions Policy, effective 6/17/24 revealed: Purpose was in infection and control intervention to reduce the spread of multi-drug resistant organisms to residents.
The Hand Hygiene Policy, Reviewed/Revised 2/25 revealed: Purpose: Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids or contaminated surfaces (even if gloves are worn); before invasive procedures; after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings). To reduce the incidence of Healthcare-acquired infections (Center for Disease Contol, 2014). Hand-Hygiene Technique: B: When washing hands with soap and water, we hands first with warm water, apply an amount of product recommended by the manufactured to hands, and rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use clean dry towel to turn off the faucet .
NJAC 8:39-21.1(h)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure that there was sufficient competent staff to ensure a) all residen...
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Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure that there was sufficient competent staff to ensure a) all residents were provided with appropriate and timely incontinence care and were consistently available to provide appropriate care to maintain residents highest practicable physical, mental, and psychosocial well-being and b) the minimum staffing requirements per the New Jersey Department of Health based on acuity of the residents was maintained. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following:
Refer to 677F, 688D
A. On 05/18/25 at 7:17 PM, the Registered Nurse Nursing Supervisor for the B -Wing Unit, informed the survey team the B- Wing Unit had 60 residents. When the surveyor asked how many Certified Nurse Aides (CNAs) were assigned to the unit, a CNA at the nursing station stated she was the only CNA on the unit and she was assigned ten residents. The CNA explained that the nurses were responsible for providing all of the care required to their assigned residents, as she had her own assignment.
On 05/18/25 at 7:30 PM, Surveyor #1 reviewed the B- Wing Unit, Assignment Sheet and confirmed 1 CNA was listed.
On 5/18/25 at 7:45 PM, Surveyor #2 toured the B- Wing Unit and observed a strong feces and urine odor in the hallway. All the residents were observed in bed at that time.
On 5/18/25 at 8:29 PM, Surveyor #2 observed Resident #82 in an enclosure bed (a complete bed system resembling a tent, designed to provide safety). The resident was facing the window. From a clear unobstructed view through the door, the surveyor observed the resident's incontinence brief was bulging from the back. The surveyor then observed the resident was asleep, and there was no sheet to cover the bed. The Surveyor then observed 3 incontinence pads on the mattress and underneath the resident.
On 5/18/25 at 9:15 PM, Surveyor #2 and surveyor #3 returned to Resident #82's room and both observed the resident in the same position with the bulging incontinence brief, and the strong smell of urine and feces permeated into the hallway.
On 05/19/25 at 10:00 AM, Surveyor #1 interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) in the presence of Surveyor #2 regarding the facility staffing pattern and use of CNAs. The LNHA stated there were nurses on medication carts and there were Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) to also provide care, it was a total care model. The surveyors informed the LNHA that the nurses had informed the surveyors that the CNAs were responsible for all of the Activities of Daily Living (ADLs- including washing, dressing, toileting) and the CNAs informed the surveyors that they were assigned to specific residents only.
On 05/19/25 at 11:05 AM, Surveyor #2 reviewed the B- Wing Unit assignment sheet and located the CNA (CNA #2) assigned to care for Resident #82. CNA #2 informed the surveyor that she would need another staff to assist with Resident #82. An LPN (LPN #2) entered the room to assist with the incontinence care. The incontinence pads and the bed were observed saturated with urine. Resident #82 was wearing two incontinence briefs. The resident's genital area was also wrapped up in an infant brief which was also saturated with urine and feces. The large sized incontinent brief was saturated with urine and filled with feces. CNA #2 turned the resident to the right side to facilitate the care. Resident #82 was covered with feces from the waist to the buttocks. CNA #2 used one pack of wipes and consistently wiped the embedded feces from Resident #82's backside and buttocks as the feces appeared to be caked on.
On 5/19/25 at 11:30 AM, Surveyor #2 inquired regarding the protocol for incontinence care. The Registered Nurse (RN #2) stated that the CNAs were responsible to provide incontinence care, and the nurses were to administer treatments and assist as needed.
On 5/19/25 at 1:10 PM, Surveyor #2 interviewed CNA #2 who was assigned to Resident # 82 on her assignment. CNA #2 stated that the night shift was responsible to wash and dress Resident #82. CNA #2 stated checked the resident this morning and Resident #82 was sleeping and confirmed that she had not yet provided incontinence care to Resident #82.
On 05/19/25 at 1:13 PM, Surveyor #1 and Surveyor #2 entered the Annex (6 single bed unit fully occupied). The medication cart was unlocked and there were no staff in attendance, the surveyor easily opened the bottom drawer of the medication cart to confirm it was unlocked. At that time Resident #66 was in the wheelchair in the room and was in full view upon entering the unit. A staff was observed at the bedside with Resident #84 (a few rooms away and out of view of Resident #66).Resident #66 disrobed and was fully exposed from the waist up. At 1:17 PM, the Registered Nurse (RN #3) assigned to the Annex, exited Resident #84's room and the surveyors showed RN #3 the opened medication cart drawer and asked if it was okay to leave the medication cart unlocked? RN #3 stated, I had to pass medication, so I leave it open. When we have enough staff, and it is not often that we do. I am all by myself and the nurse does everything. RN #3 then stated, when the Respiratory Therapist assigned to the Annex had to go on break, we have no one to cover.
On 05/20/25 at 9:45 AM, Surveyor #2 observed Resident #82 in the enclosure bed and the resident was asleep. The surveyor interviewed the LPN (#2) who assisted the CNA (#2) with the incontinence care. The LPN informed the surveyor that Resident #82 was a heavy wetter. LPN #2 added that they have an order to wrap the resident's genital area in an infant brief. The surveyor inquired regarding the rationale to wrap the resident's genital area in an infant brief. LPN #2 could not provide the rationale. The surveyor then inquired regarding the facility protocol for incontinence care.
On 05/20/25 at 9:46 AM, LPN #2 stated that the protocol was to provide incontinence care every two hours but it was unrealistic based on staffing and who was assigned to the resident.
On 05/20/25 at 2:20 PM, the surveyor observed a strong feces odor in the B- Wing Unit hallway. The surveyor observed Resident #58 standing inside an enclosure bed. The Surveyor observed a CNA (#6) in the hallway and asked to assist to observe incontinence care. CNA #6 checked Resident #58 and the incontinence brief was heavily soiled with urine and feces. CNA #6 informed the surveyor that she had Resident #58 on her assignment but was not aware that the resident returned from school. Upon return from school the CNAs were supposed to be informed if the resident needed to be changed.
On 05/21/25 at 9:09 AM, the surveyor interviewed the RN (#6) in charge of the B- Wing Unit. RN #6 stated that Resident #58 left for school at 8:30 AM and returned at 12:30 PM every day. RN #6 added, the staff at the school could also provide incontinence care but the CNAs were responsible to check on their residents upon return from school.
On 05/21/25 at 9:23 AM, Surveyor #1 interviewed the Respiratory Therapy Director (RTD) regarding the care that the Respiratory Therapists (RT) provided in the Annex. The RTD stated that there were 6 residents on the Annex and maybe only 4 of 6 received RT care because the residents were ventilator dependent (machine used when unable to breathe on their own) and RTs managed ventilatory care, all alarms, and completed airway clearance. The RTs also helped with positioning which was considered lung therapy and when the residents needed to be transferred and the RTs transferred all of the respiratory equipment. Surveyor #1 then asked if the RTs completed any other resident care? The RTD stated the RTs did not complete activities of daily living ADLs or any type of CNA work. The RTD stated the RTs could help with some things, but that was not their role, and confirmed that when the RT was on lunch or any other break that there was no coverage for the RT on the Annex.
On 05/21/25 at 9:42 AM, Surveyor #1 interviewed RT #2 on the Annex regarding her workload. RT #2 stated she was responsible for 4 of 6 resident's respiratory care on the Annex.
On 05/21/25 at 9:54 AM, the surveyor entered the Annex and felt a noticeable chill in the air temperature. The surveyor observed Resident #103 was in the room, the curtain was pulled, and staff was talking to resident while the resident was heard crying.
On 05/21/25 at 9:59 AM, the surveyor observed a sign posted outside of Resident #103's door that revealed 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 . At that time, the surveyor observed the curtain open, and a pile of linen was on the floor, while the Registered Nurse (RN #1) was observed kneeling on the floor in front of resident #103 who was in a wheelchair, then RN #1 with her gloved hands, placed socks on the resident's feet. RN #1 was not wearing a gown, picked up the soiled linen from the floor with her gloved hands and placed the linen into a bin in the hallway.
On 05/21/25 at 10:05 AM, the surveyor asked RN #1 if Resident #84 was wearing their handrolls. Both the surveyor and RN #1 observed Resident #84 in bed, and the signs behind the resident's bed regarding the directions for use of the right and left handroll. RN #1 stated, I don't see them, and the surveyor asked if they were supposed to be there? RN #1 responded yes. Surveyor #1 asked RN #1 if she had signed the Treatment Administration Record for the use of the handrolls. RN #1 stated she didn't sign, and I did not have a chance to look at that, I have to prioritize my meds [medications] and what I need to do, give meds and give care, have no idea about handrolls, maybe therapy has them?
On 05/23/25 at 10:23 AM, the survey team interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) and presented the above concerns. The DON stated, RN #3 should not have left the med cart open. The survey team asked about the adequacy of the facility staffing and the LNHA stated, we meet the requirement and confirmed the facility met the acuity staffing hours requirement. When asked if the RTs were considered part of the staffing for providing resident care, the LNHA stated RTs were not nurses and confirmed that there was no process in place to cover the time the RTs were on break if there was only 1 nurse assigned and 1 RT for the Annex. The survey team asked if the facility reviewed the CNA staff available for ADL care, and the LNHA stated, the facility was going to get a waiver (for CNA staffing) because they replaced CNAs with nurses, but our plan moving forward was to get more CNAs to help with changing residents and doing weights.
On 05/23/25 at 12:43 PM, the surveyor went to the B- Wing Unit, and again, four days after the initial observation that occurred on 5/19/25 at 11:05 AM, observed a strong urine odor in the hallway. The surveyor interviewed a random CNA (CNA #3) observed in the hallway regarding the odor. CNA #3 stated that she noticed the odor and was about to locate the CNA (CNA #4) assigned to that hallway. The surveyor entered Resident #82's room and noted that the urine odor was pervasive in the room. The surveyor met CNA #4 in the hallway and asked to check Resident #82 for incontinence. The surveyor observed that Resident #82's bed was saturated with urine, the incontinence brief was yellow stained and also saturated with urine. When inquired regarding the last time incontinence care was provided, CNA #4 stated, Not too sure, possibly around 9:00 AM or 10:00 AM. The surveyor then asked CNA #4 who assisted her with the resident's care and she stated, I checked the resident alone. I have ten residents to care for and [Resident #82] used to have an order for double briefs and it was discontinued.
B. Based on review of the Nurse Staffing Reports for the weeks of 05/04/2025 to 05/17/2025, it was determined that the facility failed to provide at least minimum staffing levels for 2 of 14 days. The required staffing hours and actual staffing hours were as follows:
For the week of 05/04/25
Required Staffing Hours: 562.75
-05/10/25 had 560 actual staffing hours, for a difference of -2.75 hours.
For the week of 05/11/25
Required Staffing Hours: 567
-05/11/25 had 488 actual staffing hours, for a difference of -79 hours.
The Administration: Staffing Plan, Effective 12/24 revealed: Purpose: To ensure adequate nurse staffing in order to provide care safely and effectively. Policy: Nursing services are provided 24-hours a day, seven days a week. Staffing plans are established based on daily census and patient acuity. Procedure: 6. Staffing shall include at least the minimum numbers of licensed and certified staff 24 hours a day, seven days a week, as defined in New Jersey Département of Health rules and regulations of total number of patients multiplied by 2.5 hours/day as well as the total number of patients receiving each service listed below, multiplied by the corresponding number of hours per day: a. Wound Care- .75 hours/day; b. Nasogastric or gastrostomy tube feedings- 1.0 hours per day; c. Oxygen therapy 0 .75 hours/day; d. Tracheostomy-1.25 hours/day; e. Intravenous Therapy-1.5 hours/day; f . Use of ventilator-1.25 hours/day; g. Head trauma stimulation/advanced neuromuscular/orthopedic care-1.5 hours/day.
The LPN Job Description effective 2/09 revealed under essential duties: 4. Assists with ADLs based on patient ability. 10. Turns/repositions residents at least every two hours. 11. Performs range of motion during daily care. 18. Delegates appropriate duties to CNAs on team and 19. Assures CNA duties performed as directed.
NJAC 8:39-27.1(a); 25.2(a)(b)(c)
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 document review it was determined that the facility failed to a) ensure the formula preparation process and nourishment area was implemented in a clean and sanitary...
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Based on observation, interview and document review it was determined that the facility failed to a) ensure the formula preparation process and nourishment area was implemented in a clean and sanitary manner, b) food items were labeled with a use by date, and c) appropriate cleaning items were utilized to prevent potential contamination. The deficient practice had the potential for development of food borne illness and was evidenced by the following:
On 5/19/25 at 8:43 AM, the surveyor conducted a tour of the kitchen with a Food Service Director (FSD) from another facility, the District Manager for the Food Service Management Company was present, and did not join the tour.
Findings include:
1. A package of undated frozen pancakes was stored in the freezer and was not tightly wrapped. The surveyor asked about a use by date, and the FSD stated she could not tell when the package was opened and discarded it.
2. A metal table, with a sink and a shelf above the sink contained three plastic containers that were appeared stained and were stored with the opening directly on red cleaning type rag which was directly on the shelf. When asked what they were used for, the FSD stated they were used to prepare the tube-feeding (special feeding prepared that are inserted directly into a tube in the abdomen when unable to eat by mouth). The containers also had a sticky substance on them and one had a hair stuck to it. The surveyor asked if the containers should be stored directly on the wipes with the open area facing the wipes, the FSD stated, no, because fibers from the wipe could enter into the formula.
3. Eight additional plastic containers were stored on the top shelf of a black cart, on top of white bath towels and the cart appeared soiled. There were two containers stored on the middle shelf of the cart, with the opening directly on the frayed towels, and the two containers were toppled behind those containers on the middle shelf and the red container tops were stored on the towel and directly on top of the middle shelf facing down. The surveyor asked if the manner that the containers was stored was sanitary and the FSD stated, no, it was not. The surveyor requested a formula policy at that time. The FSD showed the surveyor a list of 12 residents who required special formula preparations.
4. A reach in freezer, contained 20 typical quart sized deli type containers of frozen puree food. One of the containers appeared to be sunken in. The surveyor asked for all the information and manufacturer specifications related to both containers.
5. There was a pile of white towels was stored by the tray line area, visibly shredded on the ends and asked what they were used for. The FSD stated the staff used them to clean and the surveyor asked if they were appropriate to use and the FSD stated, no, maybe because they shred.
6. A reach in refrigerator had a digital thermometer that registered 45 degrees Fahrenheit and the log had 29 degrees registered. The surveyor asked if the log was correct and the FSD stated, no.
On 05/19/25 at 11:07 AM, the Registered Dietitian (RD) provided the surveyor with a computer picture of the containers from a small business and did not provide the manufactures specifications, or a policy for use for the containers. There was also no manufacturer specification provided for the larger tube-feeding/formula containers or a policy for use. The surveyor asked about the process for cleaning the tube-feeding/supplement containers. The RD stated if the containers should be air dried and they should be closed and placed in the formula station.
The Formula Preparation and Noursihment Area Maintenance Policy, effective August 2018 revealed: Policy: The formal preparation area will be designated for preparing infant formal and enteral feeding by aseptic technique. The policy did not address the use of the large containers.
NJAC 8:39-17.2(g)
CONCERN
(F)
📢 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
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure all resid...
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Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to ensure all residents received the care and services needed to maintain residents highest practicable physical, mental, and psychosocial well-being by failing to ensure: a) a thorough investigation of an injury of unknown origin was completed, b) staffing was appropriate to meet resident needs to provide incontinence care in an appropriate and timely manner and according to the facility policy, c) staff followed the Center for Disease Control (CDC) guidelines and the facility's infection control policy to prevent the spread of potential infection, d) there was a process in place to ensure staff completed their annual competency evaluations. This deficient practice affected all facility residents and was evidenced by the following:
Refer to F610, F677, F725, F730, F880
A review of the Administrator's job description provided by the facility revealed the following under position summary:
Directs and guides the activities of clinical, administrative and service departments. Manages the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern long term care facilities to assure that the highest degree of quality care can be provided to residents at all times. Ensures all employees receive orientation and ongoing training to meet the quality goals of the organization.
1. A review of the progress notes dated 3/31/25 at 5:35 PM revealed that 2 circular bruises were noted on Resident #37's right exterior elbow. According to the progress notes, the resident was to be assessed and a follow up was to be done by the medical. The surveyor requested the full investigation for the bruises. An incident report was provided and there were no statements attached. On 5/23/25 at 12:45 PM, the surveyor again inquired regarding the investigation for the bruise documented as an injury of unknown origin, no additional information was provided and it was confirmed by the Director of Nursing (DON) that statements had not been completed.
2. The facility failed to have a system in place to ensure the facility had enough staff to meet resident needs. The facility failed to ensure incontinence care was provided in a timely manner and in accordance with the facility policy.
a) On 5/18/25 at 8:29 PM, the surveyor observed Resident #82 in an enclosure bed. The resident was facing the window. From a clear unobstructed view through the open door, the surveyor observed the resident's incontinence brief was bulging from the back. The surveyor then observed the resident was asleep, and there was no sheet to cover the bed. The Surveyor then observed 3 incontinence pads on the mattress underneath the resident.
On 5/18/25 at 9:15 PM, the surveyor escorted another surveyor to the room and we both observed Resident #82 in the same position with bulging incontinence brief, and the strong smell of urine and feces permeated into the hallway.
On 05/19/25 at 8:30 AM, the surveyor returned to the B Wing Unit and observed the resident in the enclosure bed, was in the same position as observed on 5/18/25 at 8:29 PM, facing the window and the incontinence brief could be observed bulging from the back as observed on 05/18/25 at 9:15 PM.
On 05/19/25 at 11:05 AM, the Certified Nurse Aide (CNA #2 ) assigned to care for Resident #82. CNA #2 informed the surveyor that she would need another staff to assist with Resident #82. A Licensed Practical Nurse (LPN #2) entered the room to assist with the incontinence care. The incontinence pads and the bed were observed saturated with urine. Resident #82 was wearing two incontinence briefs. The resident's genital area was wrapped up in an infant brief which was also saturated with urine and feces. The larger sized incontinence brief was also saturated with urine and filled with a large amount of feces. CNA #2 turned the resident to the right side to facilitate the care. Resident #82 was observed covered with feces from the waist to the buttocks. CNA #2 used one pack of wipes and consistently wiped the embedded feces from Resident #82's backside and buttocks as the feces appeared caked on.
