STRATFORD MANOR REHABILITATION AND CARE CENTER
For profit - Limited Liability company
131 Beds
MB HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
53/100
#228 of 344 in NJ
Photo by Stratford Manor Rehabilitation & Care Center
Photo by Stratford Manor Rehabilitation & Care Center
Photo by Stratford Manor Rehabilitation & Care Center
1 / 5 photos
Last Inspection: April 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Stratford Manor Rehabilitation and Care Center has a Trust Grade of C, indicating that it is average and falls in the middle of the pack for nursing homes. It ranks #228 out of 344 facilities in New Jersey, placing it in the bottom half, and #21 out of 32 in Essex County, meaning only a handful of local options are better. The facility is currently worsening, with reported issues increasing from 5 in 2022 to 12 in 2024. Staffing is a strength, with a rating of 4 out of 5 stars and a turnover rate of 24%, significantly lower than the state average, suggesting that staff are experienced and familiar with residents. While there have been no fines, which is a positive aspect, there are concerning incidents, such as failures in medication management for residents with seizure disorders and unsanitary conditions in the kitchen that could lead to foodborne illnesses. Overall, families should weigh the facility's strengths in staffing against its recent decline in quality and specific health care management issues.
- Trust Score
- C
- In New Jersey
- #228/344
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 24% annual turnover. Excellent stability, 24 points below New Jersey's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New Jersey facilities.
- Skilled Nurses ○ Average
- Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for New Jersey. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
53/100
Bottom 34%
Review needed
5 → 12 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2022: 5 issues
2024: 12 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (24%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (24%)
24 points below New Jersey average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
3-Star Overall Rating
Near New Jersey average (3.3)
Meets federal standards, typical of most facilities
Chain: MB HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 21 deficiencies on record
1 life-threatening
Apr 2024
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call light was readily accessible. The deficient practice was identified for 1 r...
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Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call light was readily accessible. The deficient practice was identified for 1 resident (Resident #5) of 24 reviewed for the reasonable accommodations of needs/preferences as evidenced by the following.
On 4/15/24 at 10:35 AM and 4/16/24 at 9:10 AM, the surveyor observed the resident in bed awake, able to answer the surveyor's inquiry. The surveyor asked the resident if she could reach her call light cord. The resident tried to reach for it three times and said they still could not get it. The call light cord was under the resident's right chest on both days.
A review of the medical record revealed the following information.
The admission record documented that Resident #5 was admitted to the facility with diagnoses that included but were not limited to cerebrovascular (conditions that affect the blood flow in the brain) disease and left-side hemiparesis (weakness or paralysis on one side of the body). The recent Quarterly Minimum Data Set, an assessment tool dated 3/12/24, reflected that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognition.
On 4/16/24 at 9:10 AM, the surveyor called the Registered Nurse (RN) to check the resident's call light cord. The RN stated that it should be on top of the blanket so she could reach for it; the nurse repositioned the call bell.
On 4/17/24 at 1:45 PM, the surveyor team discussed the inaccessibility of the call light cord for Resident #5 with the Administrator and the Director of Nursing (DON).
On 4/18/24 at 9:40 AM, the DON provided a policy titled Call Bell Audit. However, it was noted that the policy does not specifically address the call light cord being within the resident's reach.
NJAC 8:39-27.1(a); 4.1
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the managem...
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Based on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 4 of 24 residents (Resident #2, 5, 35, and #225).
This deficient practice was evidenced by the following:
1. Resident #2 was observed to have a Quarterly MDS (QMDS) with an Assessment Reference Date (ARD) on 1/15/24, which was due to be transmitted to CMS no later than 1/29/24. However, the QMDS was not submitted to CMS until 2/9/24.
2. Resident #5 was observed to have a QMDS with an ARD on 12/12/23, which was due to be transmitted to CMS no later than 12/26/23. However, the QMDS was not submitted to CMS until 1/10/24.
3. Resident #35 was observed to have an Entry MDS (EMDS) with an ARD on 10/2/23. The EMDS was due to be transmitted to CMS no later than 10/16/23. However, the EMDS was not submitted to CMS until 10/17/23.
4. Resident #225 was observed to have an Annual MDS (AMDS) with an ARD on 9/22/22, which was due to be transmitted to CMS no later than 10/6/22. However, the AMDS was not submitted to CMS until 10/20/22.
A review of discharged Return Not Anticipated (DRNA), with an ARD on 10/10/22, was due to be transmitted to CMS by 10/24/22. The DRNA was not submitted to CMS until 11/7/22.
A review of the undated Final Validation Report for Residents #2, 5, 35, and 225 by the MDS Coordinator/Registered Nurse (MDSC/RN) revealed that The submission date is more than 14 days after Z0500B on this new assessment.
On 4/18/24 at 12:59 PM, the surveyor interviewed the MDSC/RN, who stated that she started working in February 2023 and added that she is not responsible for all those MDS submitted late. The only thing that she is responsible for is Res. #5. She is aware that the submissions were all late. The MDSC/RN stated that she follows the RAI manual.
On 4/18/24 at 1:39 PM, the survey team met with the Licensed Nursing Home Administrator and Director of Nursing. The surveyor notified the facility management of the above findings and concerns.
NJAC 8:39 - 11.1
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan to meet the resident's medical needs. This deficient...
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Based on interview and record review, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan to meet the resident's medical needs. This deficient practice was observed for 2 of 24 residents reviewed, Residents #13 and #25 as evidenced by the following:
1. The surveyor reviewed Resident #13's electronic medical records (EMR). Resident #13 was admitted to the facility with diagnoses which included Myocardial Infarction (heart attack).
A review of the Physician's Orders (PO) for Resident #13 revealed that the resident had an order for Eliquis 5 mg 1 tablet by mouth twice daily for blood clot prevention. The surveyor reviewed the resident's current care plans. There was no care plan developed regarding the resident's PO for the anticoagulant medication.
On 4/22/24 at 11:44 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to the resident. The LPN stated that a care plan for the anticoagulant medication should have been created
2. On 04/18/24 at 12:00 PM, the surveyor observed Resident #25 in bed. The resident stated that he/she took medications early in the morning and thought they were for his/her anemia, stomach and bones.
The surveyor reviewed the medical record for Resident #25.