On 5/20/25 at 11:55 AM, the surveyor interviewed the DON who stated that he was not aware that Resident #82 had an infant brief wrapped around their genital area and he stated was not aware of the order related to using an infant brief wrapped around the genitals
On 05/23/25 at 12:43 PM, the surveyor went to the B Wing Unit, and again observed a strong urine odor in the hallway. The surveyor interviewed a random CNA (CNA #3) observed in the hallway regarding the odor. CNA #3 stated that she also noticed the odor and was about to locate the CNA (CNA #4) assigned to that hallway. The surveyor entered Resident #82's room and noted that the urine odor was pervasive in the room. The surveyor met CNA #4 in the hallway and asked to check Resident #82 for incontinence. The surveyor then observed, four days after the initial observation that occurred on 5/19/25 at 11:05 AM, that Residnet #82's bed was saturated with urine, and the incontinence brief was yellow stained and also saturated with urine. When inquired regarding the last time incontinence care was provided, CNA #4 stated, Not too sure, possibly around 9:00 AM or 10:00 AM. The surveyor then asked CNA #4 who assisted her with the resident's care and she stated, I checked the resident alone. I have ten residents to care for and [Resident #82] used to have an order for double briefs and it was discontinued.
b) On 05/20/25 at 2:20 PM, the surveyor returned to the B- Wing Unit and noted a strong feces odor in the B- Wing Unit hallway. The surveyor observed Resident #58 standing inside the enclosure bed. The Surveyor observed CNA #6 in the hallway and asked to assist to observe incontinence care. CNA #6 checked Resident #58 and the incontinence brief was heavily soiled with urine and feces. CNA #6 informed the surveyor that she had Resident #58 on her assignment but was not aware that the resident returned from school. Upon return from school the CNAs were supposed to be informed if the resident needed to be changed. On 5/19/25 at 11:30 AM, the surveyor inquired regarding the protocol for incontinence care. The Registered Nurse (RN #6) informed the surveyor that all CNAs were responsible to provide incontinence care, and the nurses were to administer treatments and assist as needed. The surveyor asked the CNA assigned to the resident to assist with incontinence check. Resident #58's brief was saturated with urine and feces. The CNA stated that she was not aware that Resident #58 had returned from school.
On 5/21/25 at 9:05 AM, during an interview with the Registered Nurse in charge she informed the surveyor that Resident #58 left for school at 8:30 AM and returned every day at 12:30 PM. The RN further stated that incontinence care could be provided in school, but it was the CNA's responsibility to check their residents upon return from school for incontinence care.
3. The facility failed to ensure that staff adhere to infection control practices and follow the recommendations of the Center for Disease Control during hand hygiene. On 05/21/25 at 9:59 AM, the surveyor observed a sign posted outside of Resident #103's door that revealed 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 Ativities. Dressing, Bathing/Showereing, Transaferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting . At that time, the surveyor observed the curtain open, and a pile of linen was on the floor, while the Registered Nurse (RN #1) was observed kneeling on the floor in front of Resident #103 who was in a wheelchair, then RN #1 with her gloved hands, placed socks on the resident's feet. RN #1 was not wearing a gown and then picked up the soiled linen from the floor with her gloved hands and placed the linen into a bin in the hallway. RN #1 then re-entered Resident #103's room, removed the gloves, turned on the faucet, used the soap dispenser, and rubbed both hands under running water for 4 seconds.
05/21/25 10:00 AM, RN #1 exited the room and the surveyor interviewed her about what care she provided for Resident #103. RN #1 stated she washed the resident up every morning with care and the resident had a big poop and didn't like to be washed. The surveyor asked about putting linens on floor, and if what was observed was soiled? RN #1 stated Yes, they were soiled. The surveyor then asked if RN #1 wore a gown during care, and she stated No, I did not. The surveyor asked if Resident #103 required EBP and pointed to the sign next to the door. RN #1 looked at the sign and stated, no not for [Resident #103], the sign would have been on front of the door. RN #1 confirmed all the linens and soiled items were placed in the bin directly. The surveyor asked if was protocol to wash hands under running water and how should hands be washed. RN #1 stated, it was okay, to put the soap on the hands and put the hands under the water.
On 05/21/25 at 10:38 AM, the surveyor informed the facility Infection Preventionist Registered Nurse (IPRN) regarding the above observations and asked is it okay to change a resident and not wear a gown. The IPRN stated, no, you should be wearing a gown. The surveyor then asked if a feces soiled diaper could be placed on the floor with linen. The IPRN stated, No, your feet are tracking it all over the floor, it is disgusting and you should bag it, it should not be placed directly into the bin due to infection control. The surveyor informed the IPRN of the hand washing observation and inquired regarding the protocol for hand hygiene as the staff was observed washing their hands under running water. The IPRN confirmed that the staff should have had a gown on during incontinence care and acknowledged that 100% of the facility population was on EBP and RN #1 should have been wearing a gown when Resident #103 received incontinence care.
4. The facility failed to ensure that their CNA's had their annual performance evaluation completed at least every 12 months according to facility policy.
Review of the LNHA Job Description revealed the following: Direct and guide the activities of clinical administrative and service departments and manage the day-to-day functions of the facility .On 5/22/25 at 11:26 AM, the surveyor interviewed the LNHA regarding the facility Quality Assurance and Performance Improvement (QAPI) and his job description. The LNHA informed the surveyor that he was the abuse officer and was in charge of all investigations. The LNHA stated that his current responsibilities included: reviewing all reported incidents, conducting random audits throughout the facility, engaging directly with residents and staff regularly, and staff education on abuse at orientation, annually, and on an as-needed basis; however, the LNHA stated that he has not received formal, specialized training in abuse prevention or investigation. The LNHA stated that after the most recent abuse incident, no immediate retraining was conducted. The LNHA stated, that is where I messed up.
On 05/23/25 at 1:53 PM, the survey team met the DON and the LNHA for an exit conference. The DON and the LNHA did not provide additional information.
NJAC 8:39-4.1(a), 9.2(a), 13.4(c), 14.2, 27.1(a), 33.2(a)(b)(c)
Feb 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to develop a care plan for intermittent urinary catheterization for one of three residents (Resident (R) 24) reviewed for a urina...
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Based on observation, interview, and record review the facility failed to develop a care plan for intermittent urinary catheterization for one of three residents (Resident (R) 24) reviewed for a urinary catheter.
Findings include:
Observation of R24 on 02/19/24 at 12:47 PM revealed the resident was in bed on his back with tubing from a urinary catheter coming from under his clothes, going off the side of his bed to a urine collection bag.
Review of R24's Physician Order, dated 01/09/24, located in the resident's electronic medical record (EMR) under the Orders tab revealed Texas Cath (catheter) a condom style catheter, apply at 0600 [6:00 AM]), remove at 1800 [6:00 PM].
Review of R24's Care Plan dated 04/21/17, revealed a problem related to .episodes of retaining urine. The goal was for R24 to empty his bladder every eight hours and the interventions included documenting the amount, color, and clarity of the urine. The care plan did not include the use of a catheter.
During an interview on 02/22/24 at 3:24 PM, the Director of Nursing (DON) revealed her it was her expectation a care plan would have been developed in January 2024 when the catheter was ordered.
NJAC 8:39-11.2(b)
NJAC 8:39-27.1(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 F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on staff interview, record review, and facility document review, the facility staff failed to follow professional standards of practice regarding the signing of the on coming and off going nurse...
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Based on staff interview, record review, and facility document review, the facility staff failed to follow professional standards of practice regarding the signing of the on coming and off going nurse when narcotics were counted for each shift. This occurred on two of three units in the facility (B wing medication cart 1 and 2, and A wing high side medication cart).
Findings include:
During observation of the Medication Storage and Labeling Task, performed on 02/21/24 and 02/22/24, revealed the narcotic count sheets were missing two licensed nurses' signatures for the following dates and areas:
1.For January 2024 on the B wing medication cart 1, the narcotic and barbiturate count log were missing two nurses' signatures on 01/04/24 7:00 PM, 01/06/24 7:00 AM, 01/09/24 at 7:00 PM, 01/10/24 at 7:00 AM, 01/15/24 at 7:00 PM, and 01/26/24 at 7:00 AM.
2.For February 2024 on the B wing medication cart 1, the narcotic and barbiturate count log were missing two nurses' signatures on 02/20/24 at 7:00 PM.
3.For November 2023 on the B wing medication cart 2, the narcotic and barbiturate count log were missing two nurses' signatures on 11/10/23 at 7:00 AM and 7:00 PM, 11/14/23 at 7:00 AM and 7:00 PM, 11/18/23 at 7:00 AM and 7:00 PM, 11/19/23 at 7:00 AM and 7:00 PM, 11/26/23 at 7:00 PM, and 11/30/23 at 7:00 PM.
4.For November 2023 on the A wing high side medication cart, the narcotic and barbiturate count log were missing two nurses' signatures on 11/17/23 at 7:00 AM.
5.For December 2023 on the A wing high side medication cart, the narcotic and barbiturate count log were missing two nurses' signatures on 12/21/23 at 7:00 PM.
6.For February 2024 on the A wing high side medication cart, the narcotic and barbiturate count log were missing two nurses' signatures on 02/02/24 at 7:00 AM.
On 02/22/24 at 1:00 PM, the Director of Nursing (DON) was asked if the facility had a standard of practice they followed in regard to counting narcotics and the DON stated, We have our own resource from the pharmacy that is on the internet.
During an interview on 02/22/24 at 6:30 PM, the DON stated, The on coming and off going nurses are to count the narcotics for each shift change and they are to sign the narcotic log before leaving their shift.
Reviewed the facility policy Medication: Documentation of Controlled Substances, dated 12/23, revealed .At the change of shift, the Controlled Medication Utilization Record will be verified with the actual inventory on hand. Having accounted for all doses, verifying patient name, medication .and all routes of administration .The count must be completed by two licensed nurses.
NJAC 8:39-11.2(b)
NJAC 8:39-27.1(a)
NJAC 8:39-29.7(c)
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure appropriate techniques were used for a residents who were de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure appropriate techniques were used for a residents who were dependent on respirators during for one of three residents reviewed for respiratory care (Resident (R) 20). R20 had an episode of apnea when a respirator therapist performed a sternal rub on the resident even though the resident was conscious. R20 sustained a bruised area to the chest.
Findings include:
Review of R20's admission Record, located in the resident's electronic medical record (EMR) under the Profile revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included acute and chronic respiratory failure, tracheostomy status, dependence on respiratory (ventilator) status, and dysphasia.
Review of R20's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/16/23, located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS), was unable to be completed since R20 was rarely understood.
Review of R20's Care Plan, dated 02/10/16 and located in the resident's EMR under the Care Plan tab revealed the resident required mechanical ventilation for altered breathing related to lung disease, muscle weakness and depressed central nervous system. Interventions in place were to initiate ventilator and tracheotomy management protocol, multiple layers of monitoring as needed using tight ventilator and pulse oximeter alarms and monitor oxygen and dioxide levels.
Review of R20's Nurse's Note, dated 12/17/23 at 7:40 PM and located in the resident's EMR under the Progress Notes tab and indicated, the nursing supervisor notified R20's family that the resident was going to receive Tylenol for discomfort. Family verbalized understanding. Will continue to monitor. The note was written by Nursing Supervisor/Registered Nurse (NS) 2.
Review of R20's Nurse's Note, dated 12/18/23 and located in the resident's EMR under the Progress Notes tab indicated the resident had a bruise on their anterior chest, due to sternal rub. The note indicated R20's family was made aware, and Tylenol was given for comfort due to resident crying.
Review of Pediatric Facility Incident Report, dated 12/17/23 and provided by the facility revealed an incident involving R20 and a staff member in the resident's room when a sternal rub was given for apnea (when one stops breathing or has little airflow while sleeping) causing soft tissue damage and bruising.
Review of facility's undated and untitled Investigation into a resident bruise sustained during staff intervention on 02/17/23 R20 experienced a breath-holding incident with oxyhemoglobin (the normal, oxygen-carrying form of hemoglobin in which iron is in the reduced state) desaturation. The investigation revealed RT1 intervened using sternal rub, gentle limb restraint. Following the incident, a bruise was discovered on R20's center chest. The facility's conclusion was that while R20 sustained a bruise during the incident, the investigation determined that it was an unintended consequence of an intervention and not the result of staff negligence or misconduct.
During an interview on 02/21/24 at 10:28 AM. Registered Nurse (RN) 2 stated she was the RN on duty on 12/17/23 during the 7:00 AM to 7:00 PM shift. RN2 stated she did not remember seeing any marks or bruises on R20; however, she was not specifically looking for them. RN2 also stated staff at the facility did not typically need to do sternal rubs because if a child was unresponsive, they would call a code; however, if a sternal rub was performed, it was to be reported to the charge nurse along with the family and documented in the resident's progress notes.
During an interview on 02/21/24 at 10:54 PM, Nursing Supervisor/Registered Nurse (NS) 2
stated on 12/17/23, R20 was crying, and staff went into the room along with RN 3 who told her there was a raised red mark or bruise on R20's chest that looked like it was from a sternal rub. She said the bruise was right on the sternum and appeared fresh. NS2 stated a sternal rub was not general practice, and she has never seen one done or the need for one during the year she has worked at the facility.
An attempted call was placed on 02/21/24 at 11:17 AM to Registered Nurse (RN) 3 but was unsuccessful. A voice message was left requesting a call back. A return call was not received by the end of the survey.
An attempted call was placed on 02/21/24 at 11:42 AM to Charge Nurse (CN) 2 but was unsuccessful. A voice message was left requesting a call back. A return call was not received by the end of the survey.
During an interview on 02/22/24 at 3:35 PM, Respiratory Therapist (RT) 1 stated on 12/17/23 he was assigned to R20 during the 7:00 PM to the 7:00 AM shift. RT1 stated at approximately 8:30 PM he responded to R20's room for a desaturation (decrease in blood oxygen level) alarm sounding when he observed R20 on his ventilator, and he hyper oxygenated him, and suctioned the resident's tracheostomy (removes mucus from the windpipe so that the windpipe stays clear) him out and R20's oxygen saturation returned to above 92%. RT1 stated about two minutes later R20 desaturated again, and he knew the resident did not need suctioned again in such a short period of time. RT1 also stated R20 was grimacing, clinching his teeth, and his monitor was alarming which indicated the resident was not reaching a certain volume of air. Continued interview revealed he determined R20 was holding his breath, but he was unsure if it was intentional, so he performed a light sternum rub on R20 that lasted no longer than four to five seconds to get the resident to release his breath. RT1 stated when he returned to work the next day, he was made aware that a bruise was discovered on R20's chest. RT1 further stated he did not use the sternal rub as it was intended and should not have performed the sternal rub.
During an interview on 02/22/24 at 4:09 PM RT2 stated if there was a situation with a resident when there was a cessation of breathing, staff should try some type of gentle stimulation such as gently shaking them by holding onto their shoulders, or verbal stimulation by calling them by their name. RT2 stated sternal rubs were not used on residents of the facility. Continued interview revealed he had never been told sternal rubs were not appropriate in the facility as a technique.
During an interview on 02/22/24 at 5:07 PM, the Director of Nursing (DON) stated she was informed by the Respiratory Therapy Director that it was poor clinical judgment on RT 1's behalf to perform a sternal rub on R20because R20 was not unresponsive.
During an interview on 02/22/24 at 5:12 PM, the Medical Director stated she was new as the Medical Director and could not speak specifically to the incident that occurred on 12/17/23 with R20. The Medical Director stated when a resident was not breathing or holding their breath, there were other means of interventions such as tapping the resident or asking the resident their name.
During an interview on 02/22/24 at 5:40 PM, the Respiratory Therapy Director stated she spoke with RT1 about using a sternal run for an episode of apnea. Continued interview revealed a sternal rub was a painful stimulus and to check for a resident's actual level of responsiveness, they would not use sternal rubs. She said a formal flick of the foot would have been sufficient or the use an ambu bag.
Review of the facility's protocol for assessing level of conscience (LOC), What is a sternal Rub. Sternal rubs are a painful stimulus. They are used to assess a person's level of consciousness and response to pain. Performing a sternal rub on someone who is conscious could cause unnecessary pain and distress. There is a risk of injury. Even when performed correctly, sternal rubs can cause bruising or other skin injuries. This risk is even greater if the rub is performed incorrectly. It can be misinterpreted. A lack of response to a sternal rub does not necessarily mean that the person is unconscious. There are other factors that can affect a person's response to pain, such as medication, injury, or medical conditions. There are several alternatives to a sternal rub for assessing consciousness, each with its own advantages and limitations: Verbal Stimuli: Simple questions: Start with basic questions like What is your name? or where are you? This assesses orientation and ability to understand and respond. Commands: Give simple commands like Open your eyes or squeeze my hand. This assesses motor response and ability to follow instructions. Visual Stimuli: Bright light: Shine a bright light in the person's eyes and observe their reaction. This assesses pupillary response and basic awareness. Object movement: Wave an object in front of the person's face and watch for eye tracking. This assesses visual awareness and ability to follow movement. Tactile Stimuli: Gentle touch: Gently touch the person's shoulder or arm and observe their response. This assesses basic awareness and responsiveness to touch. Other Methods AVPU scale: This scale assesses alertness. verbal response, pain response and unresponsiveness. It's a quick and easy way to assess overall level of consciousness. Glasgow Coma Scale (GCS): This more detailed scale assesses eye opening, verbal response, and motor response. It's used by medical professionals for a more comprehensive evaluation. Important Considerations: Choose methods appropriate for the situation and your training level. Prioritize gentle and non-painful methods whenever possible. Remember, these methods are not diagnostic tools and should not be used to replace professional medical evaluation. If the person is unresponsive or shows signs of distress, call emergency services immediately.
NJAC 8:39-27.1
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure medications were acquired and dispensed for o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure medications were acquired and dispensed for one of three residents reviewed for medication administration (Resident (R) 58). The facility failed to notify the resident's family timely to ensure the medication was ordered and delivered to the facility.
Findings include:
Review of R58's undated admission Record, located in the resident's EMR under the Profile tab revealed to the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Lennox-Gastaut syndrome no intractable without status epilepticus.
Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/24, located in the resident's ERM under the MDS tab revealed a Brief Interview for Mental Status (BIMS), was unable to be completed since R58 was rarely understood.
Review of R58's Care Plan, dated 08/28/16, and located in the resident's EMR under the Care Plan tab revealed, The resident was at risk for seizure activity .Interventions .administer anti-epileptic and emergency medications as ordered .
Review of R58's Physician Orders, located in the resident's EMR under the Orders tab revealed an order dated 11/17/22, for Sabril (anticonvulsant medication) give 100 milligrams via g-tube two times a day for epileptic spasms.
Review of R58's January 2024 Medication Administration Record (MAR), located in the resident's EMR under the Orders tab revealed the Sabril medication was scheduled to be administered twice a day at 2:00 AM and 2:00 PM. Continued review of the MAR revealed the no doses of the medication were administered on 01/24/24 or 01/25/24; and on 01/26/24 the 2:00 AM dose was not administered.