A review of the quarterly Minimum Data Sheet (MDS) (an assessment tool used to facilitate the management of care) dated 3/7/24, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident had an intact cognition. In addition, the section for active diagnoses included age-related osteoporosis without current pathological fracture.
A review of the resident's Order Summary Report reflected a physician's order dated 4/24/23 for Alendronate Sodium (Fosamax) oral tablet 70 milligrams (MG), Give one tablet by mouth one time a day every Monday for osteoporosis. Give with water 30 minutes before first food/drink/med, avoid lying down x (for) 30 minutes.
A review of the resident's current Interdisciplinary Plan of Care (IDCP) had not included a plan of care that had been initiated for osteoporosis.
On 4/23/24 at 9:19 AM, the survey team met with the Director of Nursing (DON) who stated that the Unit Managers were responsible for creating and updating the resident's care plans. In addition, the DON stated that she also was responsible for inputting resident care plans. The DON acknowledged that Resident #25 was actively being treated for osteoporosis and should have had a care plan completed.
A review of the facility policy for Care Plans Comprehensive with a revised date of 6/2023 provided by the DON reflected that An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.
In addition, the facility policy reflected that The comprehensive care plan is based on a thorough assessment that includes not limited to the MDS. Each resident's comprehensive care plan is designed to: i. incorporate identified problem areas; . The policy also reflected that Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. And that The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: .iv. at least quarterly.
NJAC 8:39-11.2(e)(1)(2)(f)(h)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standard...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice by not following physician orders for 2 of the 24 residents reviewed (Residents #5 and #35). The deficient practice was evidenced by the following:
1. On 4/15/24 at 10:35 AM and 4/16/24 at 9:10 AM, the surveyor observed the resident in bed, awake, and able to respond to the surveyor's questions. The resident was not wearing a left-hand elbow resting splint on both days.
A review of electronic medical record revealed the following information.
The admission Record (AR or face sheet, an admission summary) documented that Resident #5 was admitted to the facility with diagnoses that included but were not limited to cerebrovascular (conditions that affect the blood flow in the brain) disease and left-side hemiparesis (weakness or paralysis on one side of the body). The recent Quarterly Minimum Data Set (QMDS), an assessment tool dated 3/12/24, reflected that Resident #5 had a Brief Interview for Metal Status (BIMS) score of 10 out of 15, indicating moderate cognition impairment.
A review of the resident's Order Summary Report (OSR) reflected a Physician's Order (PO) dated 3/13/24 for left hand elbow resting splint and on 4/1/22 for Don left hand and left elbow splints after AM care, doff before PM care.
A review of the April 2024 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) under Unscheduled 'Other' Orders revealed that the above-corresponding PO for left hand and left elbow resting splints were not specified in either the eMAR or eTAR.
On 04/17/24 at 12:11 PM, the surveyor interviewed the Certified Nurse Assistant (CNA#1), who had worked in the facility for 25 years, and stated that she was assigned to Resident #5. CNA#1 opened the resident's drawer; the surveyor observed the splints inside. CNA#1 said the residents should wear the splints aftercare in the morning.
On 04/17/24 at 12:17 PM, the surveyor interviewed the Licensed Practical Nurse (LPN#1), who had worked in the facility for 20 years. The LPN#1 said the physical therapist should put the elbow and hand splint on the resident.
On 04/17/24 at 12:20 PM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) and stated that the CNA should put the splint on the resident's after providing care. The LPN stated the nurse should sign in the eTAR after checking that the resident was wearing the splints. The LPN/UM added that the order for the elbow and hand splints was not in the eTAR and there was no specific order for how long they should be placed.
On 04/17/24 at 12:30 PM, the surveyor interviewed the Rehab Director (RD) who stated that Resident #5 is in the therapy program and needs the elbow and hand splints. The rehab will order the splints, and then they train nurses, including the aide, on how to apply it to the resident. They screen quarterly and revise. Resident #5 was revised on March 18, 2024. The next review is scheduled in May 2024. She added that Nursing is responsible for applying the splint.
On 4/17/24 at 1:25 PM, the surveyor team discussed the above findings and concerns with LNHA and DON.
2. On 4/15/24 at 10:00 AM, the surveyor observed Resident #35 lying in bed awake, watching television, alert and oriented, able to answer the surveyor's inquiry. Resident #35 stated that they have been in the facility for over five years. The resident stated they do not wear anything on their feet while in bed.
A review of electronic medical record revealed the following information.
The AR documented that Resident #35 was admitted to the facility with diagnoses that included but were not limited to primary osteoarthritis (conditions that affect the tissues in the joint) and cellulitis (skin infection) of the left toe. The recent QMDS, dated [DATE], reflected that Resident #35 had a BIMS score of 14 out of 15, indicating intact cognition.
A review of the resident's OSR reflected a PO dated 3/13/24 for bunny booties while in bed and a PO dated 10/2/23 for heel pads to both heels while in bed every shift for protection.
Further review of the April 2024 OSR shows no PO for surgical shoes.
A review of the April 2024 eMAR and eTAR under Unscheduled 'Other' Orders revealed that the above-corresponding PO for bunny booties and heel pads was not specified in either the eMAR or eTAR.
On 4/22/24 at 11:40 AM, the surveyor observed the resident out of bed in a wheelchair. The resident stated that they wore surgical shoes on both feet when attending therapy.
On 4/22/24 at 11:47 AM, CNA#2 was observed caring for the resident. She stated that she did not see any booties or heel pads in the resident's room.
On 4/22/24 at 12:07 PM, the surveyor interviewed LPN #1 who stated that she was unaware that the resident had bunny booties or heel pads while in bed. LPN #1 stated that when the resident was attending therapy they wore surgical shoes.
On 4/22/24 at 12:10 PM, the LPN/UM stated that bunny booties and heel pads are ordered in bed and should be taken off during care. The surveyor asked if surgical shoes were ordered and the nurse manager said there was no order.
On 4/22/24 at 12:17 PM, the surveyor interviewed the RD, who stated that the she didn't order bunny booties and added that the resident wore surgical shoes for protection when out of bed.
On 4/22/24 at 12:20 PM, the Registered Nurse (RN) was observed entering the resident's room with green bunny booties wrapped in plastic. The surveyor asked the RN where the booties came from. The RN stated that they came from the laundry.
On 4/22/24 at 1:05 PM, the surveyor team met with the Administrator and Director of Nursing (DON). The DON stated that she thought it was understood that if the resident has a full bath while in bed, the heel booties should be removed during care and a skin check for for skin integrity should be performed. She added that bunny booties and heel pads shouldn't have been ordered simultaneously.
A review of the facility policy titled Specialty Devices stated under Policy: It is the policy and procedures of this facility that residents who require preventative measures and positioning devices (i.e., foam finger spreader, etc.) will be provided with these devices in order to prevent contractures or problems associated with contractures. These measures or devices will be provided in accordance with an order from a physician, nursing, occupational therapy, and/or physical therapy.
NJAC 8:39 27.2(m)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
REPEAT DEFICIENCY
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to ...
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REPEAT DEFICIENCY
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to the physician's order, b.) ensure that all nurses signed the electronic Medication Administration Record (eMAR) when oxygen was administered, and c.) ensure respiratory tubing and cannula was stored properly. This deficient practice was identified for one (1) of one (1) resident (Resident #425) reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure.
This deficient practice was evidenced by the following:
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
On 4/17/24 at 10:23 AM, the surveyor observed the Rehab Aide (RA) propell Resident #425's wheelchair into the resident's room. Inside the resident's room, the oxygen (O2) concentrator (which can be used as an alternative to compressed gas cylinders) was on at 3 LPM (liters per minute), and the nasal cannula (n/c, a device that delivers extra O2 through a tube and into the nose) was wrapped around the half side rail of the bed. The half-side rail of the bed had a pool noodle (an extra layer of padding on a metal frame) on which the n/c was wrapped around. The n/c was not being used at that time and was not properly stored.
At that same time, the surveyor interviewed the resident after the RA left the room. The resident informed the surveyor that he/she was a subacute resident at the facility and came from the hospital due to a breathing problem. Resident #425 stated that O2 use was something new to the resident and was being used in the facility as needed (PRN). During an interview, the resident stated that he/she did not need the O2 at that time. The resident appeared to be in no distress.
On 4/18/24 at 10:07 AM, the surveyor asked the assigned Licensed Practical Nurse #1 (LPN#1) to go with the surveyor inside the resident's room. In the room, both the surveyor and the LPN observed Resident #425 seated in a regular chair, the O2 was ongoing with the n/c attached to the O2 concentrator while the other end of the n/c was wrapped around the padded half-side rail of the bed directly touching the pool noodle padding. The resident appeared to be in no distress.
On that same date and time, the surveyor asked LPN#1 to check the O2 flow rate at which the concentrator was running. The LPN checked the concentrator and informed the surveyor that the resident order for O2 was at 2 LPM. The LPN confirmed that the concentrator was at 2 liters (L). The LPN stated that the n/c should have been placed inside a plastic bag when not in use for infection control. She further stated that she would remove the n/c and change it with a new one. The surveyor observed that LPN detached the n/c and turned off the O2 concentrator.
At that same time, the LPN assessed the resident and the resident was stable.
The surveyor reviewed the medical record for Resident #425.
The admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included acute on chronic diastolic (congestive) heart failure, other seizures, essential hypertension (abnormal blood pressure), presence of prosthetic heart valve (an artificial heart valve is a one-way valve implanted into a person's heart to replace a heart valve that is not functioning properly), and unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow).
A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, showed the admission MDS was in progress (not completed) for an ARD (assessment reference date) of 4/15/24.
A review of the individualized person-centered Care Plan (CP) initiated on 4/09/24 for a focus on shortness of breath (SOB) related to decreased energy and fatigue, decreased lung expansion, acute hypoxic respiratory failure, and CHF (congestive heart failure) had an intervention that included but was not limited to patient is on O2 at 1 L PRN.
Further review of the CP did not include respiratory care on how to store the O2 cannula and supplies when not in use.
The Social Service Admission/readmission Evaluation with an effective date of 4/09/24 revealed that the resident's Brief Interview for Mental Status (BIMS) score was 8 which indicated that the resident's cognitive status was moderately impaired.
A review of the Order Summary Report included a physician's order (PO) dated 4/09/24 for O2 at 1 LPM via n/c for SOB PRN.
The above order for PRN O2 was transcribed into the eMAR for April 2024. Upon review of the April 2024 eMAR showed that there was no documentation that the nurses signed that the PRN O2 as administered.
A review of the Weights & Vitals in the electronic medical record (eMR) revealed the following dates that the resident had O2 via n/c with O2 saturation (Sats):
O2 Sats (noninvasive method of measuring the saturation of O2 in a person's blood) Summary:
Date Time Sats Nurse
4/16/2024 00:03
95.0% Oxygen via Nasal Cannula LPN#2
4/13/2024 23:25
95.0% Oxygen via Nasal Cannula LPN#2
4/12/2024 14:38
97.0% Oxygen via Nasal Cannula LPN#3
4/11/2024 23:10
95.0% Oxygen via Nasal Cannula LPN#2
4/10/2024 22:36
95.0% Oxygen via Nasal Cannula LPN#2
4/10/2024 11:38
95.0% Oxygen via Nasal Cannula LPN#3
4/09/2024 22:42
94.0% Oxygen via Nasal Cannula LPN#2
Further review of the eMR revealed that on dates 4/09/24, 4/10/24 (twice), 4/11/24, 4/12/24, 4/13/24, and 4/16/24 the eMAR should have been signed by nurses indicated the PRN O2 was administered.
On 4/18/24 at 10:17 AM, LPN#1 informed the surveyor that the order for O2 was 1 LPM and not 2 LPM. The LPN asked the surveyor to go again with LPN#1 to the resident's room and check that it was on 1 LPM now.
In the resident's room both the surveyor and the LPN observed that the O2 was below 1 LPM and there was a yellow light on. LPN#1 stated that she had to replace the O2 concentrator because the yellow light meant that there was a problem with the concentrator. LPN#1 acknowledged that it was probably broken.
At this time, the surveyor notified LPN#1 of the surveyor's observation on 4/17/24 that it was at 3 L and wrapped around the half-side rail.