Review of R58's Nurse's Note, dated 01/25/24 and located in the resident's EMR under the Progress Notes tab indicated Family Member (F58) called the facility and asked about R58's Sabril medication being ordered. F58 was informed the facility did not have the medication on hand and it needed to be ordered. F58 stated she would call the pharmacy.
During an interview on 02/21//24 at 1:48 PM, Licensed Practical Nurse (LPN) 3 stated nursing staff were responsible for contacting F58 about R58's prescription for the Sabril medication because F58 ordered the medication and had it sent to the facility in the mail. She was unsure how far in advance the facility was supposed to notify F58.
During an interview on 02/21/24 at 2:32 PM, LPN1 stated nursing staff dated all medications when they were opened to track when they were getting low. LPN1 stated she went to administer R58's Sabril medication on 01/23/24 and noticed it was the last dose. LPN1 also stated she locked the medication cart and told Nursing Supervisor/Registered Nurse (NS) 1 there was only one dose left and the system was not allowing her to reorder it. NS1 informed her it was a medication the family member needed to reorder, and he would contact them to get it refilled.
During an interview on 02/21/24 at 2:48 PM, LPN4 stated R58's family was responsible for ensuring the resident's Sabril medication was refilled. LPN4 stated she became aware that R58's Sabril prescription was out during shift report, and she reported that to NS1, but she could not remember what day that was. LPN4 stated she told NS1 she would contact F58; however, she instead asked LPN3 to call F58.
During an interview on 02/21/24 at 2:57 PM, F58 stated the facility's nursing staff never called her until R58 was completely out of the Sabril medication. F58 stated she needed the facility to give her a week's notice to ensure the resident does not go without the medication.
During an interview on 02/22/24 at 11:31 AM, NS1 stated he called F58 on 01/23/24 when the last dose of Sabril was about to be administered. NS1 also stated he relied on the medication nurses to notify him when the prescription was low, and it was unacceptable. F58 was not notified until the last dose was about to be administered. Continued interview revealed the facility did not have a process in place to track the medication to ensure F58 was notified in time to have the medication refilled before it ran low. NS1 stated it was the facility's fault that R58 ran out of her medication and went without it for 2 1/2 days. By not having her medication, it put R58 at risk of seizure activity, or a potential change in mental status which would make her more combative and put her health and wellbeing at risk.
During an interview on 02/22/24 at 5:32 PM, the Director of Nursing (DON) stated nursing staff should have notified F58 when there was at least a minimum of two days of medication left.
NJAC 8:39-29.2
NJAC 8:39-29.7
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 F0602
(Tag F0602)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation for seven of seven unsampled residents reviewed for misappropriation (Resident (R) 39, R36, R35, R94, R6, R87, and R70). Specifically, nursing staff borrowed medications from the residents and administered the medications to other residents.
Findings include:
1. Review of R39's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed R39 was admitted to the facility on [DATE] with the diagnoses of epilepsy, and spastic quadriplegic cerebral palsy.
Review of R39's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/23 and located in the resident's EMR under the MDS tab revealed R39 was in a persistent vegetative state with no discernible consciousness.
Review of R39's Physician Orders located under the Orders tab in the EMR revealed an order dated 12/23/23 for R39 to receive lorazepam concentrate (a narcotic antianxiety medication) two mg/ml (milligram per milliliter) give two ml by G-tube (gastrostomy tube) every four hours as needed for myoclonus/storming.
Review of R39's Controlled Drug Receipt/Record/Disposition Form provided by the facility revealed four doses of the resident's lorazepam concentrate medication were misappropriated and administered to R4 on 12/31/23, 01/03/24, 01/04/24, and 01/27/24. R4 had a physician order for lorazepam concentrate two mg/ml give 1.5 ml by G-tube at bedtime.
Continued review of R39's Controlled Drug Receipt/Record/Disposition Form revealed 11 doses of lorazepam concentrate were misappropriated and administered to R57 on 01/28/24 through 01/29/24. R57 had a physician order for lorazepam concentrate two mg/ml give 0.9 ml by G-tube every four hours for muscle spasms.
2. Review of R36's undated admission Record located under the Profile tab in the EMR revealed R36 was readmitted to the facility on [DATE] with the diagnoses of respiratory failure with hypoxia and autonomic dysreflexia.
Review of R36's quarterly MDS with an ARD of 02/08/24 revealed R36 was in a persistent vegetative state with no discernible consciousness.
Review of R36's Physician Orders located under the Orders tab in the EMR revealed an order dated 11/04/22 for R36 to receive diazepam oral concentrate (a narcotic antianxiety medication) five mg/ ml by G-tube every four hours as needed for sustained clonus and/or tachycardia.
Review of R36's Controlled Drug Receipt/Record/Disposition Form provided by the facility revealed one dose of the resident's diazepam oral concentrate medication was borrowed for R11on 01/13/24. R11 had a physician order for diazepam oral solution five mg/ ml give five ml by G-tube every six hours as needed for anxiety causing respiratory distress prior to trach changes.
Continued review of R36's Controlled Drug Receipt/Record/Disposition Form revealed one dose of diazepam was misappropriated and administered to R47 on 02/16/24. R47 had a physician order for diazepam oral concentrate 3.5 ml by G-tube.
3. Review of R35's undated admission Record located under the Profile tab in the EMR revealed R35 was readmitted to the facility on [DATE] with the diagnoses of respiratory failure with hypoxia and epilepsy.
Review of R35's quarterly MDS with an ARD of 11/21/23 revealed R35 had short term and long-term memory problems and was severely impaired in making daily decisions.
Review of R35's Physician Orders located under the Orders tab in the EMR revealed an order dated 12/10/23 for R35 to receive diazepam solution five ml by G-tube every six hours as needed for pre-procedure agitation.
Review of R35's Controlled Drug Receipt/Record/Disposition Form revealed six doses of the resident's diazepam solution medication was misappropriated to R49 on 12/11/23, 12/12/23, and 01/08/24. R49 had a physician order for diazepam oral solution five mg/ ml give 7.5 ml by G-tube every six hours for spasticity.
Continued review of R35's Controlled Drug Receipt/Record/Disposition Form revealed seven doses of the resident's diazepam were misappropriated and administered to R105 on 12/29/23 12/30/23, 12/31/23, and 01/01/24. R105 had a physician order for diazepam oral solution five mg/five ml give five ml by G-tube three times a day for spasticity/storming.
Further review of R35's Controlled Drug Receipt/Record/Disposition Form revealed 11 doses of the resident's diazepam were misappropriated and administered to R95 on 01/03/24, 01/04/24, 01/05/24, and 01/06/24. R95 had a physician order for diazepam solution one mg/ml give 1.2 ml by G-tube four times a day for spasticity.
Additionally, R35 had 17 doses of diazepam medication misappropriated and administered to R55 on 01/06/24, 01/19/24, 01/21/24, 01/22/24, 01/23/24, 01/24/24, and 01/25/24.
4. Review of R94's undated admission Record located under the Profile tab in the EMR revealed R94 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy.
Review of R94's quarterly MDS with an ARD of 11/14/23 revealed R94 had short and long-term memory problems and was severely impaired in daily decision making.
Review of R94's Physician Orders located under the Orders tab in the EMR revealed an order dated 12/08/23 for R94 to receive diazepam solution five mg/five ml give two ml by G-tube every six hours as needed for tachycardia, autonomic storming.
Review of R94's Controlled Drug Receipt/Record/Disposition Form revealed one dose of diazepam solution was misappropriated and administered to R55 on 12/11/23. R55 had a physician order for diazepam 0.6 ml to be given on 12/11/23 at 12:01 AM.
Continued review of R94's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the diazepam solution medication was misappropriated and administered to R49 on 12/11/23. R49 had a physician order for diazepam oral solution five mg/five ml give three times a day by G-tube for spasticity.
Further review of R94's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the resident's diazepam was misappropriated and administered to R56 on 02/13/24. R56 had a physician order for diazepam solution five mg/five ml give 7.5 ml by G-tube as needed for 30 minutes prior to dental exam and procedures.
5. Review of R6's undated admission Record located under the Profile tab in the EMR revealed R6 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy.
Review of R6's quarterly MDS with an ARD of 02/06/24 revealed R6 had short term and long-term memory problems and was severely impaired in making daily decisions.
Review of R6's Physician Orders located under the Orders tab in the EMR revealed an order dated 08/08/23 for R6 to receive nayzilam (a benzodiazepine medication) five mg nasal spray give 0.1 ml in one nostril every five minutes as needed for seizures greater than five. May repeat times one if still seizing.
Review of R6's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the nayzilam medication was misappropriated and administered to R24 on 01/19/24. R24 had a physician order for nayzilam nasal solution five mg/0.1 ml give 0.1 alternating nostrils every 10 minutes as needed for seizure rescue medication.
6. Review of R87's undated admission Record located under the Profile tab in the EMR revealed R87 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and respiratory failure hypoxia.
Review of R87's quarterly MDS with an ARD of 12/28/23 revealed R87 was in a persistent vegetative state with no discernible consciousness.
Review of R87's Physician Orders located under the Orders tab in the EMR revealed an order dated 04/14/22 for R87 to receive diazepam 10 mg rectal gel insert 10 mg rectally as needed for a seizure greater than five minutes.
Review of 87's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the resident's diazepam medication was misappropriated and administered to R88 on 08/05/23. R88 had a physician order for Diastat (diazepam) rectal gel 10 mg insert 10 mg rectally every six hours as needed for seizure activity lasting greater than five minutes or clusters of seizures without returning to baseline within five minutes.
7. Review of R70's undated admission Record located under the Profile tab in the EMR revealed R70 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy.
Review of R70's quarterly MDS with an ARD of 11/03/23 revealed R70 had short term and long-term memory problems and was severely impaired in making daily decisions.
Review of R70's Physician Orders located under the Orders tab in the EMR revealed an order dated 10/21/22 for R70 to receive diazepam 10 mg rectal gel insert 10 mg rectally as needed for a seizure greater than five minutes.
Review of R70's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the resident's diazepam medication was misappropriated to R97 on 05/12/23. R97 had a physician order for diazepam 10 mg rectal gel insert 10 mg rectally as needed for a seizure greater than five minutes.
Review of the facility's Quality Improvement Plan dated 02/16/24, provided by the facility revealed under the Problem stated, According to the Consultant's Unit Inspection Report - it was noted that there was discrepancy on the controlled drug log - borrowing resident medication. Under the area of Action revealed All medication nurses were educated on the protocols of not borrowing resident medication. In-servicing was arranged with Polaris connect portal of tracking medication and reorder.
During an interview on 02/21/24 at 2:00 PM, Licensed Practical Nurse (LPN) 6 stated, When we need the medicine we borrow it. We know it's wrong but what else do we do when we have a child that needs it.
During an interview on 02/22/24 at 3:18 PM, the Administrator stated, We did not even consider misappropriation . The DON stated, We felt it was more of a medication issue.
An attempt to reach the medical director by phone on 02/22/24 at 3:40 PM was unsuccessful. A message was left asking for a return call.
Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation dated 06/2023 revealed, .Misappropriation means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .
NJAC 8:39-4.1(a)15
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to identify and investigate misappropriation ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to identify and investigate misappropriation of residents' narcotic medications for seven of seven unsampled residents (Resident (R) 39, R36, R35, R94, R6, R87, and R70). This placed all residents at risk for further incidents of misappropriation.
Findings include:
1. Review of R39's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed R39 was admitted to the facility on [DATE] with the diagnoses of epilepsy, and spastic quadriplegic cerebral palsy.
Review of R39's Controlled Drug Receipt/Record/Disposition Form provided by the facility revealed 15 doses of the resident's lorazepam concentrate (a narcotic antianxiety medication) were misappropriated.
2. Review of R36's undated admission Record located under the Profile tab in the EMR revealed R36 was readmitted to the facility on [DATE] with the diagnoses of respiratory failure with hypoxia and autonomic dysreflexia.
Review of R36's Controlled Drug Receipt/Record/Disposition Form provided by the facility revealed two doses of the resident's diazepam oral concentrate (a narcotic antianxiety medication) were misappropriated.
3. Review of R35's undated admission Record located under the Profile tab in the EMR revealed R35 was readmitted to the facility on [DATE] with the diagnoses of respiratory failure with hypoxia and epilepsy.
Review of R35's Controlled Drug Receipt/Record/Disposition Form revealed 41 doses of the resident's diazepam solution medication were misappropriated.
4. Review of R94's undated admission Record located under the Profile tab in the EMR revealed R94 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy.
Review of R94's Controlled Drug Receipt/Record/Disposition Form revealed three doses of the resident's diazepam solution were misappropriated.
5. Review of R6's undated admission Record located under the Profile tab in the EMR revealed R6 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy.
Review of R6's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the nayzilam (a benzodiazepine) medication was misappropriated.
6. Review of R87's undated admission Record located under the Profile tab in the EMR revealed R87 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and respiratory failure hypoxia.
Review of 87's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the resident's diazepam medication was misappropriated.
7. Review of R70's undated admission Record located under the Profile tab in the EMR revealed R70 was readmitted to the facility on [DATE] with the diagnoses of epilepsy and cerebral palsy.
Review of R70's Controlled Drug Receipt/Record/Disposition Form revealed one dose of the resident's diazepam medication was misappropriated.
During an interview on 02/22/24 at 3:18 PM, the Administrator stated, We did not even consider misappropriation . The DON stated, We felt it was more of a medication issue.
An attempt to reach the medical director by phone on 02/22/24 at 3:40 PM was unsuccessful. A message was left asking for a return call.
During an interview on 02/22/24 at 3:18 PM, the Administrator stated, We did not even consider misappropriation . but if we had considered that, we would have reported it.
Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation dated 06/2023 revealed, .Misappropriation means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .Any allegation of abuse, neglect, exploitation or misappropriation resident property from any source shall be investigated and every effort shall be made to prevent recurrence . The Administrator/designee shall complete an investigation report. The report shall be completed as soon as possible, and forwarded to the appropriate agencies/authorities as necessary .
NJAC 8:39-9.4(f)
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 F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility staff failed to: 1. have correct labels on medic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility staff failed to: 1. have correct labels on medications and failed to obtain pharmacy labels to affix to the Controlled Drug Receipt/Record/Disposition Form for three of 19 residents (Resident (R)94, R55, and R15); 2. waste a narcotic medication after the physician's order end date for one of 19 residents (R6); and 3. failed to have a pharmacy label on an opened bottle of liquid lorazepam (antianxiety medication) stored in the medication refrigerator on one of three units (Annex unit).
Findings include:
1.Review of R94's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed R94 was readmitted to the facility on [DATE] with the diagnosis of epilepsy and cerebral palsy.
Review of R94's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R94 had short term and long-term memory problems and was severely impaired in daily decision making.
Review of R94's Controlled Drug Receipt/Record/Disposition Form revealed the pharmacy label read, Diazepam [antianxiety medication] Sol [solution] 5mg/5ml [milligram per milliliter] Give 2 ml via [by] G-tube [gastrostomy tube] every 6 hours as needed for tachycardia [rapid heartbeat], autonomic storming 2 ml = 2 mg. Give Give (sic) 2 tablets (650 mg) by mouth every 4 hours .
Review of the label on bottle of diazepam medication for R94 revealed the same information as documented above as being on the Controlled Drug Receipt/Record/Disposition Form.
During an interview on [DATE] at 4:18 PM, Nursing Supervisor/Registered Nurse(NS)1 stated, That label is wrong, he [R94] doesn't get anything by mouth.
During an interview, the Director of Nursing (DON) on [DATE] at 5:30 PM stated, The nurse [referring to NS1] told me about the label being wrong. The DON confirmed the label was wrong for R94.
2.Review of R55's undated admission Record located under the Profile tab in the EMR revealed R55 was readmitted to the facility on [DATE] with the diagnosis of epilepsy, and respiratory failure with hypoxia (low oxygen levels).
Review of R55's quarterly MDS with an ARD of [DATE] revealed R55 was in a persistent vegetative state with no discernible consciousness.
Review of R55's Controlled Drug Record revealed there was no label from the pharmacy on this record however, it was noted a staff member had handwritten [R94's name] and Diazepam Solution 5mg/5ml on this form.
Interview on [DATE] at 10:45 AM NS1 stated, The nurse should have called the pharmacy and requested a new form with a label that comes from the pharmacy. They should not write this information in on this form.
Interview on [DATE] at 5:30 PM, the DON confirmed the Controlled Drug Record should have the label on it from the pharmacy.
3.Review of R15's undated admission Record located under the Profile tab in the EMR revealed R15 was readmitted to the facility on [DATE] with the diagnosis of epilepsy, spastic quadriplegic cerebral palsy, and anoxic (lack of oxygen) brain damage.
Review of R15's annual MDS with an ARD of [DATE] revealed R15 had short term and long-term memory problems and was severely impaired in making daily decisions.
Review of R15's Controlled Drug Receipt/Record/Disposition Form revealed the pharmacy label stated, Diazepam Tab [tablet] 5 mg Give ½ tablet by mouth (2.5 mg) via [by] G-tube [gastrostomy tube] four times a daily for Epilepsy. Give with 10 mg tablet to equal a total dose of 12.5 mg.
Interview n [DATE] at 10:50 AM, NS1 stated, He [R15] doesn't get medications by mouth, they are given in his G-tube. NS1 confirmed the directions were wrong for R15.
On [DATE] at 5:30 PM the DON confirmed the directions on the route to use to give this medication was wrong.
4.Review of R6's undated admission Record located under the Profile tab in the EMR revealed R6 was readmitted to the facility on [DATE] with the diagnosis of epilepsy and cerebral palsy.
Review of R6's quarterly MDS with an ARD of [DATE] revealed R6 had short term and long-term memory problems and was severely impaired in making daily decisions.
Review of R6's Controlled Drug Receipt/Record/Disposition Form revealed Diazepam Sol [solution] Give 2 ml (milliliter) via [by] G-tube [gastrostomy tube] every 6 hours as needed for anxiety, trach [tracheostomy] pulling for 14 days. The date of this order was [DATE]. An observation of this medication being stored in the narcotic drawer of the medication cart in the Annex unit was made on [DATE] at 4:30 PM. NS1 stated, This should had been taken out of the narcotic drawer and wasted [destroyed] because this order ran out.
Interview on [DATE] at 5:30 PM, the DON confirmed the medication found in the narcotic drawer for R6 should have been wasted because the order was no longer in effect.
On [DATE] at 4:45 PM, an opened bottle of lorazepam was stored in the medication refrigerator on the Annex unit. This bottle of lorazepam did not have a pharmacy label on it, nor did it have the box the medication came in from pharmacy. NS1 was notified of this documented finding and NS1 stated, The nurse will waste this medication since it doesn't have a label on it.
On [DATE] at 5:30 PM, the DON stated NS1 had made her aware and confirmed the bottle of lorazepam should have a label on it or have the box with a pharmacy label attached.
Review of the facility's policy Medication Ordering and Receiving From Pharmacy, dated [DATE], revealed .An individual resident's controlled substance record is prepared by the pharmacy or the facility for each controlled substance prescribed for a resident. The following information is completed upon dispensing or upon receipt of the controlled substance: 1) Name of the resident, 2) Prescription number, 3) Drug name, strength (if designated), and dosage form of medication, 4) Date received, 5) quantity received, and 6) Name of the person receiving the medication supply.