On 4/18/24 at 01:39 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The surveyor notified the facility management of the above findings and concerns regarding O2 observations, orders not followed, and nurses not signing the eMAR when O2 was administered as evident in the O2 Sats records in the Weights & Vitals (7 x the resident was on O2).
On 4/19/24 at 10:10 AM, the surveyor interviewed the Registered Nurse (RN) who worked on 4/17/24 at the 7 AM to 3 PM shift. The RN informed the surveyor that Resident #425 was cognitively intact with some forgetfulness and was on 1 LPM O2 PRN. The RN stated that if the nurse administered the PRN O2, the nurse should document and sign the eMAR.
At that same time, the surveyor notified the RN of the above findings and concerns. The surveyor asked the RN why the resident's O2 on 4/17/24 during the observation was at 3 L wrapped around the half-side rail, not properly stored when not in use, and the eMAR was not signed. The RN had no response.
On 4/19/24 at 10:19 AM, the surveyor called and left a message to LPN#2.
On 4/19/24 at 12:01 PM, the surveyor interviewed the Infection Preventionist Nurse/RN (IPN/RN). The IPN/RN informed the surveyor that she was responsible for in-service/education regarding infection control including respiratory care and use of O2 and nebulizer (neb) supplies on how to properly store when not in use. The IPN/RN stated that it was an expectation that the nursing staff store O2 and neb supplies like tubing and masks inside a plastic bag when not in use and change it once a week for infection control because bacteria can accumulate in the tubing and mask when exposed to resident's environment.
On that same date and time, the surveyor notified the IPN/RN of the above findings and concerns regarding O2 n/c wrapped around the half-side rail on two observations. The IPN/RN stated that it was not appropriate that the O2 n/c was not stored when not in use and that was not the facility's practice.
On 4/19/24 at 12:11 PM, the surveyor interviewed LPN#3 via phone conference. LPN#3 informed the surveyor that she remembered Resident #425 with an O2 and the LPN thought the order for O2 was continuous. The LPN stated that if the order was PRN for O2, then the PRN O2 should have been signed. The LPN further stated that she was unable to remember why the PRN O2 in the April 2024 eMAR was not signed but it should have been signed.
A review of the facility's Respiratory Tubing Storage Policy with an updated date of 9/2023 that was provided by the IPN/RN included that it was the policy and procedure of the facility to ensure the sanitation of all O2 accessories for residents' care. The procedure included but was not limited to when the mask or n/c is not in use, it will be stored in the bag.
A review of the facility's Oxygen Administration Policy with an updated date of 12/2023 that was provided by the RN Supervisor included that it was the policy and procedure of the facility to provide O2 to residents in compliance with their physician order.
On 4/19/24 at 12:25 PM, the surveyor met with the LNHA and DON. The LNHA stated that the facility management acknowledged the concerns and that the facility would continue to monitor the O2.
NJAC 8:39-11.2(b); 19.4(a); 27.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and relevant document review, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was ...
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Based on observation, interview, and relevant document review, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in one (1) of three (3) medication carts and one (1) one of two (2) medication storage rooms inspected on two (2) of two (2) units. This deficient practice was evidenced by the following:
On 4/16/24 at 10:56 AM the surveyor in the presence of another surveyor and the Licensed Practical Nurse (LPN#1) assigned to the medication cart inspected the medication cart identified as the northwest cart.
The surveyor observed one (1) brown package containing one (1) vial of latanoprost eye drops (a medication used to treat glaucoma). The brown packaging was labeled with a dispensing pharmacy label which reflected a dispensing date of 3/29/24. There was no date when the vial was opened observed on the packaging or on the vial.
The surveyor observed one (1) package containing Fluticasone/salmeterol discus 500/50 (a medication used to treat asthma and chronic obstructive pulmonary disease). The packaging was labeled with a dispensing pharmacy label which reflected a dispensing date of 4/11/24. The medication device which is used to administer the medication was observed to have an automatic dosage counter that reflects the number of doses used/remaining. The counter reflected fifty-five (55) out of sixty (60) uses. There was no date when the medication was opened observed on the packaging or on the medication device.
The surveyor observed one (1) package containing Fluticasone/salmeterol discus 250/50 that reflected a date when opened of 2/23/24.
The surveyor observed that the medication cart contained a separate lockable box that contained controlled substances. The surveyor observed that the box was not locked by lifting the lid without the use of a key. The surveyor observed on closing the lid that it was blocked from fully closing by excess medication packages outside the box.
The surveyor discussed the above areas of concern with LPN#1. LPN #1 agreed that the latanoprost and fluticasone/salmeterol should have a date when opened, the fluticasone/salmeterol dated 2/23/24 was opened more than 30 days, and that the lock box containing controlled substances should always be locked when not in use.
The surveyor in the presence of another surveyor entered the northwest medication room with assistance from a nurse. The surveyor observed a locked refrigerator with a temperature log on the door that reflected documentation of refrigerator temperatures twice a day. The surveyor observed that the temperature log had blank spaces for the dates of 4/12/24 AM, 4/12/24 PM and 4/13/24 AM.
The surveyor reviewed the manufacturer package insert for latanoprost. The section labeled storage reflects: Once a bottle is opened for use, it may be stored at room temperature up to 25°C (77°F) for 6 weeks.
The surveyor reviewed the manufacturer package insert for fluticasone/salmeterol. The section labeled 16 How Supplied/Storage reflects: The device should be discarded 1 month after removal from the moisture-protective foil overwrap pouch or after all blisters have been used (when the dose indicator reads 0), whichever comes first.
On 4/16/24 at 1:33 PM, the surveyor in the presence of the survey team discussed the concerns with the Administrator and Director of Nursing (DON). The DON stated that she had removed the medications of concern the previous day and educated the staff.
On 4/17/24 at 1:15 PM the DON provided to the surveyor a policy for medication storage. The policy reflects on line nine (9) All controlled drugs are stored under double-lock and key.
NJAC 8:39-29.4(g)(h), 8:39-29.7(c)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that the facility failed to establish appropriate infection control practices for environmental cleaning for 1 of 24 residents (Re...