Review of the facility's policy Medication: Documentation of Controlled Substances, dated 12/23, revealed .Each controlled substance will have a Controlled Medication Utilization Record issues with the medication from the pharmacy .Scheduled narcotics that are discontinued or expired are to be wasted in the presence of an RN and another licensed nurse .
NJAC 8:39-29.4
NJAC 8:39-29.7(c)
Oct 2023
3 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ# 166667
Based on interviews, Medical Record (MR) review, and review of other pertinent facility documentation on 10/4/23 and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NJ# 166667
Based on interviews, Medical Record (MR) review, and review of other pertinent facility documentation on 10/4/23 and 10/5/23, it was determined that the facility's administration failed to ensure that the facility's policy Reportable Events was followed and implemented for an incident that occurred at the facility on 7/24/23. The incident involved a Certified Nursing Assistant (CNA) who performed a procedure outside of her scope of practice. The facility also failed to report the actions of the CNA to the New Jersey Department of Health (NJDOH). This deficient practice was identified for Resident #3, 1 of 6 sampled residents and was evidenced by the following:
According to the admission Record, Resident #3 was readmitted on [DATE] with diagnoses which included but were not limited to: autonomic dysreflexia (a dangerous syndrome involving an overreaction of your autonomic nervous system), spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder causing limitation on all four limbs), anoxic brain damage (brain injury caused by a complete lack of oxygen to the brain), artificial opening of gastrointestinal tract, and constipation.
Review of Resident #3's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/20/23, revealed that Resident #3 had severe cognitive impairment. The MDS also showed that the resident was incontinent of bowel and bladder and required total assist of one person for all Activities of Daily Living (ADLs).
Review of the 7/26/23 at 12:53 PM Progress Notes revealed an addendum to previous Note, completed by the Registered Nurse (RN), that Soap suds enema (SSE) given with Nurse Practitioner (NP) present, [NAME] loose to watery stools noted 15-20 min [minutes] after, Patient was cleaned, remains afebrile, HR [heart rate] 160s, abdomen remains distended, approx. [approximately] 3:30 PM returned to patient's room to follow up with clinical status and further results of soap suds enema, rectal tube found inserted in patient, nursing supervisor made aware.
Review of the facility's Incident Report on 7/24/23 at 5:00 PM, completed by the RN Supervisor, revealed the CNA inserted a rectal tube into [Resident #3]. There was no order and no one instructed her to do so. It is beyond [the CNA's] scope of practice to do this.
During an interview with the surveyor on 10/4/23 at 2:15 PM, the Director of Nursing (DON) stated that the RN administered a SSE to Resident #3 earlier in the day and went to lunch. Upon return from lunch, the RN noted that a rectal tube had been inserted into Resident #3's rectum. At which time, the RN had a discussion with the CNA and the CNA admitted to inserting the rectal tube. The CNA stated, I thought I was helping you. I thought I was doing you a favor. At that time, the RN removed the rectal tubing. The DON further stated that the CNA should not have inserted the rectal tube into the resident because it was outside of her scope of practice. The DON also stated the incident was not reported to the NJDOH because the Licensed Nursing Home Administrator (LNHA), and the Director of Quality Safety and Compliance (DQSC) did not believe it was willful neglect, intent to harm or abuse of the resident.
During an interview with the surveyor on 10/4/23 at 6:34 PM, the DQSC stated that only a RN or Licensed Practical Nurse (LPN) can insert a rectal tube and give a SSE to a resident with a physician's order (PO). When the surveyor inquired about the CNA inserting a rectal tube into Resident #3's rectum, the DQSC stated, The CNA did not realize she was working outside of her scope of practice, and she realized, afterwards, that it was something she should not have done. He further stated, The CNA shouldn't have done the rectal tube insertion because she wasn't educated on how to do it, nor was it in her scope of practice. The DQSC stated he did not feel as if the incident was willful neglect, intent to harm, or abuse to the resident, therefore, the facility did not report the incident to the NJDOH.
During an interview with the surveyor on 10/5/23 at 1:00 pm, the LNHA stated if an incident occurred in the facility, he would collect all the facts related to the incident and then determine if it fell within the guidelines of a reportable event. The LNHA stated he was notified of the incident by the DQSC and the DON, that a CNA was trying to help the nurse and did something she should not have done. The surveyor inquired how the CNA knew what fell under her certification, to which he replied, All CNAs have certification and know what falls under their certification. The CNAs don't have the education required to complete that procedure [rectal tube insertion]. The LNHA further stated, The CNA should have known that only a nurse could do that task with a physician's order; she's been here a long time. The LNHA continued, The CNA had no willful intent to harm the resident, but used poor judgement when she took it upon herself to perform a procedure she was not authorized to do. We didn't feel as if it was willful neglect, intentional harm or abuse, so it was collectively decided that it shouldn't be reported to the NJDOH.
The surveyor asked the facility administration how they determined that the actions of the CNA were not willful neglect, intentional harm or abuse of the resident. The facility could not provide an answer or any other documented evidence that the actions of the CNA had no willful neglect, intentional harm or abuse to the resident.
Review of the facility's policy, Reportable Events, reviewed/revised on 1/22, revealed under the Purpose section, To comply with the New Jersey licensing standard 8:36-5.10 Reportable Events. Under the Policy section reflected that Should any event occur that jeopardizes the health and safety of patients . immediate notification will be made to the Administrator or Administrator-on-call. Under the Procedure section indicated events that should be reported to the NJDOH by the designated Facility User include, but are not limited to: m. any other unusual event as determined by the Administrator.
NJAC 8:39-9.4(f)
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ#166667
Based on interviews, medical records review, and review of other pertinent facility documentation on 10/4/23 and 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ#166667
Based on interviews, medical records review, and review of other pertinent facility documentation on 10/4/23 and 10/5/23, it was determined that the facility failed to ensure that a Certified Nursing Assistant (CNA) worked within her scope of practice.
The deficient practice was identified for Resident #3, 1 or 6 sampled residents reviewed and was evidenced by the following:
According to the admission Record (AR), Resident #3 was readmitted on [DATE] with diagnoses which included but were not limited to: autonomic dysreflexia (a dangerous syndrome involving an overreaction of your autonomic nervous system), spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder causing limitation on all four limbs), anoxic brain damage (brain injury caused by a complete lack of oxygen to the brain), artificial opening of gastrointestinal tract, and constipation.
Review of Resident #3's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/20/23, revealed that Resident #3 had severe cognitive impairment. The MDS also showed that the resident was incontinent of bowel and bladder and required total assist of one person for all Activities of Daily Living (ADLs).
Review of Resident #3's Care Plan (CP) revealed a Focus, initiated on 12/8/20, of Constipation. Under the Goal section, indicated that the resident will have bowel movement every 24 hours. Under Interventions, indicated to administer medications as ordered, monitor stool output, bowel sounds and any abdominal distention. The CP revealed a Focus, initiated on 12/8/20, that Resident #3 had a history of abdominal distention. Under the Goal section, reflected that Resident #3's abdominal distention will be relieved with nursing interventions. Under Interventions, indicated to monitor bowel sounds and to administer rectal tube as needed. Under the Position section for the aforementioned intervention reflected Licensed Practical Nurse (LPN).
Review of Resident #3's physician's Order Summary Report for active orders as of 10/4/23, revealed a physician order (PO) dated 3/10/21, for rectal tube for abdominal distention every four hours as needed. There was also a PO, dated 3/9/21, that reflected that an enema may be repeated one time after the Registered Nurse (RN) assesses the abdomen, documents bowel sounds and appearance . Administer one enema two hours after initial enema given.
Review of the 7/26/23 at 12:53 PM Progress Notes revealed an addendum to previous Note, completed by the Registered Nurse (RN), that Soap suds enema (SSE) given with Nurse Practitioner (NP) present, [NAME] loose to watery stools noted 15-20 min [minutes] after, Patient was cleaned, remains afebrile, HR [heart rate] 160s, abdomen remains distended, approx. [approximately] 3:30 PM returned to patient's room to follow up with clinical status and further results of soap suds enema, rectal tube found inserted in patient, nursing supervisor made aware.
Review of the facility's 7/24/23 at 5:00 PM Incident Report, completed by the RN Supervisor, revealed that the CNA inserted a rectal tube into [Resident #3]. There was no order and no one instructed her to do so. It is beyond [the CNA's] scope of practice to do this.
Review of The RN's 7/24/23 statement indicated that the RN returned from lunch and went to re-assess Resident #3. The CNA was present in the room with an orientee and was noted standing over the resident. Resident #3 was observed with a rectal tube. The RN asked the CNA who placed the rectal tube in the resident. The CNA told the RN that she did.
Review of the RN Supervisor's 7/24/23 statement revealed the RN went to lunch and upon her return had checked on Resident #3. The RN found that someone had taken the enema bag and used it as a rectal tube. The CNA was at the bedside and admitted to inserting the rectal tube because she thought she was doing the RN a favor. The RN had informed her of what the CNA had done, and she immediately removed the CNA from patient care.
Review of the facility's 7/25/23 Department of Nursing Termination Notice revealed under the Statement of Problem section that the CNA performed duties outside of her scope of practice as a Certified Nursing Assistant by inserting a rectal soap suds enema on a resident on 7/24/23. Under the Plan of Action section indicated Termination.
During an interview with the surveyor on 10/4/23 at 1:44 PM, the RN stated she received an order from the NP to give a SSE after she reported Resident #3 has a hard, distended abdomen. The RN administered the SSE and the resident immediately had a bowel movement. Resident #3's stomach was softer, and he/she appeared more comfortable. She cleaned the resident and went to lunch. Upon her return from lunch, she went to check on Resident #3's status and observed a rectal tube inserted into the resident's rectum. The RN stated she asked who ordered the rectal tube insertion because resident did not have one when she left for lunch. She asked the CNA, who was present in the room at that time, but the CNA did not provide a response. She then proceeded to ask the other staff on the unit and reported the incident to the RN Supervisor. The RN assessed the resident, removed the rectal tube, and no blood was noted at the time.
During an interview with the surveyor on 10/4/23 at 2:15 PM, the Director of Nursing (DON) stated that the RN administered a SSE to Resident #3 earlier in the day and went to lunch. Upon return from lunch, the RN noted that a rectal tube had been inserted into Resident #3's rectum. At which time, the RN had a discussion with the CNA and the CNA admitted to inserting the rectal tube. The CNA stated, I thought I was helping you. I thought I was doing you a favor. At that time, the RN removed the rectal tubing. The DON further stated that the CNA should not have inserted the rectal tube into the resident because it was outside of her scope of practice.
During an interview with the surveyor on 10/4/23 at 3:00 PM, the RN Supervisor stated she was informed by the RN that a SSE had been administered with positive results. The RN Supervisor further stated she was informed by the RN, after her lunch break, she went to provide care to Resident #3 for the second time. At that time, the RN found a rectal tube inserted into Resident #3's rectum. The surveyor asked the RN supervisor about the 7/24/23 Incident Report she completed. She responded, the CNA took it upon herself to insert a rectal tube into the resident's rectum to contain his/her loose stool. The RN Supervisor stated the CNA should not have inserted the rectal tube into the resident's rectum because it was outside her scope of practice. The CNA was removed from the assignment and sent to the conference room. The RN Supervisor added that the CNA knew she was not supposed to do that because she was crestfallen (sad and disappointed) and stated, I tried to help and I shouldn't have done that.
During an interview with the surveyor on 10/4/23 at 6:34 PM, the Director of Quality Safety and Compliance (DQSC) stated that a LPN or RN can insert a rectal tube and administer a SSE to a resident. The surveyor asked the DQSC about the 7/24/23 incident. The DQSC stated he received a call from the RN Supervisor and was informed that a CNA had gone into a resident's room and inserted a rectal tube into the resident's rectum. The DQSC stated the CNA did not realize she was working outside of her scope of practice, and she realized, afterwards, that it was something she should not have done. The CNA was immediately suspended. The DQSC further stated the CNA should not have done a rectal tube insertion on Resident #3 because she was not educated on how to do it nor was it in her scope of practice.
During an interview with the surveyor on 10/5/23 at 1:00 PM, the Licensed Nursing Home Administrator (LNHA) stated he was notified of the 7/24/23 incident by the DON and the DQSC. The LNHA was informed that a CNA was trying to help the nurse and did something she should not have done. The surveyor asked how the CNA knew what fell under her scope of practice, to which he replied, All CNAs have certification and know what falls under their certification. The CNAs don't have the education required to complete that procedure [rectal tube insertion]. It is the RNs and LPNs who have the education. The LNHA further stated, The CNA should have known that only a nurse could do that task with a physician's order; she's been here a long time.
Review of the facility, Invasive Procedure: Rectal Tubes, policy, with the effective date of 5/22, indicated under Responsibility: RN, LPN.
Review of the facility's policy Job Description/Performance Evaluation for CNAs, with the effective date of 5/07, revealed under the Position Summary section that the CNA Functions under the direction of a licensed practical nurse or registered professional nurse in providing direct patient care.
N.J.A.C.: 8.39-27.1(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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ 166667
Based on interviews, Medical Record (MR) review, and review of other pertinent facility documentation on ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ 166667
Based on interviews, Medical Record (MR) review, and review of other pertinent facility documentation on 10/4/23 and 10/5/23, it was determined that the facility failed to maintain a complete MR which contained a Universal Transfer Form (UTF) for a resident who was sent to the hospital. The deficient practice was identified for Resident #3, 1 of 6 sampled residents, and was evidenced by the following:
According to the admission Record, Resident #3 was readmitted on [DATE] with diagnoses which included but were not limited to: autonomic dysreflexia (a dangerous syndrome involving an overreaction of your autonomic nervous system), spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder causing limitation on all four limbs), anoxic brain damage (brain injury caused by a complete lack of oxygen to the brain), artificial opening of gastrointestinal tract, and constipation.
Review of Resident #3's Progress Notes revealed a 7/24/23 at 7:01 PM Medical Progress Note completed by the Nurse Practitioner, that she was called by the Registered Nurse (RN) Supervisor and informed that Resident #3 was now passing stool with streaks of frank blood in [his/her] stool. Under the Assessment & Plan section it reflected to send the resident to the emergency department (ER) for further evaluation of acute lower gastrointestinal bleed with firm abdominal distension and minimal bowel sounds.
Review of Resident #3's MR revealed no UTF for the 7/24/23 transfer to the hospital.
Review of Resident #3's hospital Discharge Summary revealed an admission date of 7/24/23 and a discharge date of 7/31/23.
During an interview with the surveyor on 10/4/23 at 4:25 pm, the Director of Nursing (DON) stated she was unable to locate the missing 7/24/23 UTF for Resident #3. The DON further stated the RN did not make a copy before sending it with the resident. At which time, the DON stated the RN should have made a copy for the resident's MR.
Review of the facility policy titled, Admissions, Discharges & Transfers: Universal Transfer Form, dated 1/12, revealed under the Procedure section that 5. A licensed healthcare facility or program shall retain a completed copy of the Universal Transfer Form sent with the patient when a patient is transferred as part of the patient's medical record.
NJAC 8:39-35.2(k)
Apr 2023
5 deficiencies
3 IJ (1 facility-wide)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00110496
Based on interviews, review of records, and the facility policy, the facility neglected to ensure one res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00110496
Based on interviews, review of records, and the facility policy, the facility neglected to ensure one resident out of four residents (Resident (R) 5) reviewed for wheelchair safety was safely secured in the wheelchair to prevent accident hazards. On [DATE], the facility's failure resulted in actual harm of R5 due to accidental asphyxiation [deprivation of oxygen supply to body tissues] caused by the wheelchair chest harness. Following the incident, the facility determined human error as the cause and neglected to take measures to prevent future accidents.
On [DATE] at 9:07 PM, the Administrator and the Quality Safety Coordinator (QSC) were notified of an Immediate Jeopardy (IJ) for F600 Neglect. The Immediate Jeopardy began on [DATE] when the facility neglected to ensure staff safely secured R5 in the wheelchair which resulted in R5 suffering asphyxiation by R5's chest harness; and subsequently failed to take actions to prevent future accidents caused by human error.
The Administrator and QSC were informed that immediate jeopardy was still present and ongoing at the time of exit from the survey on [DATE] at 8:15 PM.
The facility submitted an acceptable removal plan on [DATE]. The removal plan was verified as implemented on site by surveyors on [DATE].
Findings include:
Review of the facility's policy titled Safety: Abuse & Neglect, dated [DATE], revealed The facility has an obligation to protect the welfare of its residents.
Review of the facility's policy titled Wheelchair Positioning, dated [DATE], revealed To position resident in a therapeutic and safe adaptive seating device, in order to provide increased mobility and to insure proper positioning . once resident is positioned in the wheelchair secure the seat belt to prevent any unexpected movement or fall . Align the resident's trunk support and secure all straps on chair . Place feet on the foot rests and secure with foot straps if present . Ensure that any type of head or neck support system is properly in place and supporting the resident properly . Place lap tray on wheelchair if present .
Review of R5's undated admission RECORD located on the electronic medical record (EMR) revealed R5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses to include epileptic spasms, and functional quadriplegic [complete inability to move due to severe disability], and used a wheelchair for mobility.
Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not completed and R5 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility.
Review of R5's Physician's Orders, dated [DATE], under the Orders tab located on the EMR lacked an order for wheelchair safety/straps/harness.
Review of R5's Medication Administration Record [MAR] and Treatment Administration Record [TAR], [DATE], under Orders tab located on the EMR revealed there were no orders for wheelchair safety/straps/harness.
Review of R5's Care Plan under Care Plan tab located on the EMR revealed no interventions for wheelchair safety/straps/harness.
Review of R5's CODE BLUE RESUSCITATION SHEET, [DATE], revealed . Time Ventilation Initiated . 2:08 PM.
Review of R5's Progress Note, [DATE] at 2:30 PM, under Progress Notes tab located on R5's EMR revealed . was sent out to . ED [emergency department] for evaluation after having a respiratory arrest and requiring bagging with oxygen. Spontaneous respirations returned with bagging .
Review of R5's ED Provider Notes, provided by the QSC, [DATE] at 2:57 PM revealed . presents to the ED via EMS [Emergency Medical Services] for evaluation of asphyxiation . found belted into wheel chair [sic] slumped over into top half of the belt, cutting off circulation to . head . cyanotic [bluish hue to the skin indicative of low oxygen] and had petechiae [pinpoint, round spots that appear on the skin as a result of bleeding] to neck and face . EMS reports on their examination pt [patient] had tenderness to back of neck . Physical Exam . tachycardia [rapid heart rate] present . Skin . Diffused petechiae to neck up including face . Medical Decision Making/Plan . Likely asphyxia event . Transfer to [hospital] for observation .
Review of R5's PEDIATRIC HISTORY AND PHYSICIAL, [DATE], provided by the Director of Nursing (DON) revealed . presenting as a direct admission . for concerns of accidental asphyxia injury . per report . patient was left in wheelchair estimated to be unattended 30-40 minutes, found to have wheelchair seatbelt wrapped around neck. Patient found to be not breathing and was subsequently bagged with return of spontaneous respirations. Reported that no CPR [cardiopulmonary resuscitation] initiated and pulses intact . was cyanotic and had petechiae on . neck and face. Per report, facility staff was sternal rubbing patient when EMS arrived . Review of Systems . Petechiae on face . Skin . Diffuse facial petechiae . accidental seatbelt strangulation. Dry skin and scattered rashes to neck, dry skin with scratches to back . Intermittently having breath holding spells with desaturations but resolves saponaceous .
Review of R5's REPORTABLE EVENT RECORD/REPORT, [DATE], provided by QSC revealed Type of incident: Resident Care . Child was up in wheel chair [sic] awaiting therapy. Child was found to be apneic and unresponsive. [R5] had slid down in the chair with [R5's] legs hanging, and neck at the level of the chest harness straps. [R5] was placed in the bed, code was called, and bagged immediately with rescue breaths. [R5] responded to bagging and began breathing [independently]. [R5] did not require any chest compressions . Prior to the event was plan of care developed that addressed this issue . Custom wheelchair with chest harness for support and lap belt, heart rate and pulse oximetry monitoring .
During an interview on [DATE] at 2:22 PM, Licensed Practical Nurse (LPN) 1 recalled entering R5's room on [DATE] because Certified Nursing Assistant (CNA) 1 was heard frantically yelling for help. LPN 1 recalled witnessing R5's lifeless body hanging from R5's wheelchair by the neck from the chest harness on [DATE]. LPN1 stated R5's butt was not on the seat of the wheelchair but was dangling along with R5's legs and feet. LPN1 stated R5 was unconscious, not breathing and R5's lips were blue. LPN1 stated R5's lap belt was not buckled or secured around R5. LPN1 stated Registered Nurse Charge (RNC) 3 entered R5's room and transferred R5 to the bed and began manual respirations. LPN1 verified R5's care plan did not include an intervention to secure the resident in the wheelchair with chest harness, lap belt, or footrest.
During an interview on [DATE] at 3:22 PM, LPN2 stated the facility did not require staff to demonstrate knowledge or skills of buckling the resident's safety belts or harness on their wheelchairs during their yearly training. LPN2 stated R5 required a chest harness, lap rest, and footrest to secure R5 in the wheelchair.
During a brief interview on [DATE] at 3:45 PM, the QSC reported CNA1 was not available for interview.
During an interview on [DATE] at 11:48 AM, the DON stated she went to R5's room on [DATE] because R5's code bell was alarming, and staff were providing R5 with manual respiratory resuscitation via and ambu bag [A self-refilling bag used for artificial respiration] when she arrived. The DON stated R5 developed petechiae around both temples and mouth. The DON stated R5's petechiae was possibly related to the harness strap around R5's neck and asphyxiation. The DON stated the facility investigated R5's room accident/incident and determined the cause was due to human error. The DON stated the staff failed to ensure R5's seat belt was strapped/closed to ensure R5 could not slip out of the wheelchair. The DON stated the facility did not identify R5's physician's orders, care plan, or TAR did not include care or safety for the use of the wheelchair including the seat belt, chest harness or footrest and should have. The DON stated the nurse manager was responsible for ensuring R5's care plan included those interventions and did not. The DON stated the facility's omission of the resident's care plan interventions for safety of wheelchairs or physician's orders did not occur to the leadership while investigating R5's incident accident. The DON stated no training or education was provided for staff on wheelchair safety following R5's incident.
During an interview on [DATE] at 1:30 PM, Registered Nurse (RN) 1 stated she was providing care for R5 on [DATE], the date of the incident, and was taking lunch break at the time. RN1 stated she transferred R5 from the bed to the wheelchair prior to the lunch break and had secured and buckled R5's chest harness, lap belt, and had placed R5's feet on R5's footrest and buckled R5's feet. RN1 stated R5's physician's orders, TAR, or care plan did not include wheelchair safety or information about seat belt, footrest, or chest harness. RN1 stated she was informed of what and how to strap R5 into the wheelchair via another staff member. RN1 stated she was a new employee at the facility and gained employment in [DATE].
During an interview on [DATE] at 4:53 PM, Registered Nurse Charge (RNC) 3 recalled going to R5's room on [DATE] because CNA1 was yelling and on the way the code bell was heard alarming. RNC3 recalled when entering R5's room, R5's lap belt was not secured around R5's waist, and R5's chest harness was around R5's neck. RNC3 stated R5 was dangling from the wheelchair. RNC3 stated R5 was breathless, face was blue, and mouth was open. RNC3 recalled unclasping R5's chest harness and scooping R5's body from the wheelchair, transferring R5 to the bed and providing artificial respirations. RNC3 recalled R5 had developed petechiae on the temporal area and on the head. RNC3 stated R5 was required to have the wheelchair lap belt secured but did not and RNC3 was unsure why. RNC3 stated the staff just know the residents should be secured while in their wheelchairs. RNC3 stated all the residents' wheelchairs were different. RNC3 stated the facility's residents with wheelchairs did not have interventions on their care plans to secure them on their wheelchairs with their safety straps which increased their risk for accidents. RNC3 stated the facility provided some wheelchair training upon hire, but it was not resident individualized care.
During a brief interview on [DATE] at 6:40 PM, the QSC reported 101 residents at the facility utilized wheelchairs with safety harness/straps.
During an interview on [DATE] at 2:22 PM, Nurse Practitioner (NP) 1 recalled going to R5's room on [DATE] because the code bell was alarming, and the staff were providing manual respiratory resuscitation to R5. NP1 stated R5 developed petechiae around both temples and mouth. NP1 stated R5's petechiae was possibly related to the harness strap around R5's neck and caused asphyxiation. NP1 stated the residents' care plan interventions guided all the facility's staff directives for providing care for the residents and should contain interventions for wheelchair safety and harness. NP1 stated R5's incident/accident was discussed with the facility's Medical Director but they did not discuss care plan interventions or physician orders for wheelchair safety for the residents. NP1 was unsure why they did not think about all the rest of the children utilizing wheelchair safety and entering orders for the other resident but should have. NP1 stated the facility did not provide her with wheelchair safety education at the start of employment in [DATE]. NP1 stated R5's incident was a preventable accident, and the facility should have ensured the nursing staff were competent to secure the child in the wheelchair. NP1 stated the residents' wheelchair safety belts and harness were a safety hazard.
During an interview on [DATE] at 4:41 PM, the Social Services Director (SSD) stated residents' care plan interventions were the drivers of the care the facility provided for the residents. The SSD stated the facility did not include every little thing on the residents' care plans that utilized wheelchairs. The SSD stated the facility did not conduct a care conference after R5's accident/incident. The SSD stated R5's care plan was not revised to include interventions to secure R5 on the wheelchair after the accident. The SSD stated wheelchair safety was not an intervention that needed to be included on the resident's care plan because the staff just knew about securing the residents to their wheelchairs and it was not something that needed to be on the resident's care plan or interventions.
During an interview on [DATE] at 5:54 PM, the Medical Director stated she was one of the first staff in R5's room on [DATE] because R5's code bell was alarming. The Medical Director stated R5 began breathing independently and had a pulse but became paler and developed petechiae on the face. The Medical Director stated petechiae was not something related to seizure activity but developed from obstruction of the upper airway. The Medical Director stated petechiae was something seen during an autopsy of a deceased body due to strangulation. The Medical Director stated she examined R5 and talked to the staff. The Medical Director stated R5 was not on the wheelchair properly which caused airway obstruction. The Medical Director stated she absolutely thought the incident could have been prevented. The Medical Director stated she thought R5's accident was a result of a human error by the nurse that put R5 in the wheelchair. The Medical Director stated they looked at R5's wheelchair and determined the wheelchair was adequate and decided the incident was caused because the lap belt was not clasped correctly. The Medical Director stated she expected the resident's care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated she expected the resident's physician's orders to have wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated she had been at the facility for years, and it had never been on their radar to include resident's physician's orders for wheelchair safety and different devices like chest straps and such even though the staff utilized the resident's TAR to provide care. The Medical Director stated the only explanation that they had was the lap belt was not secured properly or not secured at all and they put R5 in the annex to have closer supervision but did not put any interventions or other actions in place for R5 or the other 100 residents with safety straps/harness on their wheelchairs.
NJAC:8:39-4.1 (a) 5
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00110496
Based on interviews, review of records, and the facility policy, the facility neglected to ensure one res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00110496
Based on interviews, review of records, and the facility policy, the facility neglected to ensure one resident out of 101 residents (Resident (R) 5) residing at the facility who utilized wheelchairs was safely secured in the wheelchair to prevent accident hazards. On [DATE], the facility's failure resulted in actual harm to R5 due to accidental asphyxiation [deprivation of oxygen supply to body tissues] by the wheelchair chest harness. The facility failed to have care planned interventions or physician's orders for wheelchair safety in place for four of four residents (R5, R18, R23, and R15) reviewed for wheelchair safety, and 97 other residents utilizing wheelchairs in the facility, increasing the risk of accident hazards for all 101 residents.
On [DATE] at 9:07 PM, the Administrator and the Quality Safety Coordinator (QSC) were notified of an Immediate Jeopardy (IJ) for F689: Accident Hazards. The Immediate Jeopardy began on [DATE] when staff failed to safely secure R5 in the wheelchair which resulted in R5 suffering asphyxiation by R5's chest harness. R5 and the other 100 residents who utilized wheelchairs did not have care plan interventions or physician's orders for wheelchair safety.
The Administrator and QSC were informed that immediate jeopardy was still present and ongoing at the time of exit from the survey on [DATE] at 8:15 PM.
The facility submitted an acceptable removal plan on [DATE]. The removal plan was verified as implemented on site by surveyors on [DATE].
Findings include:
Review of the facility's policy titled Wheelchair Positioning, dated 04/04, revealed To position resident in a therapeutic and safe adaptive seating device, in order to provide increased mobility and to insure proper positioning . once resident is positioned in the wheelchair secure the seat belt to prevent any unexpected movement or fall . Align the resident's trunk support and secure all straps on chair . Place feet on the foot rests and secure with foot straps if present . Ensure that any type of head or neck support system is properly in place and supporting the resident properly . Place lap tray on wheelchair if present .
1. Review of R5's undated electronic medical record (EMR) admission RECORD revealed R5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses to include epileptic spasms, and functional quadriplegic [complete inability to move due to severe disability], and used a wheelchair for mobility.
Review of R5's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of [DATE], located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not completed and R5 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility.
Review of R5's Physician's Orders, dated 04/23, under the EMR Orders tab revealed there were no orders for wheelchair safety/straps/harness.
Review of R5's Medication Administration Record [MAR] and Treatment Administration Record [TAR], dated 04/23, under the EMR Orders tab revealed there were no orders for wheelchair safety/straps/harness.
Review of R5's Care Plan under EMR Care Plan tab revealed the care plan lacked interventions for wheelchair safety/straps/harness.
Review of R5's CODE BLUE RESUSCITATION SHEET [DATE] revealed . Time Ventilation Initiated . 2:08 PM.
Review of R5's Progress Note, [DATE] at 2:30 PM. under the EMR Progress Notes tab revealed . was sent out to . ED [emergency department] for evaluation after having a respiratory arrest and requiring bagging with oxygen. Spontaneous respirations returned with bagging.
Review of R5's ED Provider Notes, provided by QSC and dated [DATE] at 2:57 PM, revealed . presents to the ED via EMS [emergency medical services] for evaluation of asphyxiation . found belted into wheel chair slumped over into top half of the belt, cutting off circulation to . head . cyanotic [bluish who to the skin indicative of loss of oxygen] and had petechiae to neck and face . EMS reports on their examination pt [patient] had tenderness to back of neck . Physical Exam . tachycardia [rapid heart rate] present . Skin . Diffused petechiae [pinpoint, round spots that appear on the skin as a result of bleeding] to neck up including face . Medical Decision Making/Plan . Likely asphyxia event . Transfer to [hospital] for observation .
Review of R5's hospital PEDIATRIC HISTORY AND PHYSICIAL, dated [DATE] and provided by the Director of Nursing (DON), revealed . presenting as a direct admission . for concerns of accidental asphyxia injury . per report . patient was left in wheelchair estimated to be unattended 30-40 minutes, found to have wheelchair seatbelt wrapped around neck. Patient found to be not breathing and was subsequently bagged with return of spontaneous respirations. Reported that no CPR [cardiopulmonary resuscitation] initiated and pulses intact . was cyanotic and had petechiae on . neck and face. Per report, facility staff was sternal rubbing patient when EMS arrived . Review of Systems . Petechiae on face . Skin . Diffuse facial petechiae . accidental seatbelt strangulation. Dry skin and scattered rashes to neck, dry skin with scratches to back . Intermittently having breath holding spells with desaturations but resolves saponaceous .
Review of R5's REPORTABLE EVENT RECORD/REPORT [DATE] provided by QSC revealed Type of incident: Resident Care . Child was up in wheel chair [sic] awaiting therapy. Child was found to be apneic and unresponsive. [R5] had slid down in the chair with [R5's] legs hanging, and neck at the level of the chest harness straps. [R5] was placed in the bed, code was called, and bagged immediately with rescue breaths. [R5] responded to bagging and began breathing [independently]. [R5] did not require any chest compressions . Prior to the event was plan of care developed that addressed this issue .Custom wheelchair with chest harness for support and lap belt, heart rate and pulse oximetry monitoring .
During an interview on [DATE] at 2:22 PM, Licensed Practical Nurse (LPN) 1 recalled entering R5's room on [DATE] because Certified Nursing Assistant (CNA) 1 was heard frantically yelling for help. LPN 1 recalled witnessing R5's lifeless body hanging from R5's wheelchair by the neck from the chest harness on [DATE]. LPN1 stated R5's butt was not on the seat of the wheelchair but was dangling along with R5's legs and feet. LPN1 stated R5 was unconscious, not breathing and R5's lips were blue. LPN1 stated R5's lap belt was not buckled or secured around R5. LPN1 stated Registered Nurse Charge (RNC) 3 entered R5's room and transferred R5 to the bed and began manual respirations. LPN1 verified R5's care plan did not include an intervention to secure the resident in the wheelchair with chest harness, lap belt, or footrest.
During an interview on [DATE] at 3:22 PM, LPN2 stated the facility did not require her to demonstrate her knowledge or skills of buckling the resident's safety belts or harness on their wheelchairs during their yearly training. LPN2 stated R5 required a chest harness, lap rest, and footrest to secure R5 in the wheelchair.
During a brief interview on [DATE] at 3:45 PM the QSC reported CNA1 was not available for interview.
During an interview on [DATE] at 11:48 AM, the DON stated she went to R5's room on [DATE] because R5's code bell was alarming, and staff were providing R5 with manual respiratory resuscitation via an ambu bag [A self-refilling bag used for artificial respiration] when she arrived. The DON stated R5 developed petechiae around both temples and mouth. The DON stated R5's petechiae was possibly related to the harness strap around R5's neck and asphyxiation. The DON stated the facility investigated R5's room accident/incident and determined the cause was due to human error. The DON stated the staff failed to ensure R5's seat belt was strapped/closed to ensure R5 could not slip out of the wheelchair. The DON stated the facility did not identify R5's physician's orders, care plan, or TAR did not include care or safety for the use of the wheelchair including the seat belt, chest harness, or footrest and should have. The DON stated the nurse manager was responsible for ensuring R5's care plan included those interventions and did not. The DON stated the facility's omission of the residents' care plan interventions for safety of wheelchairs or physician's orders did not occur to the leadership while investigating R5's incident accident.
During an interview on [DATE] at 1:30 PM, Registered Nurse (RN) 1 stated she was providing care for R5 on [DATE] and was taking lunch break at the time of the incident. RN1 stated she transferred R5 from the bed to the wheelchair prior to the lunch break and had secured and buckled R5's chest harness, lap belt; and had placed R5's feet on R5's footrest and buckled R5's feet. RN1 stated R5's physician's orders, TAR, or care plan did not include wheelchair safety or information about seat belt, footrest, or chest harness. RN1 stated she was informed of what and how to strap R5 into the wheelchair via another staff member. RN1 stated she was a new employee at the facility and gained employment in [DATE].
During an interview on [DATE] at 4:53 PM, Registered Nurse Charge (RNC) 3 stated she went to R5's room because she heard CNA1 yelling and, on the way, she heard the code bell alarming. RNC3 stated when she entered R5's room she found R5's lap belt was not secured around R5's waist, and the chest harness was around R5's neck. RNC3 stated R5 was dangling from the wheelchair. RNC3 stated R5 was breathless, face was blue, and mouth was open. RNC3 stated she unclasped R5's chest harness and scooped R5's body from the wheelchair, transferred R5 to the bed and began providing artificial respirations. RNC3 stated she noted R5 developed petechiae on the temporal area and head. RNC3 stated R5 was required to have the wheelchair lap belt secured but did not and she was unsure why.
During an interview on [DATE] at 2:22 PM, Nurse Practitioner (NP) 1 stated she went to R5's room on [DATE] because the code bell was alarming, and the staff were providing manual respiratory resuscitation to R5. NP1 stated R5 developed petechiae around both temples and mouth. NP1 stated R5's petechiae was possibly related to the harness strap around R5's neck and caused asphyxiation. NP1 stated she discussed R5's incident/accident with the facility's Medical Director but did not discuss care plan interventions or physician orders for wheelchair safety for the residents. NP1 stated she was unsure why she did not think about all the rest of the children utilizing wheelchair safety and entering orders for the other resident, but she should have. NP1 stated R5's incident was a preventable accident, and the facility should have ensured the nursing staff were competent to secure the child in the wheelchairs. NP1 stated the residents' wheelchair safety belts and harness were a safety hazard.
During an interview on [DATE] at 4:41 PM, the Social Services Director (SSD) stated the facility did not conduct a care conference after R5's accident/incident. The SSD stated R5's care plan was not revised to include interventions to secure her on her wheelchair after her accident. The SSD stated wheelchair safety was not an intervention that needed to be included on the resident's care plan because the staff just knew about securing the residents to their wheelchairs and it was not something that needed to be on the resident's care plan or interventions.
During an interview on [DATE] at 5:54 PM, the Medical Director stated she was one of the first staff in R5's room on [DATE] because R5's code bell was alarming. The Medical Director stated R5 began breathing independently and had a pulse but became paler and developed petechiae on the face. The Medical Director stated petechiae developed from obstruction of the upper airway. The Medical Director stated petechiae was something seen during an autopsy of a deceased body due to strangulation. The Medical Director stated she examined R5 and talked to the staff. The Medical Director stated R5 was not on the wheelchair properly and caused airway obstruction. The Medical Director stated she absolutely thought the incident could have been prevented. The Medical Director stated she thought R5's accident was a result of a human error by the nurse that put R5 in the wheelchair. The Medical Director stated they looked at R5's wheelchair and determined the wheelchair was adequate and decided the incident was caused because her lap belt was not clasped correctly. The Medical Director stated she expected the residents' care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated she expected the resident's physician's orders to have wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated the only explanation that they had was the lap belt was not secured properly or not secured at all and they put R5 in the annex to have closer supervision but did not put any interventions or plans in place for R5.