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Based on observation, interview, and record review, it was determined that the facility failed to establish appropriate infection control practices for environmental cleaning for 1 of 24 residents (Resident #5). This deficient practice was evidenced by the following:
On 04/15/24 at 10:40 AM, the first day during rounds in Resident #5 room, the surveyor noticed a splash of a creamy substance on the right-side wall near the metal pole, extending from the resident's bedside table to the electrical outlet. The Registered Nurse (RN) stated that it looked like a tube feeding milk on that wall and added that she would ask housekeeping to clean it.
On 4/17/24 at 1:25 PM, the surveyor team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) about the concern regarding the splash of creamy milk-like substance on the wall. The LNHA stated it was already clean and did not provide further information.
NJAC 8:39-19.1(a)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected multiple residents
Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents'...
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Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders to ensure that the residents' current medical regimen was appropriate. This deficient practice was observed for 6 of 24 residents (Resident #12, #16, #22, #111, #13, and #62) reviewed and occurred over several months.
This deficient practice was evidenced by the following:
1. A review of the hybrid medical record for Resident #12 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January 2024, February 2024, and March 2024. The monthly physician's orders were not in the chart and there was no electronic signature.
2. A review of the hybrid medical record for Resident #16 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for January 2024, February 2024, and March 2024. The monthly physician's orders were not in the chart and there was no electronic signature.
3. A review of the hybrid medical record for Resident #22 revealed the resident's physician had not hand signed or electronically signed the monthly physician's orders for February 2024 and March 2024. The monthly physician's orders were not in the chart and there was no electronic signature.
5. A review of the hybrid medical record for Resident # 13 revealed there were no monthly orders signed by the Physician for the months of January 2024, February 2024 and March 2024.
6. A review of the hybrid medical record for Resident # 62 revealed there were no monthly orders signed by the Physician for the months of January 2024 and February 2024.
On 4/22/24 at 11:25 AM, the surveyor interviewed License Practical Nurse (LPN) #1, who was also the Unit Manager (UM) for North and [NAME] Wing Units and has been working in the facility for two years. The UM stated, The primary physicians come in every 1-2 weeks or monthly. The Director of Nursing (DON), who was also present stated, The doctors have started signing orders in the Electronic Health Records (EHR) since last year, they used to come in and sign on paper but now they come in to sign orders in EHR.
On 4/22/24 at 11:44 AM , the surveyor interviewed LPN # 2, who stated that the Physicians should be signing the residents' orders monthly in the electronic health record.
On 4/22/24 at 1:05 PM, the survey team met with the Administration: License Nursing Home Administrator (LNHA) and the DON, regarding missing physician monthly orders review and signature from January 2024 through March 2024. The administration acknowledged that the physicians should be coming in monthly to sign orders.
On 4/23/24 at 9:00 AM, the DON provided the facility policy and procedure for Physician Orders dated 12/23. The Physician Orders policy reflected, All verbal or written orders must be signed by the prescriber monthly.
NJAC 8:39-23.2(b)
4. A review of the hybrid medical record for Resident #111 revealed there were no monthly orders signed by the Physician for the months of January 2024, February 2024 and March 2024.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
REPEAT DEFICIENCY
Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensu...
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REPEAT DEFICIENCY
Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring that manufacturer's specifications were followed for the administration time and sequence of a medication Alendronate Sodium (Fosamax)(a medication used to treat and prevent osteoporosis/low bone mass) from October 2023 until surveyor inquiry. This occurred for one (1) of 11 residents, (Resident #25), reviewed for medication management.
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
The deficient practice was evidenced by the following:
On 4/18/24 at 12:00 PM, the surveyor observed Resident #25 in bed. The resident stated that he/she took medications early in the morning and thought they were for his/her anemia, stomach and bones. The resident added that she received his/her early morning medications all together.
The surveyor reviewed the medical record for Resident #25.
A review of the quarterly Minimum Data Sheet (MDS) (an assessment tool used to facilitate the management of care) dated 3/7/24, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident had an intact cognition. In addition, the section for active diagnoses included age-related osteoporosis without current pathological fracture.
A review of the resident's Order Summary Report reflected a physician's order (PO) dated 4/24/23 for Alendronate Sodium (Fosamax) (a medication to oral tablet 70 milligrams (MG), Give one tablet by mouth one time a day every Monday for osteoporosis. Give with water 30 minutes before first food/drink/med, avoid lying down x [for] 30 minutes.
A review of the April electronic medication administration record (EMAR) revealed the above PO for Fosamax had a time of administration every Monday at 6:30 AM.
Further review of the EMAR revealed that there was a PO dated 3/6/24 for Pantoprazole (Protonix) (a medication used to reduce acid in the stomach) that had a time of administration of 6:30 AM and was administered every day at that time. In addition, there was a PO dated 10/12/2023 for Ferrous Sulfate (Iron) (a medication used to increase red blood cells) that had a time of administration of 6:00 AM.
On 4/18/24 at 1:30 PM, the surveyor interviewed the CP via the telephone. The CP acknowledged that Fosamax had specific instructions for administration and should be administered as the first medication in the morning with no other medications for at least 30 minutes and that a recommendation should be made regarding these instructions. The CP acknowledged that the Fosamax instructions for administration were not being followed because the iron supplement had a time of administration of 6 AM.
On 4/18/24 at 1:38 PM, the surveyor team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON acknowledged that Fosamax had specific administration instructions that it was the first medication to be administered in the morning with no other medications. The DON also stated that she thought there would have been a recommendation from the CP and then the nurses would have to change the medication times. The DON acknowledged that the nurses were to follow cautionary warnings. The DON added that she would have to check.
On 4/22/24 at 7:18 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) via telephone. The LPN stated that she had worked the 7 PM to 7 AM shift and was responsible for administering the early morning medications to Resident #25. The LPN was unsure which medications she had administered and had to check the EMAR. The LPN then stated that she had checked the EMAR and had administered all three of the resident's medications at the same time that morning because they were timed together. The LPN could not speak to the cautionary warning.
On 4/22/24 at 11:50 AM, the surveyor interviewed the owner of the CP company (OCP) who acknowledged the Fosamax manufacturer's administration instructions. The OCP also stated that the cautionary warning was on the Fosamax package. The OCP added that the iron supplement time of 6 AM would have to be changed and that the Protonix could be administered without regard to meals so the 6:30 AM time should also be changed.