2. Review of R18's undated EMR admission RECORD revealed R18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegia cerebral palsy, and ileostomy.
Review of R18's quarterly MDS with an ARD of [DATE], located in the EMR MDS tab, revealed a BIMS was not assessed and R18 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility.
Review of R18's Physician's Orders 04/23 under the Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness.
Review of R18's MAR and TAR 04/23 under Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness.
Review of R18's Care Plan, target date [DATE] and located under the EMR Care Plan tab, revealed no interventions for wheelchair safety.
3. Review of R15's undated EMR admission RECORD revealed R15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegic cerebral palsy, and Crohn's disease.
Review of R15's quarterly MDS with an ARD of [DATE], located in the EMR MDS tab, revealed a BIMS was not assessed and R15 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility.
Review of R15's Physician's Orders 04/23 under the Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness.
Review of R15's MAR and TAR 04/23 under Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness.
Review of R15's Care Plan, located under the EMR Care Plan tab with a target date of [DATE], revealed no interventions for wheelchair safety.
4. Review of R23's undated EMR admission RECORD revealed R23 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome and spastic quadriplegic cerebral palsy.
Review of R23's quarterly MDS with an ARD of [DATE] and located in the EMR MDS tab, revealed a BIMS was not assessed and R23 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility.
Review of R23's Physician's Orders 04/23 under the Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness.
Review of R23's MAR and TAR 04/23 under Orders tab located on the EMR revealed no order for wheelchair safety/straps/harness.
Review of R23's Care Plan, located under the EMR Care Plan tab with a target date of [DATE], revealed no interventions for wheelchair safety.
During an interview on [DATE] at 3:22 PM, LPN2 stated the facility did not require her to demonstrate her knowledge or skills of buckling the residents' safety belts or harness on their wheelchairs during their yearly training.
During an interview on [DATE] at 11:48 AM, the DON stated the facility's omission of the residents' care plan interventions for safety of wheelchairs or physician's orders did not occur to the leadership while investigating R5's incident accident.
During an interview on [DATE], RNC3 stated the staff just know the residents should be secured while in their wheelchair. RNC3 stated all the residents' wheelchairs were different. RNC3 stated the facility's residents with wheelchairs did not have interventions on their care plans to secure them on their wheelchairs with their safety straps which increased their risk for accidents. RNC3 stated the facility provided some wheelchair training upon hire, but it was not resident individualized care.
During a brief interview on [DATE] at 6:40 PM, the QSC reported 101 resided at the facility utilizing wheelchairs with safety harness/straps.
During an interview on [DATE] at 2:22 PM, NP1 stated she discussed R5's incident/accident with the facility's Medical Director but did not discuss care plan interventions or physician orders for wheelchair safety for the residents. NP1 stated she was unsure why she did not think about all the rest of the residents utilizing wheelchair safety and entering orders for the other residents, but she should have. NP1 stated the facility did not provide her with wheelchair safety education at the start of her employment in [DATE]. NP1 stated the residents' wheelchair safety belts and harness were a safety hazard.
During an interview on [DATE] at 4:41 PM, the Social Services Director (SSD) stated residents' care plan interventions were the drivers of the care the facility provided for the residents. The SSD stated the facility did not include every little thing on the residents' care plans that utilized wheelchairs. The SSD stated wheelchair safety was not an intervention that needed to be included on the residents' care plan because the staff just knew about securing the residents to their wheelchairs and it was not something that needed to be on the residents' care plan or interventions.
During an interview on [DATE] at 5:54 PM, the Medical Director stated she expected the residents' care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated she expected the residents' physician's orders to have wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated she had been at the facility for years, and it had never been on their radar to include residents' physician's orders for wheelchair safety and different devices like chest straps and such even though the staff utilized the residents' TAR to provide care. The Medical Director stated the facility did not put any interventions or plans in place for R5 or the other 100 residents with safety straps/harness on their wheelchairs.
N.J.A.C. 8:39-27.1 (a)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Comprehensive Care Plan
(Tag F0656)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00110496
Based on interviews, review of records, and review of facility policy, the facility failed to ensure for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00110496
Based on interviews, review of records, and review of facility policy, the facility failed to ensure for all 101 of 101 residents utilizing wheelchairs that their care plans addressed wheelchair safety (securing on wheelchair). The facility's deficient practice resulted in R5 suffering accidental asphyxiation [deprivation of oxygen supply to body tissues] by a chest harness when the resident was not properly secured in the wheelchair.
On [DATE] at 9:07 PM, the Administrator and the Quality Safety Coordinator (QSC) were notified of an Immediate Jeopardy (IJ) at F656: Develop/Implement Comprehensive Care Plan. The Immediate Jeopardy began on [DATE] when R5 suffered accidental asphyxiation after being improperly secured by staff in R5's wheelchair. Individualized wheelchair safety interventions were not included on the care plans of all 101 residents, including R5, who utilized wheelchairs in the facility.
The Administrator and QSC were informed that immediate jeopardy was still present and ongoing at the time of exit from the survey on [DATE] at 8:15 PM.
The facility submitted an acceptable removal plan on [DATE]. The removal plan was verified as implemented on site by surveyors on [DATE].
Findings include:
1. The facility's policy for comprehensive care plans was requested but was not provided for review.
Review of R5's undated electronic medical record (EMR) admission RECORD revealed R5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses to include epileptic spasms, and functional quadriplegic [complete inability to move due to severe disability], and used a wheelchair for mobility.
Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not completed and R5 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility.
Review of R5's Care Plan under the EMR Care Plan tab revealed R5's care plan lacked interventions for wheelchair safety/straps/harness.
Review of R5's Progress Note, [DATE] at 2:30 PM, under the EMR Progress Notes tab . was sent out to . ED [emergency department] for evaluation after having a respiratory arrest and requiring bagging with oxygen. Spontaneous respirations returned with bagging .
Review of R5's ED Provider Notes, provided by QSC and dated [DATE] at 2:57 PM, revealed . presents to the ED via EMS [emergency medical services] for evaluation of asphyxiation . found belted into wheel chair slumped over into top half of the belt, cutting off circulation to . head . cyanotic [bluish hue to the skin indicative of low oxygen] and had petechiae to neck and face . EMS reports on their examination pt had tenderness to back of neck . Physical Exam . tachycardia [rapid heart rate] present . Skin . Diffused petechiae [pinpoint, round spots that appear on the skin as a result of bleeding] to neck up including face . Medical Decision Making/Plan . Likely asphyxia event . Transfer to [hospital] for observation .
Review of R5's PEDIATRIC HISTORY AND PHYSICIAL, [DATE], provided by the Director of Nursing (DON) revealed . presenting as a direct admission . for concerns of accidental asphyxia injury . per report . patient was left in wheelchair estimated to be unattended 30-40 minutes, found to have wheelchair seatbelt wrapped around neck. Patient found to be not breathing and was subsequently bagged with return of spontaneous respirations. Reported that no CPR [cardiopulmonary resuscitation] initiated and pulses intact . was cyanotic and had petechiae on . neck and face. Per report, facility staff was sternal rubbing patient when EMS arrived . Review of Systems . Petechiae on face . Skin . Diffuse facial petechiae . accidental seatbelt strangulation. Dry skin and scattered rashes to neck, dry skin with scratches to back . Intermittently having breath holding spells with desaturations but resolves saponaceous.
Review of R5's REPORTABLE EVENT RECORD/REPORT, [DATE], provided by QSC revealed Type of incident: Resident Care . Child was up in wheel chair [sic] awaiting therapy. Child was found to be apneic and unresponsive. [R5] had slid down in the chair with [R5's] legs hanging, and neck at the level of the chest harness straps. [R5] was placed in the bed, code was called, and bagged immediately with rescue breaths. [R5] responded to bagging and began breathing [independently]. [R5] did not require any chest compressions . Prior to the event was plan of care developed that addressed this issue . Custom wheelchair with chest harness for support and lap belt, heart rate and pulse oximetry monitoring .
During an interview on [DATE] at 2:22 PM, Licensed Practical Nurse (LPN) 1 recalled entering R5's room on [DATE] because Certified Nursing Assistant (CNA) 1 was heard frantically yelling for help. LPN 1 recalled witnessing R5's lifeless body hanging from R5's wheelchair by the neck from the chest harness on [DATE]. LPN1 stated R5's butt was not on the seat of the wheelchair but was dangling along with R5's legs and feet. LPN1 stated R5 was unconscious, not breathing and R5's lips were blue. LPN1 stated R5's lap belt was not buckled or secured around R5. LPN1 stated Registered Nurse Charge (RNC) 3 entered R5's room and transferred R5 to the bed and began manual respirations. LPN1 verified R5's care plan did not include an intervention to secure the resident in the wheelchair with chest harness, lap belt, or footrest.
During an interview on [DATE] at 11:48 AM, the Director of Nursing (DON) stated she went to R5's room on [DATE] because R5's code bell was alarming, and staff were providing R5 with manual respiratory resuscitation via and ambu bag [A self-refilling bag used for artificial respiration] when she arrived. The DON stated R5 developed petechiae around both temples and mouth. The DON stated R5's petechiae was possibly related to the harness strap around R5's neck and asphyxiation. The DON stated the facility investigated R5's room accident/incident and determined the cause was due to human error. The DON stated the staff failed to ensure R5's seat belt was strapped/closed to ensure R5 could not slip out of the wheelchair. The DON stated the facility did not identify that R5's care plan did not include care or safety for the use of the wheelchair including the seat belt, chest harness or footrest and should have. The DON stated the nurse manager was responsible for ensuring R5's care plan included those interventions and did not. The DON stated the facility's omission of the resident's care plan interventions for safety of wheelchairs or physician's orders did not occur to the leadership while investigating R5's incident accident.
During an interview on [DATE] at 1:30 PM, Registered Nurse (RN) 1 stated she was providing care for R5 on [DATE], the date of the incident, and was taking lunch break at the time. RN1 stated she transferred R5 from the bed to the wheelchair prior to the lunch break and had secured and buckled R5's chest harness, lap belt; and had placed R5's feet on R5's footrest and buckled R5's feet. RN1 stated R5's care plan did not include wheelchair safety or information about seat belt, footrest, or chest harness. RN1 stated she was informed of what and how to strap R5 into the wheelchair via another staff member. RN1 stated she was a new employee at the facility and gained employment in [DATE].
During an interview on [DATE] at 4:53 PM, Registered Nurse Charge at (RNC) 3 recalled going to R5's room on [DATE] because CNA1 was yelling and on the way the code bell was heard alarming. RNC3 recalled when entering R5's room, R5's lap belt was not secured around R5's waist, and R5's chest harness was around R5's neck. RNC3 stated R5 was dangling from the wheelchair. RNC3 stated R5 was breathless, face was blue, and mouth was open. RNC3 recalled unclasping R5's chest harness and scooping R5's body from the wheelchair, transferring R5 to the bed and providing artificial respirations. RNC3 recalled R5 had developed petechiae on the temporal area and on the head. RNC3 stated R5 was required to have the wheelchair lap belt secured but did not and RNC3 was unsure why. RNC3 stated the staff just know the residents should be secured while in their wheelchairs.
During an interview on [DATE] at 2:22 PM, Nurse Practitioner (NP) 1 stated she went to R5's room on [DATE] because the code bell was alarming, and the staff were providing manual respiratory resuscitation to R5. NP1 stated R5 developed petechiae around both temples and mouth. NP1 stated R5's petechiae was possibly related to the harness strap around R5's neck and caused asphyxiation. NP1 stated she discussed R5's incident/accident with the facility's Medical Director but did not discuss care plan interventions for wheelchair safety for the residents. NP1 stated R5's incident was a preventable accident, and the facility should have ensured the nursing staff were competent to secure the child in the wheelchair. NP1 stated the residents' wheelchair safety belts and harness were a safety hazard.
During an interview on [DATE] at 4:41 PM, the Social Services Director (SSD) stated the facility did not conduct a care conference after R5's accident/incident. The SSD stated R5's care plan was not revised to include interventions to secure R5 on the wheelchair after the accident. The SSD stated wheelchair safety was not an intervention that needed to be included on the residents' care plan because the staff just knew about securing the residents to their wheelchairs.
During an interview on [DATE] at 5:54 PM, the Medical Director stated she was one of the first staff in R5's room on [DATE] because R5's code bell was alarming. The Medical Director stated R5 began breathing independently and had a pulse but became paler and developed petechiae on the face. The Medical Directors stated petechiae was not something related to seizure activity but developed from obstruction of the upper airway. The Medical Director stated petechiae was something seen during an autopsy of a deceased body due to strangulation. The Medical Director stated she examined R5 and talked to the staff. The Medical Director stated R5 was not on the wheelchair properly and that caused airway obstruction. The Medical Director stated she absolutely thought the incident could have been prevented. The Medical Director stated she thought R5's accident was a result of a human error by the nurse that put R5 in the wheelchair. The Medical Director stated they looked at R5's wheelchair and determined the wheelchair was adequate and decided the incident was caused because the lap belt was not clasped correctly. The Medical Director stated she expected the residents' care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated the only explanation that they had was the lap belt was not secured properly or not secured at all and they put R5 in the annex to have closer supervision but did not put any interventions or plans in place for R5.
2. Review of R18's undated EMR admission RECORD revealed R18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegia cerebral palsy, and ileostomy.
Review of R18's quarterly MDS with an ARD of [DATE], located in the EMR MDS tab, revealed a BIMS was not assessed and R18 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility.
Review of R18's Care Plan, target date [DATE] and located under the EMR Care Plan tab, revealed no interventions for wheelchair safety.
3. Review of R15's undated EMR admission RECORD revealed R15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegic cerebral palsy, and Crohn's disease.
Review of R15's quarterly MDS with an ARD of [DATE], located in the EMR MDS tab, revealed a BIMS was not assessed and R15 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility.
Review of R15's Care Plan, located under the EMR Care Plan tab with a target date of [DATE], revealed no interventions for wheelchair safety.
4. Review of R23's undated EMR admission RECORD revealed R23 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome and spastic quadriplegic cerebral palsy.
Review of R23's quarterly MDS with an ARD of [DATE] and located in the EMR MDS tab, revealed a BIMS was not assessed and R23 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility.
Review of R23's Care Plan, located under the EMR Care Plan tab with a target date of [DATE], revealed no interventions for wheelchair safety.
During an interview on [DATE] at 11:48 AM, the DON stated the facility's omission of the resident's care plan interventions for safety of wheelchairs or physician's orders did not occur to the leadership while investigating R5's incident accident. The DON confirmed residents were not care planned for wheelchair safety.
During an interview on [DATE] at 4:35 PM, Registered Nurse Charge (RNC) 3 stated the staff just know the residents should be secured while in their wheelchairs. RNC3 stated all the residents' wheelchairs were different. RNC3 stated the facility's residents with wheelchairs did not have interventions on their care plans to secure them on their wheelchairs with their safety straps which increased their risk for accidents. RNC3 stated the facility provided some wheelchair training upon hire, but it was not resident individualized care.
During a brief interview on [DATE] at 6:40 PM, the QSC reported 101 resided at the facility utilizing wheelchairs with safety harness/straps.
During an interview on [DATE] at 2:22 PM, NP1 stated the residents' care plan interventions guided all the facility's staff directives for providing care for the residents and should contain interventions for wheelchair safety and harness. NP1 stated she discussed R5's incident/accident with the facility's Medical Director but did not discuss care plan interventions for wheelchair safety for the residents. NP1 stated she was unsure why she did not think about all the rest of the residents utilizing wheelchair safety and entering orders for the other resident, but she should have. NP1 stated the residents' wheelchair safety belts and harness were a safety hazard.
During an interview on [DATE] at 4:41 PM, the SSD stated residents' care plan interventions were the drivers of the care the facility provided for the residents. The SSD stated the facility did not include every little thing on the residents' care plans that utilized wheelchairs. The SSD stated wheelchair safety was not an intervention that needed to be included on the residents' care plan because the staff just knew about securing the residents to their wheelchairs and it was not something that needed to be on the residents' care plan or interventions.
During an interview on [DATE] at 5:54 PM, the Medical Director stated she expected the residents' care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated the facility did not put any interventions or plans in place for R5 or the other 100 residents with safety straps/harness on their wheelchairs.
N.J.A.C.: 8:39-27.1 (a)
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0710
(Tag F0710)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00110496, NJ00107644
Based on record review, interviews, and policy review, the facility failed to ensure 101 of 1...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00110496, NJ00107644
Based on record review, interviews, and policy review, the facility failed to ensure 101 of 101 residents utilizing wheelchairs at the facility had physician orders for wheelchair safety. This resulted in actual harm when Resident (R) 5 was not appropriately secured in the wheelchair and suffered asphyxiation. The facility failed to ensure two residents out of three residents (R23, R18) reviewed for physician services had physician's orders included for Remicade (Generic name infliximab, infusion therapy used to decrease inflammation and treat Crohn's disease, ulcerative colitis, and rheumatoid arthritis.) The facility's deficient practice increased R23 and R18's resident's risk of treatment (medication administration) overlooked and not administered.
Findings include:
Review of the facility's policy titled Physician Services [DATE] revealed .The resident's attending physician has oversight in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultant or treatment when called by the facility, and overseeing a relevant plan of care for the resident . prescribe an appropriately regimen . Physician orders . shall be maintained in accordance .
1. Review of R5's undated admission RECORD located on her electronic medical record (EMR) revealed R5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses to include epileptic spasms, and functional quadriplegic and used a wheelchair for mobility.
Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) with a score of was not assessed and R5 was assessed by staff as severely impaired cognitively and used a wheelchair for mobility.
Review of R5's Physician's Orders, dated [DATE] and located under the EMR Orders tab, lacked orders for wheelchair safety/straps/harness.
Review of R5's Medication Administration Record [MAR] and Treatment Administration Record [TAR] [DATE] under EMR Orders tab lacked orders for wheelchair safety/straps/harness.
Review of R5's hospital PEDIATRIC HISTORY AND PHYSICIAL, dated [DATE] and provided by the Director of Nursing (DON), revealed . presenting as a direct admission . for concerns of accidental asphyxia injury . per report . patient was left in wheelchair estimated to be unattended 30-40 minutes, found to have wheelchair seatbelt wrapped around neck. Patient found to be not breathing and was subsequently bagged with return of spontaneous respirations. Reported that no CPR [cardiopulmonary resuscitation] initiated and pulses intact . was cyanotic [bluish hue to the skin indicative of low oxygen] and had petechiae [pinpoint, round spots that appear on the skin as a result of bleeding] on . neck and face. Per report, facility staff was sternal rubbing patient when EMS [emergency medical services] arrived . Review of Systems . Petechiae on face . Skin . Diffuse facial petechiae . accidental seatbelt strangulation. Dry skin and scattered rashes to neck, dry skin with scratches to back . Intermittently having breath holding spells with desaturations but resolves saponaceous.
Review of R5's REPORTABLE EVENT RECORD/REPORT, dated [DATE] and provided by the Quality Safety Coordinator (QSC), revealed Type of incident: Resident Care . Child was up in wheel chair [sic] awaiting therapy. Child was found to be apneic and unresponsive. [R5] had slid down in the chair with [R5's] legs hanging, and neck at the level of the chest harness straps. [R5] was placed in the bed, code was called, and bagged immediately with rescue breaths. [R5] responded to bagging and began breathing [independently]. [R5] did not require any chest compressions . Prior to the event was plan of care developed that addressed this issue . Custom wheelchair with chest harness for support and lap belt, heart rate and pulse oximetry monitoring .
During an interview on [DATE] at 2:22 PM, Licensed Practical Nurse (LPN) 1 stated she entered R5's room because Certified Nursing Assistant (CNA)1 was heard frantically yelling for help. LPN 1 recalled witnessing R5's lifeless body hanging from R5's wheelchair by the neck from the chest harness on [DATE]. LPN1 stated R5's butt was not on the seat of the wheelchair but was dangling along with R5's legs and feet. LPN1 stated R5's was unconscious, not breathing, and R5's lips were blue. LPN1 stated R5's lap belt was not buckled or secured around R5. LPN1 stated Registered Nurse Charge (RNC) 3 entered R3's room and transferred R3 to the bed and began manual respirations. LPN1 verified R5's care plan did not include an intervention to secure R5 in the wheelchair with chest harness, lap belt or footrest.
During an interview on [DATE] at 11:48 AM, the DON stated she went to R5's room on [DATE] because R5's code bell was alarming, and staff were providing R5 with manual respiratory resuscitation via and ambu bag [A self-refilling bag used for artificial respiration] when she arrived. The DON stated R5 developed petechiae around both temples and mouth. The DON stated R5's petechiae was possibly related to the harness strap around R5's neck and asphyxiation. The DON stated the facility investigated R5's room accident/incident and determined the cause was due to human error. The DON stated the staff failed to ensure R5's seat belt was strapped/closed to ensure R5 could not slip out of the wheelchair. The DON stated the facility did not identify R5's physician's orders, care plan or TAR did not include care or safety for the use of the wheelchair including the seat belt, chest harness or footrest and should have. The DON stated the facility's omission of the resident's physician's orders for safety of wheelchairs did not occur to the leadership while investigating R5's incident accident.
During an interview on [DATE] at 1:30 PM, RN1 stated she was providing care for R5 on [DATE] and was taking lunch break at the time of the incident. RN1 stated she transferred R5 from the bed to the wheelchair prior to the lunch break and had secured and buckled R5's chest harness, lap belt and had placed R5's feet on R5's footrest and buckled. RN1 stated R5's physician's orders, TAR, or care plan did not include wheelchair safety or information about seat belt, footrest, or chest harness. RN1 stated she was informed of what and how to strap R5 into the wheelchair via another staff member. RN1 stated she was a new employee at the facility and gained employment in [DATE].
During an interview on [DATE] at 4:53 PM, Registered Nurse Charge (RNC)3 stated she went to R5's room because she heard CNA1 yelling and, on the way, she heard the code bell alarming. RNC3 stated when she entered R5's room she found R5's lap belt was not secured around R5's waist, and the chest harness was around R5's neck. RNC3 stated R5 was dangling from the wheelchair. RNC3 stated R5 was breathless, face was blue, and mouth was open. RNC3 stated she unclasped R5's chest harness and scooped R5's body from the wheelchair, transferred R5 to the bed and began providing artificial respirations. RNC3 stated she noted R5 developed petechiae on the temporal area and head. RNC3 stated R5 was required to have the wheelchair lap belt secured but did not and she was unsure why. RNC3 stated the staff just know the residents should be secured while in their wheelchair. RNC3 stated all the resident's wheelchairs were different. RNC3 stated the facility's residents with wheelchairs did not have interventions on their care plans to secure them on their wheelchairs with their safety straps which increased their risk for accidents. RNC3 stated the facility provided some wheelchair training upon hire, but it was not resident individualized care.
During a brief interview on [DATE] at 6:40 PM, the QSC reported 101 resided at the facility utilizing wheelchairs with safety harness/straps.
During an interview on [DATE] at 2:22 PM, Nurse Practitioner (NP) 1 stated she went to R5's room on [DATE] because the code bell was alarming, and the staff were providing manual respiratory resuscitation to R5. NP1 stated R5 developed petechiae around both temples and mouth. The NP stated R5's petechiae was possibly related to the harness strap around R5's neck and caused asphyxiation. NP1 stated the residents' care plan interventions guided all the facility's staff directives for providing care for the residents and should contain interventions for wheelchair safety and harness. The NP1 stated she discussed R5's incident/accident with the facility's Medical Director but did not discuss care plan interventions or physician orders for wheelchair safety for the residents. The NP1 stated she was unsure why she did not think about all the rest of the children utilizing wheelchair safety and entering orders for the other resident, but she should have. The NP1 stated the facility did not provide her with wheelchair safety education at the start of her employment in [DATE]. The NP1 stated R5's incident was a preventable accident, and the facility should have ensured the nursing staff were competent to secure the child in the wheelchairs. The NP1 stated the residents' wheelchair safety belts and harness were a safety hazard.
During an interview on [DATE], the Medical Director stated she was one of the first staff in R5's room on [DATE] because R5's code bell was alarming. The Medical Director stated R5 began breathing independently and had a pulse but became paler and developed petechiae on the face. The Medical Director stated petechiae was not something related to seizure activity but developed from obstruction of the upper airway. The Medical Director stated petechiae was something seen during an autopsy of a decreased body due to strangulation. The Medical Director stated she examined R5 and talked to the staff. The Medical Director stated R5 was not on the wheelchair properly and caused R5's airway obstruction. The Medical Director stated she absolutely thought the incident could have been prevented. The Medical Director stated she thought R5's accident was a result of a human error by the nurse that put R5 in the wheelchair. The Medical Director stated they looked at R5's wheelchair and determined the wheelchair was adequate and decided the incident was caused because the lap belt was not clasped correctly. The Medical Director stated she expected the residents' care plans to include wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated she expected the resident's physician's orders to have wheelchair safety interventions, chest straps, neck braces, tray, leg straps, and waist belt and she was unsure why it was not included. The Medical Director stated it was her responsibility to ensure the residents' care and orders were correct. The Medical Director stated she had been at the facility for years, and it had never been on their radar to include resident's physician's orders for wheelchair safety and different devices like chest straps and such even though the staff utilized the resident's TAR to provide care. The Medical Director stated, the only explanation that we had was the lap belt was not secured properly or not secured at all and we put [R5] in the annex to have closer supervision but did not put any interventions or plans in place for R5 or the other 100 residents with safety straps/harness on their wheelchairs.
2. Review of R23's undated EMR admission RECORD revealed R23 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegic cerebral palsy, constipation unspecified and ulcerative colitis.
Review of R23's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score was not completed and R23 was assessed by staff to be severely impaired cognitively and used a wheelchair for mobility.
Review of R23's Physician's Orders, from [DATE] through [DATE] under the EMR Orders tab, lacked orders for Remicade medication.
Review of R23's MAR and TAR, from [DATE] through [DATE] under EMR Orders tab, lacked orders for Remicade.
Review of R23's Care Plan under the EMR Care Plan tab revealed .colitis. normal bowel movements . Remicade as ordered. date initiated [DATE] and did not indicate the frequency.
Review of R23's History & Physical under the EMR MISC tab revealed:
a. [DATE] Chief Complaint: bloody diarrhea for 4 weeks . bloody diarrhea likely UC [ulcerative colitis] flare (likely due to delays of the last two infliximab infusions and set off by the recent C diff [Clostridioides difficile, bacteria that causes diarrhea] infection) .C diff. Screen negative today . PLAN start steroids . by Physician.
b. [DATE] Patient with improving diarrhea and resolution of bloody BM [bowel movements]. Symptoms improving on steroids . Likely has UC flare triggered by her recent C Diff infection . by Medical Doctor Gastrointestinal.
c. [DATE] .Hospitalist Daily Progress Note . Patient presented with bloody diarrhea likely due to ulcerative colitis flare due to delays of the last two infliximab infusion and complicated by recent C diff infection. by the Hospitalist.
During an interview on [DATE] at 12:07 PM, the Nurse Manager (NM, a Registered Nurse) stated R23 had a diagnosis of colitis and was treated with Remicade infusions. The NM stated he was unsure of R23's schedule for receiving infusions. The NM verified R23 did not have orders for Remicade on the EMR. The NM verified R23's care plan intervention did not have Remicade schedule and should. The NM stated R23's Remicade dose was administered late but he was unsure of the exact date or why it occurred other than a nurse did not order the supplies.
During an interview on [DATE] at 3:03 PM, NP1 stated R23 had a diagnosis of colitis and required Infliximab infusions every six weeks. NP1 verified R23's did not have a physician's order on the EMR for Infliximab infusions and should have. NP1 stated R23 missed doses of Infliximab infusions at the facility and it caused R23 to flare up with ulcerative colitis and R23 was sent to the hospital by the facility.
During an interview on [DATE] at 6:37 PM, the Medical Director stated she expected residents to have physician's orders for their Remicade medication infusions along with the frequency of administration. The Medical Director stated it was a terrible thing that R23's Remicade administration late and R23 suffered the consequences. The Medical Director stated R23 was provided with boluses of fluids for dehydration. The Medical Director stated R23 was sent to the hospital emergency room for treatment and evaluation.
3. Review of R18's undated EMR admission RECORD revealed R18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegia cerebral palsy, and ileostomy.
Review of R18's quarterly MDS with an ARD of [DATE] and located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) was not completed at R18 was assessed by staff as severely impaired cognitively.
Review of R18's Physician's Orders, dated [DATE] and located in EMR Orders tab included:
a. follow up . on [DATE] . Crohn's Disease . dated [DATE].
b. There was no order for Remicade.
Review of R18's MAR and TAR, dated [DATE] and located under the EMR Orders tab did not include orders for Remicade.
Review of R18's Care Plan under the EMR Care Plan tab .Cronh's [sic] disease. initiated [DATE] revised on [DATE] and did not have an intervention for Remicade medication administration.
During an interview on [DATE] at 3:03 PM, NP1 stated R18 had a diagnosis of Chron's disease and required Remicade infusions every four weeks. NP1 confirmed R18 did not have a physician's order on the EMR for Remicade. NP1 stated R18's physician's order on R18's EMR should include the Remicade intravenous administration. NP1 verified R18's care plan did not have interventions for Remicade medication or specify the frequency of his doses or to monitor for side effects and should.
N.J.A.C. : 8:39-27.1 (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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00107644
Based on record review, interviews, and policy review, the facility failed to ensure one resident out of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00107644
Based on record review, interviews, and policy review, the facility failed to ensure one resident out of three residents (Residents (R)23) reviewed for quality of care, with a diagnosis of ulcerative colitis was administered Remicade [(generic name infliximab) infusion therapy used to treat (decreases inflammation) Crohn's disease, ulcerative colitis, and rheumatoid arthritis.]. The facility's deficient practice resulted in R23 suffering inflamed bowels symptoms and admitted to the hospital on [DATE].
Findings include:
Review of the facility's policy titled Physician Services, dated April 2023, revealed . The resident's attending physician has oversight in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultant or treatment when called by the facility, and overseeing a relevant plan of care .
1. Review of R23's undated admission RECORD located on the electronic medical record (EMR) revealed R23 was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnosis to include epileptic syndrome, spastic quadriplegic cerebral palsy, constipation unspecified, and ulcerative colitis (inflammatory bowel disease (IBD) that causes inflammation and ulcers (sores) in the digestive tract.).
Review of R23's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 01/31/23 and located in the EMR under the MDS tab, revealed Brief Interview for Mental Status [BIMS] was not completed and R23 was assessed by staff as severely impaired cognitively.
Review of R23's Physician's Orders, dated November 2022 to April 2023 and located under the EMR Orders tab lacked orders for Remicade medication.
Review of R23's Medication Administration Record [MAR] and Treatment Administration Record [TAR] for November 2022 through April 2023, under the EMR Orders tab, lacked orders for Remicade.
Review of R23's Care Plan under the EMR Care Plan tab revealed .colitis. normal bowel movements . Remicade as ordered. date initiated 03/11/16 and did not indicate the frequency.
Review of R23's progress notes in the EMR Progress Notes tab revealed:
a. 01/27/23 . supervisor spoke with . PA [physician assistant] GI [gastrointestinal] . lab values are showing that a flare up may be occurring . requested if symptoms get worse to call right away .
b. 02/01/23 . having loose BM's [bowel movements] . total of 3 looseBM's [sic] this shift .
c. 02/01/23 . supervisor spoke with DR [doctor] . regarding resident loose stools x 3 today . stools were reported to be large and loose, stringy, brown with mucus and with a foul odor .
d. 02/02/23 Stool C.diff [Clostridioides difficile, bacteria that causes diarrhea and inflammation of the colon] POSTIVE .
Review of R23's History & Physical under the MISC tab located on the EMR revealed:
a. 02/17/23 Complaint: bloody diarrhea for 4 weeks . bloody diarrhea likely UC [ulcerative colitis] flare (likely due to delays of the last two infliximab infusions and set off by the recent C diff infection) . C diff. Screen negative today . PLAN start steroids . by the Medical Doctor.
b. 02/20/23 Patient with improving diarrhea and resolution of bloody BM [bowel movements]. Symptoms improving on steroids . Likely has UC flare triggered by her recent C Diff infection . by Medical Doctor Gastrointestinal.
c. 02/21/23 .Hospitalist Daily Progress Note . Patient presented with bloody diarrhea likely due to ulcerative colitis flare due to delays of the last two infliximab infusion and complicated by recent C diff infection. by the Hospitalist.
During an interview on 04/06/23 at 12:07 PM, the Nurse Manager (NM, a Registered Nurse) stated R23 had a diagnosis of colitis and was treated with Remicade infusions. The NM stated he was unsure of R23's schedule for receiving infusions. The NM verified R23 did not have orders for Remicade on the EMR. The NM verified R23's care plan interventions did not have Remicade schedule and should. The NM stated R23's Remicade dose was administered late but he was unsure of the exact date or why it occurred other than a nurse did not order the supplies.
During an interview on 04/06/23 at 3:03 PM, Nurse Practitioner (NP) 1 stated R23 had a diagnosis of colitis and required Infliximab infusions every six weeks. The NP verified R23's did not have a physician's order in the EMR for Infliximab infusions and should have. The NP1 stated R23 missed doses of Infliximab infusions at the facility, and it caused her to flare up with her ulcerative colitis and R23 was sent to the hospital by the facility.
During an interview on 04/06/23 at 6:37 PM, the Medical Director stated she expected residents to have physician's orders for their Remicade medication infusions along with the frequency of administration. The Medical Director stated it was a terrible thing that R23 Remicade administration late and R23 suffered the consequences. The Medical Director stated R23 was provided with boluses of fluids for dehydration by the facility. The Medical Director stated R23 was sent to the hospital emergency room for treatment and evaluation.
N.J.A.C. : 8:39-27.1 (a)
Sept 2021
4 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
2. On 09/22/21 at 11:03 AM, the surveyor observed Resident #84 lying in bed. The resident did not respond to the surveyor's greeting.
According to the admission Record, Resident #84 was over three yea...
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2. On 09/22/21 at 11:03 AM, the surveyor observed Resident #84 lying in bed. The resident did not respond to the surveyor's greeting.
According to the admission Record, Resident #84 was over three years of age and was admitted with diagnoses which included, but were not limited to, unspecified intellectual disabilities and dysphagia.
Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/30/20, included the resident had severely impaired cognition. Further review of the MDS included that the resident received 51% or more of total calories through tube feedings.
Review of the Weights and Vitals Summary, dated 01/01/2020 - 12/31/2020, included that the resident weighed 35.2 kg on 06/07/2020 and then 29.4 kg on 07/05/2020, a 5.8 kg (16.5%) weight loss in one month. There were no re-weights recorded for the month of July 2020.
Review of the Nutrition/Dietary Note, dated 05/07/20, included that the resident's usual body weight was 33-34 kg.
Review of the Nutrition/Dietary Note, dated 08/06/20, included that the resident was, demonstrating weight loss of -5.5 kg x 3 months (15%) and, [Resident] may benefit from 10-15% increase in [kilocalorie] content of feedings to prevent further weight loss and promote age appropriate weight gain and growth.
Review of all Progress Notes for Resident #84 dated between 07/05/20 and 08/06/20 revealed no other documentation that identified and addressed the resident's significant weight loss.
Review of the Order Report Recap, dated 07/01/20 - 08/31/20, included a tube feeding order that was discontinued on 08/06/20 with a reason of unplanned weight loss and a new order for an increased tube feeding, with a start date of 08/06/20.
During an interview with the surveyor on 09/20/21 at 9:30 AM, the RN Supervisor of B-Wing Unit stated the primary nurse is responsible for obtaining the resident's weight and recording it in the electronic medical record. If the weight recorded in the electronic medical record is a significant change, it will appear in red and the nurse will re-weigh the resident. The RN Supervisor further stated that if there was a significant weight change, the nurse would notify the charge nurse, supervisor, dietician, and physician. The RN Supervisor defined a significant weight change as five pounds in either direction, depending on the size of the child.
During an interview with the survey team on 09/29/21 at 10:43 AM, the RD stated that the nursing staff was responsible for obtaining the residents' weights, and the RD was responsible for tracking the weights. The RD further stated that a 10% difference in weight from the resident's usual body weight would require a re-weight and follow up by the RD. The RD then confirmed that Resident #84 had a significant weight loss in July 2020, but that she was not notified by the nursing staff and that she did not identify the significant weight loss until August 2020, during the resident's quarterly assessment. The RD further stated that the weight loss should have been addressed immediately upon obtaining the July 2020 weight.
During a telephone interview with the survey team on 09/29/21 at 12:11 PM, the MDS Nurse stated the weights section of the electronic medical record would alert if the current weight recorded is a significant weight change of 5% or 10% from the previous weight.
During an interview with the survey team on 09/29/21 at 2:24 PM, the DON stated that the nursing staff obtains the residents' weights and compares the current weight to the previous weight to determine if there is a significant weight change of 5%. The DON further stated that if a significant weight change was identified, the nursing staff should notify the RD and physician. The DON then confirmed that Resident #84 had a significant weight loss in July 2020 and stated that the weight loss should have been addressed at the time in July 2020.
A review of the facility's policy, Voorhees Pediatric Facility Nursing Manual, effective 11/99 and revised 09/20, included it is necessary to re-weigh a resident if there is a 5% discrepancy from the previous weight.
The surveyor also obtained a reviewed the facility's policy, Voorhees Pediatric Facility Nursing Manual which referenced Effective Date: Reviewed 3/11. According to the policy, there are criteria which require a need for comprehensive reassessment, including an unplanned weight loss of 5-10% within one month, in children over 3 years of age.