A review of the Fosamax packaging labeled for Resident #25 that was in the medication cart reflected a cautionary warning on a red colored sticker Take 8 ounces of water at least 30 minutes before first food/beverage/drug of the day.
On 4/22/24 at 1:02 PM, the survey team met with the LNHA and DON. The DON acknowledged that the nurses should have been aware of the instructions for Fosamax as per the PO. The DON also acknowledged the administration times on the EMAR for the resident's early morning medications had administration times that were not able to follow the specific instructions for Fosamax administration and should have been changed.
A review of the facility policy for Medication Administration revised 10/2023 provided by the DON reflected for accuracy Right Drug-Compare the pharmacy label/package to the EMAR . and Right Time-Medications are scheduled to avoid drug/food interactions and per manufacturer recommendations. In addition, for medication administration general instructions included Cautionary warnings followed.
A review of the manufacturer's specifications reflected Take Fosamax first thing in the morning, at least 30 minutes before you eat or drink anything or take any other medicine. The specifications also reflected, Take with a full glass (6 to 8 ounces) of plain water. Do not use coffee, tea, soda, juice or mineral water. Do not eat or drink anything other than plain water. In addition, For at least 30 minutes after taking Fosamax: Do not lie down or recline. Do not take any other medicine including vitamins, calcium or antacids.
NJAC 8:39-11.2(b), 29.2 (a)(d), 29.4(b)(3)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
2. On 4/15/24 at 10:40 AM the surveyor attempted to interview Resident #103. The resident was in a wheelchair watching television. The resident was not able to answer basic questions posed by the surv...
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2. On 4/15/24 at 10:40 AM the surveyor attempted to interview Resident #103. The resident was in a wheelchair watching television. The resident was not able to answer basic questions posed by the surveyor. The surveyor was unable to conduct an interview due to the resident's cognitive status.
The surveyor reviewed the electronic medical record (EMR) for Resident #103. A review of the 4/10/24 quarterly Minimum Data Sheet (MDS) ,an assessment tool used to facilitate the management of care, reflected the resident was unable to complete a brief interview for mental status (BIMS) due to cognitive impairment. The MDS section H also reflected use of an indwelling urinary catheter and was not on any toileting or weaning program. A review of the resident's active diagnoses included, Alzheimer's disease, retention of urine and infection and inflammation reaction due to indwelling urethral catheter.
The surveyor reviewed the resident's medications in the EMR. The EMR reflected an order for tamsulosin, also known as Flomax, (a medication used to treat urinary retention, usually in males) with an initial date of 1/2/2024 that coincides with a readmission from the hospital.
On 4/17/24 at11:09 AM the surveyor interviewed the RN who was assigned to the resident. The RN stated that the resident is scheduled to be discharged home soon and will have the catheter removed.
The surveyor reviewed the manufacturer package insert for tamsulosin. The section labeled Indications and Usage did not indications for off-label use.
A further review of the EMR, including the physician's progress notes, had not revealed any documentation of urinary retention or the use of tamsulosin with or without a urinary catheter.
On 4/17/24 at 12:15 PM, the surveyor reviewed the CP reports from 10/23/23 to present for Resident #103. Review of the CP notes had not revealed any recommendation directed to the facility or physician requesting clarification or additional documentation regarding the rationale for use of tamsulosin with or without a catheter or in an approved indication for use or off-label use.
On 4/18/24 at 9:09 AM, the surveyor interviewed CP#2 by telephone in the presence of the survey team. The CP #2 stated she comes to the facility once a month and was doing the medication reviews until January 2024. CP#1 now did the reviews. However, she could speak to the facility issues. The CP#2 stated she reviewed records for appropriate diagnosis and indications and was familiar with the medication tamsulosin. The CP#2 stated she would not necessarily comment on off label or unapproved use depending on what the physician was using it for. The CP#2 stated that there are studies where tamsulosin is used in an unapproved manor effectively. She also stated other studies reviewed use of the medication when weaning off a catheter to facilitate urine flow. She stated this was a common use.
The CP#2 provided no further information regarding irregularities for use of tamsulosin for an off-label use with or without a catheter.
On 4/18/24 at 11:06 AM, the surveyor interviewed the DON. The DON stated she had a discussion with the CP#2 and thought there were studies for an off-label indication. The DON stated that the medication was started at the hospital. The DON agreed that a continued off-label use of a medication without supportive documentation from the physician would be considered an irregularity.
REPEAT DEFICIENCY
Based on observation, interviews, record review and a review of pertinent facility documents, it was determined that the facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities to the physician and the facility regarding a.) a rationale for the length of therapy for a medication (Enoxaparin)(a medication used to reduce the risk of blood clots) from August 2023 until surveyor inquiry, b.) the appropriate documentation of vital sign parameters for a medication (Metoprolol)(a medication used to treat high blood pressure) as ordered by the physician according to standards of clinical practice and facility practice, c.) a rationale for the continued off-label use of a medication (Flomax) (a medication used to treat urinary retention usually in males) from January 2024 until surveyor inquiry and d.) following a cautionary warning for a medication (Alendronate)(Fosamax)(a medication used to treat and prevent osteoporosis/low bone mass) from October 2023 until surveyor inquiry. The deficient practices were identified for three (3) of 11 residents, (Resident #72, #103 and #25 ) reviewed for medication management.
The deficient practice was evidenced by the following:
1. On 4/17/24 at 10:20 AM, the surveyor observed Resident #72 laying on the bed with eyes closed and there was one Certified Nursing Aide (CNA) inside the room.
The surveyor reviewed the medical record of Resident #72.
Resident #72's admission Record (AR; or face sheet, an admission summary) reflected that the resident had diagnoses that included but were not limited to unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (dementia is a term used to describe a group of symptoms affecting memory, thinking and social abilities), anemia (refers to low levels of healthy red blood cells), and essential hypertension (high blood pressure that doesn't have a known cause).
The quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an ARD (assessment reference date) of 01/04/24, included in Section C Cognitive Patterns a BIMS (brief interview for mental status) score of 4 which indicated that the resident's cognitive status was severely impaired. The qMDS showed that the resident was on an anticoagulant.
The April 2024 Order Summary Report (OSR) included a physician's order (PO) with a start date of 4/04/24 for Metoprolol Tartrate tablet (tab) 25 MG (milligrams) to give one tab by mouth two times (2x) a day for HTN (hypertension), hold for SBP (systolic blood pressure) less than 110 and HR (heart rate) less than 60.
A review of the resident's Pharmacy Review 2024 (or MRR) by CP#1, located in a binder which was provided by the Licensed Practical Nurse/Unit Manager (LPN/UM), revealed the last MRR date was on 4/11/24. The 4/11/24 report did not identify the irregularities regarding the absence of documentation of the resident's SBP and HR in the eMAR for April 2024.
Further review of the April 2024 OSR showed that there was PO with a start date of 8/19/23 for Enoxaparin sodium injection solution prefilled syringe 40 MG/0.4 ML (milliliters), inject 0.4 ML subcutaneously one time a day for dvt (deep vein thrombosis, a blood clot in a deep vein, usually in the legs) prophylaxis.
The above order for Enoxaparin was transcribed into the eMAR from August 2023 through April 17, 2024.
A review of the resident's Progress Notes (PN) showed that there was no physician's documentation about indications of continued use of Enoxaparin.
The Consultant Pharmacist's Reports for 2023 and 2024 revealed that the med Enoxaparin was not identified in the MRR for any irregularities.
On 4/17/24 at 10:28 AM, the surveyor interviewed the Registered Nurse (RN) in the nursing station. The RN informed the surveyor that she was the assigned nurse of Resident #72. The RN stated that residents with blood pressure (bp) meds with parameters for SBP and HR should be obtained before administering meds and document the SBP and HR in the eMAR according to the facility's practice. She further stated that the SBP and HR can be seen also in the Weights & Vitals section of the electronic medical record (eMR).
On that same date and time, the surveyor asked the RN if the nurse should follow the PO for Metoprolol for the resident about the SBP and HR and she responded Yes. The surveyor then asked the RN again, why the resident's April 2024 eMAR did not have documentation of the resident's SBP and HR 2x a day for the Metoprolol order. The RN stated she did not know why it was not documented.
Later on, the RN acknowledged there should be documentation of 2x a day SBP and HR in the April 2024 eMAR. The RN stated that she would fix the eMAR in order for nurses to document the required SBP and HR. She indicated that when the order was entered, there was a dropdown that should have been checked to include supplemental documentation of SBP and HR. She further stated that was the reason why the SBP and HR were not documented 2x a day as supposed to be.
On 4/17/24 at 10:39 AM, the surveyor interviewed the LPN/UM. The LPN/UM stated that per facility protocol, SBP, and HR parameters should have been documented in the eMAR. She further stated that the CP comes to the facility once a month to do MRR and it was her responsibility as a UM to act upon the CP's review and recommendations.
On 4/17/24 at 01:36 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The surveyor notified the facility management of the above findings and concerns for Enoxaparin and Metoprolol.
On 4/18/24 at 9:09 AM, the surveyor called CP#2 in the presence of the survey team. CP#2 informed the surveyor that she was the CP that went to the facility monthly until January 2024 and now it was CP#1. CP#2 stated that CP#1 was unavailable and that CP#2 would answer surveyors' inquiries on behalf of CP#1. CP#2 informed the surveyor that it was her responsibility as CP to identify irregularities with meds and notify the physician and the facility, and this included the meds with parameters and justification of continued use of meds.
At that same time, the surveyor notified CP#2 of the above findings and concerns. The surveyor asked CP#2 why the CPs did not identify the irregularities with Enoxaparin without indications for continued use of med from the physician and APN, and the Metoprolol parameters. CP#2 did not respond.
On 4/18/24 at 11:01 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The DON and the LNHA did not provide additional information and responses for the above concerns and findings.
A review of the facility's Medication Administration Policy that was provided by the DON with a reviewed date of 10/2023 included that it is the policy and procedure of the facility to provide the nursing staff with an understanding of proper med administration.
On 4/19/24 at 12:25 PM, the surveyor met with the LNHA and DON. The DON and the LNHA stated that there was no additional information.
3. On 4/18/24 at 12:00 PM, the surveyor observed Resident #25 in bed. The resident stated that he/she took medications early in the morning and thought they were for his/her anemia, stomach and bones. The resident added that she received his/her early morning medications all together.
The surveyor reviewed the medical record for Resident #25.
A review of the quarterly Minimum Data Sheet (MDS) (an assessment tool used to facilitate the management of care) dated 3/7/24, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident had an intact cognition. In addition, the section for active diagnoses included age-related osteoporosis without current pathological fracture.
A review of the resident's Order Summary Report reflected a physician's order (PO) dated 4/24/23 for Alendronate Sodium (Fosamax) oral tablet 70 milligrams, Give one tablet by mouth one time a day every Monday for osteoporosis. Give with water 30 minutes before first food/drink/med, avoid lying down x (for) 30 minutes.
A review of the April electronic medication administration record (EMAR) revealed the above corresponding PO for Fosamax with a time of administration every Monday at 6:30 AM.
Further review of the EMAR revealed that there was a PO dated 3/6/24 for Pantoprazole (Protonix) (a medication used to reduce acid in the stomach) that had a time of administration of 6:30 AM and was administered every day at that time. The same time of administration as Fosamax.
In addition, the EMAR revealed that there was a PO dated 10/12/2023 for Ferrous Sulfate (Iron) (a medication used to increase red blood cells) that had a time of administration of 6:00 AM. The administration time was before the administration of Fosamax.
A review of the Consultant Pharmacist's reports from 10/2023 to 4/2024 revealed that there was no recommendation made regarding Fosamax for Resident #25.
On 4/18/24 at 1:30 PM, the surveyor interviewed the CP#2 via the telephone. The CP#2 acknowledged that Fosamax had specific instructions for administration and should be administered as the first medication in the morning with no other medications for at least 30 minutes and that a recommendation should be made regarding these instructions. The CP#2 stated that she had been the CP who was completing the reports a while ago but recently another CP#1 had been doing the reports so she could not speak for anyone else. CP#2 stated that CP#1 was unavailable for interview.