NJAC 8:39 - 27.2 (a)
Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to identify and address significant weight changes.
This deficient practice was identified for 2 of 2 residents reviewed for nutrition (Residents #25 and #84) and was evidenced by the following:
1. On 09/24/21 at 1:09 PM, the surveyor observed Resident #25 lying in bed with his/her eyes closed. He/she was receiving Pediasure Peptide (a nutritional feeding formula) 1.0 at a rate of 95 milliliters (ml) per hour.
According to the admission Record, Resident #25 was over three years of age and was admitted with diagnoses which included, but were not limited to, unspecified dysphagia (a difficulty or discomfort in swallowing), unspecified lack of expected normal physiological development in childhood, and failure to thrive.
Review of the Order Recap Report, dated 08/01/21 - 09/30/21, for Resident #25 revealed an order to administer 290 ml of Pediasure Peptide 1.0 four times per day at a rate of 95 ml/hour via G-tube (gastrostomy tube, a surgically placed device that allows direct access to the stomach for the purposes of supplemental feeding) for nutrition, with a date of 09/16/21, and a specific order to check the resident's weight once, on 09/14/21.
Review of the Order Summary Report, for Active Orders As of 09/29/21, revealed an order for weekly weights on night shift every Sunday, dated 07/05/21.
A review of the resident's 09/21 Medication Administration Record (MAR) included weights and dates as follows:
18.4 kilograms (kg) on 09/14/21
16.3 kg on 09/19/21
16.3 kg on 09/26/21
The weights obtained on 09/14/21, 09/19/21 and 09/26/21 were also recorded on the Weights and Vitals Summary for Resident #25 on 09/14/21, 09/20/21, and 09/27/21 respectively. The Weights and Vitals Summary further reflected explicit alerts referencing weight decreases of 10% on 09/14/21, 09/20/21, and 09/27/21.
Review of the progress notes from 07/01/21 to 09/29/21 included that the resident was last evaluated by the Registered Dietitian (RD) for nutritional status on 07/06/21. An Orders - Administration Note, dated 09/14/21, revealed a one-time only order to weigh the resident, and reflected that the resident's cast was removed, and that resident was wearing a pair of pants and a sweatshirt, during the weighing process.
During an interview with the surveyor on 09/29/21 at 9:12 AM, the Licensed Practical Nurse (LPN) stated that weights for individual residents (children) are taken with the scale zeroed, whereby the scale is calibrated to account for any extra clothing, covering, or other items, so that an accurate weight can be recorded. The LPN stated that she thinks the primary nurse is responsible for tracking weights. In addition, she stated that the computer program will alert significant weight changes with a red asterisk. She further stated that if a significant weight change occurs, it is reported, according to a chain of command, and referenced nurses, nursing supervisors, the dietician, and physicians. According to the LPN, it is a group effort, so that everyone involved in a child's care will be aware of changes and developments in status. Finally, the LPN confirmed that a child should be weighed again if there is a significant change in weight, that she thinks a change of five or more pounds would be considered a significant change, and the re-weight, due to a significant change, should likely be taken the next day.
During an interview with the surveyor on 09/29/21 at 9:24 AM, the Registered Nurse (RN) confirmed that she was the Nursing Manager for the A-Wing Unit. The RN stated that the physician's order determines the frequency of weight monitoring, the weights are recorded into the medical record, and the scale is calibrated to zero, to account for the presence of a diaper or other clothing worn by the child. These steps described are taken to obtain an accurate weight. The RN further stated the dietician and medical team monitor weights, and that nurses understand the need to report discrepancies in weights of children, so that weights can be repeated the next day if necessary, due to possible discrepancies. According to the RN, this process is important, because it will allow the dietician and medical team to evaluate the need for necessary adjustments and determine whether changes in weight occurred due to dietary or medical issues. The RN stated that a weight change of 5% would be considered a significant change and a repeated follow-up weight would ordinarily be obtained the next day.
During an interview with the surveyor, the Registered Dietician - Certified Specialist in Pediatrics (RD) stated that nurses oversee the weighing process, and the RD is primarily responsible for tracking weights. The RD would implement necessary changes in frequency of monitoring weights, if deemed appropriate, and based on developments or changes that occur. The RD further stated that a significant change in weight may or may not warrant the need to take an additional weight. The RD stated that a decrease in weight of 10% or more would be considered a significant change. In addition, a thorough assessment is done on a quarterly basis (every 3 months), if the RD is not otherwise informed of significant weight changes, and a weight loss of 10% during this period would be significant. A weight loss of 10% or more within a week or less, would be considered very serious. The RD also acknowledged that not being informed of a decrease in weight, in a timely manner, could be a problem, because a significant weight change for which she is informed, would prompt her to reevaluate the resident sooner than the subsequent quarter.
The RD confirmed specific details about Resident #25. She stated that the resident's weight on 09/14/21 was 18.4 kg and that his/her weights were 16.3 kg on 09/20/21 and 09/27/21, using a mechanical-lift scale, bath scale, and then a mechanical-lift scale, respectively. The RD confirmed that the weight loss was greater than 10%, the loss was a significant one, and that she should have been notified of the significant change, either by nursing staff or directly by the individual who obtained the weights. The RD further stated that it was both important and necessary for her to be advised of the weight decrease, so that further evaluations and possible interventions could have been implemented sooner. She confirmed that there was no evaluation of Resident #25's nutritional status since 07/06/21, due to her lack of awareness of the referenced weight changes. Finally, the RD stated that she did not receive any alert of the weight loss through the computer system, further conveying that the computer program (electronic medical record) was designed for monitoring adults, rather than pediatric (child) groups. The RD stated that she had previously made a request for such an alerting system to be implemented, to no avail.
During an interview with the surveyor on 09/29/21 at 2:20 PM, the Director of Nursing (DON) stated that nurses take weights in accordance with physician's orders, there is accounting for clothes, and the scales are calibrated to ensure accurate weights are obtained. The DON further stated that a weight change of 5% or greater would be significant, it would be her expectation that a significant weight change would be addressed at the next available morning meeting, and that such meetings occur on every weekday. The DON acknowledged the weight decrease, identified by the surveyor, was a significant change, because it was greater than 10%. The DON also clarified that the computer system (electronic medical record) did consist of a functioning alert system for weights but was uncertain as to which facility staff had access to this feature.
During a follow up interview with the surveyor on 09/30/21 at 9:10 AM, the DON acknowledged there was no evaluation or documentation regarding Resident #25's weight change and that there should have been follow-up activity and documentation, due to the significant decrease in weight. The DON further stated that the resident's nutrition (feeding) order was current and remained unchanged, since October 2020. She also clarified that facility staff does receive alerts from the electronic medical record related to significant weight changes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and review of facility documentation, it was determined that the facility failed to: a.) ensure food was stored in a manner to minimize the potential for cross contami...
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Based on observation, interview, and review of facility documentation, it was determined that the facility failed to: a.) ensure food was stored in a manner to minimize the potential for cross contamination, b.) discard potentially hazardous foods past their date of expiration, c.) maintain kitchen equipment in a clean and sanitary manner to prevent microbial growth, and d.) ensure staff consistently covered hair to minimize the potential for contamination. This deficient practice was identified in the main kitchen and on one of two resident units (A-Wing Unit) and was evidenced by the following:
On 09/22/21 at 10:33 AM, the surveyor, in the presence of the Dining Service Director (DSD), observed the following during the kitchen tour:
1. The surveyor observed the DSD with a hat on his head and hair exposed out of the back of his hat. When interviewed, the DSD stated it was alright because he had a hat on. The DSD failed to address the hair exposed out of the back of his hat.
2. In the reach-in freezer, the surveyor observed a container labeled pureed bisculli dated 07/19/21 with a use by date of 08/19/21. The surveyor further observed the container's label date had been altered to reflect 08/19/21 with a use by date of 09/19/21.
3. In the reach-in freezer, the surveyor observed a container of pureed cinnamon roll dated 07/22/21 with a use by date of 08/22/21. The surveyor further observed the container's label had been altered to reflect the date of 08/22/21 with a use by date of 09/22/21. When interviewed, the DSD stated the container labeled pureed bisculli and the pureed cinnamon roll should not have been in the reach-in freezer. The DSD was unable to provide a response to the handwritten date changes noted on the labels.
4. In the reach-in freezer, the surveyor observed a container of pureed cinnamon roll dated 08/27/21 with a use by date of 09/01/21. The label further indicated a shelf life of five days. When interviewed, the DSD stated the container of pureed cinnamon roll should not have been in the reach-in freezer and confirmed that the pureed cinnamon roll had a shelf life of five days.
5. A stack of clear plastic containers was stored on a multi-tiered cart. The surveyor observed a dead bug inside one of the plastic containers. When interviewed, the DSD stated that he was not aware of any bug issues and that he would inform the plant manager of the surveyor's findings.
On 09/29/21 at 12:58 PM, the surveyor observed the following in the A-Wing Unit nourishment room:
6. The surveyor observed an ice scooper holder mounted on the wall next to the ice machine. The surveyor observed that the bottom of the ice scooper holder had build-up and was covered with a black unknown substance.
On 09/29/21 at 1:32 PM, the surveyor, in the presence of the DSD, observed the following in the kitchen:
7. The surveyor observed the DSD with a hat on his head and hair exposed out of the back of his hat.
8. The surveyor observed an ice scooper holder mounted on the side of the ice machine. The surveyor observed that the ice scooper holder was bottomless and that the tip of the ice scooper came in contact with the rim of the ice machine. Upon further inspection, the surveyor noted that the rim of the ice machine was covered with white and black unknown substances. When interviewed, the DSD stated the tip of the ice scooper should not touch the rim of the ice machine and that he would inform maintenance.
9. In the walk-in refrigerator, the surveyor observed a pan of raw chicken wrapped in plastic stored directly on top of a pan of raw turkey breast wrapped in plastic. When interviewed, the DSD stated the raw chicken breast should not have been stored directly on top of the pan of raw turkey breast.
A review of the facility's Food Storage: Cold Foods policy, with revision date of 04/2018, revealed that all foods would be arranged in a manner to prevent cross contamination.
A review of the facility's Staff Attire policy, with revision date of 09/2017, revealed that all staff members would have their hair confined in a hair net or cap.
A review of the facility's Environment policy, with the revision date of 09/2017, revealed that the DSD would ensure that the kitchen was maintained in a clean and sanitary manner. The policy further revealed that the DSD would ensure that routine cleaning was in place for all cooking equipment, food storage areas, and surfaces.
NJAC 8:39-17.2(g)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that staff w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure that staff were tested for Coronavirus Disease 2019 (COVID-19) at a frequency per facility policy. This deficient practice was identified for 7 of 11 staff members reviewed for testing and was evidenced by the following:
On 09/22/21 at 8:30 AM, the surveyor met with the Director of Nursing (DON), who stated that the facility was currently in an active COVID-19 outbreak (outbreak) and that there were two staff members that tested positive on 09/09/21 and 09/10/21. The DON stated that staff were being tested weekly and that she based the frequency of the testing on the COVID-19 Activity Level Index ([NAME]) Weekly Report (a report that provides data on COVID-19 transmission risk by regions). The DON further stated that no residents had tested positive for COVID-19 during the current outbreak. The surveyor requested the facility's testing plan, line listing and the two most recent COVID-19 test results for staff.
During an interview with the surveyor on 09/23/21 at 12:15 PM, the Infection Preventionist (IP) stated that all staff, vaccinated and unvaccinated, were tested weekly for COVID-19 and that the test results were tracked using testing logs located in the testing area. The IP stated that during an outbreak, testing could be done by contact tracing or facility-wide testing and confirmed the facility was conducting facility-wide testing.
During a telephone interview with the surveyor, in the presence of the DON and IP, on 09/23/21 at 1:45 PM, the Local Health Department representative stated the facility should be testing all residents and staff every three to seven days per the facility's outbreak testing policy.
A review of the facility staff 's most recent two COVID-19 test results and work schedule for the seven staff reviewed included the following:
1. A Registered Nurse (RN) tested negative for COVID-19 on 09/07/21 and 09/17/21 (10 days apart). The RN worked on 09/16/21 without being tested.
2. A Registered Nurse Supervisor (RNS) tested negative for COVID-19 on 09/8/21 and 09/19/21 (11 days apart). The RNS worked on 09/16/21 without being tested.
3. A Licensed Practical Nurse (LPN) tested negative for COVID-19 on 09/07/21 and 09/17/21 (10 days apart). The LPN worked on 9/16/21 without being tested.
4. A Respiratory Therapist (RT #1) tested negative for COVID-19 on 09/7/21 and 09/15/21 (8 days apart). RT #1 worked on 09/14/21 without being tested.
5. A Medical Director (MD) tested negative for COVID-19 on 09/07/21 and 09/17/21 (10 days apart). The MD worked on 09/14/21 without being tested.
6. RT #2 tested negative for COVID-19 on 09/07/21 and 09/17/21 (10 days apart). RT #2 worked on 09/15/21 and 09/16/21 without being tested.
7. A Therapeutic Recreation (TR) staff member tested negative for COVID-19 on 09/07/21 and 09/17/21 (10 days apart). The TR worked on 09/14/21 and 09/16/21 without being tested.
A review of the facility's Voorhees Pediatrics Facility Infection Control Manual: Subject: Covid-19 Testing, revised 09/2021, included that testing of residents and staff would be based on current guidance from the Centers for Medicare & Medicaid Services (CMS), the New Jersey Department of Health (NJDOH), the Occupational Safety and Health Administration (OSHA), and the Centers for Disease Control and Prevention (CDC). The manual also included that all staff and residents that test negative would be retested every three to seven days until no new cases of COVID-19 infections for a period of at least 14 days since the most recent positive result.
A review of the NJDOH guidance titled, Testing in Response to a Newly Identified COVID-19 Case in Long-term Care Facilities (LTCF), dated 05/17/2021, included to continue to perform outbreak testing of all residents and healthcare professionals every three to seven days regardless of vaccination status until 14 days have elapsed since the most recent positive.
A review of the CDC guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 (COVID-19) Spread in Nursing Homes, dated 09/10/21, included that if additional cases were identified, testing should continue facility-wide every three to seven days until there are no new cases identified for 14 days.
NJAC 8:39-5.1(a); 19.1(a)
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MD...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) assessments for 1 of 2 residents (Resident #84) reviewed for nutrition.
This deficient practice was evidenced by:
According to the admission Record, Resident #84 was admitted with diagnoses, that included but were not limited to, unspecified intellectual disabilities and dysphagia (difficulty swallowing).
Review of the Quarterly MDS, dated [DATE], included coding that the resident did not have a significant weight loss of 5% or more in the last month or 10% or more in the last six months.
Review of the Weights and Vitals Summary, dated 01/01/2020 - 12/31/2020, included the following weights:
On 01/13/2020, the resident weighed 33.5 kg (kilograms)
On 06/07/2020, the resident weighed 35.2 kg
On 07/05/2020, the resident weighed 29.4 kg (a 12.2% weight loss in six months, and a 16.5% weight loss in one month)
Review of the Nutrition/Dietary Note, dated 08/06/20, included, [Resident #84] demonstrating weight loss of -5.5 kg x 3 months (15%).
Review of the Quarterly MDS, dated [DATE], included coding that the resident did not have a significant weight loss of 5% or more in the last month or 10% or more in the last six months.
Further review of the Weights and Vitals Summary, dated 01/01/2020 - 12/31/2020, included the following weights:
On 04/12/2020, the resident weighed 34.1 kg
On 10/04/2020, the resident weighed 30.4 kg (a 10.9% weight loss in six months)
Review of the Nutrition/Dietary Note, dated 10/15/20, included, [kilocalorie] content of [enteral nutrition] regimen increased today in response to unplanned weight loss [approximately] 2-3 months ago and failure to regain weight in interim.
During an interview with the survey team on 09/29/21 at 10:43 AM, the Registered Dietician stated that Resident #84 had a significant weight loss in July 2020, but that the MDS Nurse was responsible for completing Section K, Swallowing/Nutrition Status, a portion of the MDS.
During a telephone interview with the survey team on 09/29/21 at 12:11 PM, the MDS Nurse stated she is responsible for completing Section K of the MDS. She further stated that she reviews the residents' weights in the electronic medical record to determine if there was a significant weight change.
During an interview with the survey team on 09/29/21 at 2:24 PM, the Director of Nursing (DON) stated that she would expect the MDS Nurse to accurately complete Section K of the MDS.
During a follow-up interview with the survey team on 09/30/21 at 9:43 AM, the DON acknowledged that Section K of the quarterly MDS assessments dated 07/30/20 and 10/29/20 were coded incorrectly.
Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, included instructions for Section K: Swallowing/Nutrition Status. According to the manual, staff are to compare the resident's weight in the current observation period to his or her weight in the observation period 30 and 180 days ago, and if the current weight is less than the weight in the observation period 30 and/or 180 days ago, calculate the percentage of weight loss. The manual further includes that staff are to code weight loss as yes, not on physician-prescribed weight loss regimen if the resident experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight was not planned and prescribed by a physician.
NJAC 8:39-11.1
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
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 30% annual turnover. Excellent stability, 18 points below New Jersey's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s), 1 harm violation(s), $285,780 in fines. Review inspection reports carefully.
- • 30 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $285,780 in fines. Extremely high, among the most fined facilities in New Jersey. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Voorhees Pediatric Facility's CMS Rating?
CMS assigns Voorhees Pediatric Facility an overall rating of 2 out of 5 stars, which is considered below average nationally. Within New Jersey, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Voorhees Pediatric Facility Staffed?
CMS rates Voorhees Pediatric Facility's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 30%, compared to the New Jersey average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Voorhees Pediatric Facility?
State health inspectors documented 30 deficiencies at Voorhees Pediatric Facility during 2021 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 25 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Voorhees Pediatric Facility?
Voorhees Pediatric Facility 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 MILLENNIUM HEALTH SYSTEMS, a chain that manages multiple nursing homes. With 122 certified beds and approximately 108 residents (about 89% occupancy), it is a mid-sized facility located in VOORHEES, New Jersey.
How Does Voorhees Pediatric Facility Compare to Other New Jersey Nursing Homes?
Compared to the 100 nursing homes in New Jersey, Voorhees Pediatric Facility's overall rating (2 stars) is below the state average of 3.2, staff turnover (30%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Voorhees Pediatric Facility?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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 facility's Immediate Jeopardy citations.
Is Voorhees Pediatric Facility Safe?
Based on CMS inspection data, Voorhees Pediatric Facility has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New Jersey. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Voorhees Pediatric Facility Stick Around?
Staff at Voorhees Pediatric Facility tend to stick around. With a turnover rate of 30%, the facility is 16 percentage points below the New Jersey average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was Voorhees Pediatric Facility Ever Fined?
Voorhees Pediatric Facility has been fined $285,780 across 1 penalty action. This is 8.0x the New Jersey average of $35,937. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Voorhees Pediatric Facility on Any Federal Watch List?
Voorhees Pediatric Facility 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.