On 4/18/24 at 1:38 PM, the survey team met with the Licensed Nursing Home Administrator and the Director of Nursing (DON). The DON acknowledged that Fosamax had specific administration instructions that it was the first medication to be administered in the morning with no other medications. The DON also stated that she thought there would have been a recommendation from the CP and then the nurses would have to change the medication times on the EMAR. The DON added that she would have to check.
On 4/22/24 at 11:50 AM, the surveyor interviewed the owner of the CP company (OCP) who stated that there was a recommendation made on 2/13/24 regarding the Fosamax instructions for administration. The OCP provided a copy of the CP's Nursing Summary Report dated 2/13/24. The report had not been initialed by a facility staff member or had a completed date by the facility. The recommendation reflected Fosamax must be given as the first med of the day and given alone. Schedule all other meds at least 30 minutes after the administration of Fosamax (alendronate).
On 4/23/24 at 9:19 AM, the survey team met with the DON who stated that the OCP had shown her the CP report with the Fosamax recommendation dated 2/13/24 but that according to her portal the facility had not received that recommendation.
On 4/23/24 at 10:06 AM, the surveyor, in the presence of another surveyor, interviewed the DON and OCP. The DON stated that when she received the computerized CP report, she would print it out and give the report to the corresponding Unit Manager (UM). The DON added that the UM would complete the CP report and give back the report initialed and dated. The OCP then explained that she had a new employee who ran the report in February and that the facility had not received the whole report. The OCP also stated that the next month when the CP had reviewed the EMAR and saw that the timing of the Fosamax was not acted upon then the CP should have repeated the comment regarding Fosamax. The OCP acknowledged that there was no other recommendation made by the CP regarding Fosamax for Resident #25.
The surveyor requested a Policy and Procedure for the Consultant Pharmacist reports. There was no policy and procedure provided.
NJAC 8:39-29.3(a)(1)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication b...
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Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication by failing to document on the effectiveness, appropriate indication, or benefit vs risk statement for an unapproved use for one (1) of eleven (11) residents reviewed for medication management (Resident #103).
The deficient practice was evidenced by the following:
On 4/15/24 at 10:40 AM the surveyor attempted to interview Resident #103. The resident was in a wheelchair watching television. The resident was not able to answer basic questions posed by the surveyor. The surveyor was unable to conduct an interview due to the resident's cognitive status.
The surveyor reviewed the electronic medical record (EMR) for Resident #103. A review of the quarterly Minimum Data Sheet (MDS) (an assessment tool used to facilitate the management of care) dated 4/10/24, reflected the resident was unable to complete a brief interview for mental status (BIMS) test due to cognitive impairment. The MDS section H also reflected use of a urethral catheter (a medical device inserted into the urinary tract to allow urine to flow freely) and was not on any toileting or weaning program. A review of the resident's active diagnoses included, Alzheimer's disease, retention of urine and infection and inflammation reaction due to indwelling urethral catheter.
The surveyor reviewed the resident's medications in the EMR. The EMR reflected an order for tamsulosin, also known as Flomax, (a drug used to treat the signs and symptoms of benign prostatic hyperplasia which can include urinary retention, primarily in men) with an initial date of 1/2/2024 that coincides with a readmission from the hospital.
On 4/17/24 at11:09 AM the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to the resident. The LPN stated that the resident is scheduled to be discharged home soon and will have the catheter removed.
The surveyor reviewed the manufacturer package insert for tamsulosin. The section labeled Indications and Usage reflected, Flomax is an alpha1 adrenoceptor antagonist indicated for treatment of the signs and symptoms of benign prostatic hyperplasia.
A review of the EMR, specifically the physician's progress notes for the dates of 1/1/24 through 4/18/24 inclusive, did not reveal any notation of urinary retention, or use of tamsulosin with or without a catheter until 4/18/24 in a discharge note after it was brought to the facility's attention by the surveyor.
A further review of the EMR, specifically the physician's progress notes entered and signed by the Advance Practice Nurse (APN) for the dates of 1/1/24 through 4/18/24 inclusive, did not reflect any use of tamsulosin.
The surveyor reviewed the resident's care plan (a summary of a resident's health conditions, specific care needs and current treatments). The care plan reflected that the resident had urinary retention, an indwelling urethral catheter and impaired cognitive function/dementia.
On 4/18/24 at11:06 AM the surveyor interviewed the Director of Nursing (DON). The DON stated that she was aware of the resident receiving tamsulosin and that the medication was started at the hospital. The DON agreed that the physician should document about continued unapproved use of tamsulosin in the resident's chart and that she had contacted the physician and asked him to provide documentation.
N.J.A.C. 8:39-11.2(b)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.)...
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Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following:
On 4/18/24 at 9:52 AM, in the presence of the Dietary Director (DD), the surveyor observed the following:
1. In the food preparation area, the surveyor observed seven of seven oven knobs and the oven handle soiled with a brown colored substance, which was able to be lifted with the tip of a pen. In the food preparation area, the surveyor also observed 1 of 2 handles of the convection oven soiled with a brown colored substance, which was also able to be lifted with the tip of a pen. The DD stated that these areas should be cleaned.
2. In the dry storage room, the surveyor observed the following cans with dents, which were in rotation for use:
- A number 10 sized can of butterscotch pudding which had a ½ inch dent on the
upper lip of the can,
- A number 10 sized can of tapioca pudding which had a 1 inch dent to the upper
lip of the can,
The DD stated that the cans on this shelf are in rotation for use and that there should not be any dents in them.
On 4/18/24 at 1:50 PM, the surveyor discussed the above concerns with the Administrator and Director of Nursing.
NJAC 8:39-17.2(g)
Mar 2022
5 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0760
(Tag F0760)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and other pertinent facility documentation, it was determined that the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and other pertinent facility documentation, it was determined that the facility failed to ensure: a.) 2 of 3 anti-seizure medications (Vimpat and Keppra) ordered upon discharge from the hospital were appropriately discussed with the Physician for re-order, reconciled, received from the Provider Pharmacy, and administered in accordance with hospital discharge instructions for a resident with recent seizure activity (Resident #163), and b.) an anti-seizure medication (Vimpat) was available and administered as ordered for a second resident with a history of seizure disorders (Resident #27).
This deficient practice was identified for 2 of 3 residents reviewed for anti-seizure medication management (Resident #27 and #163).
Resident #163, who had a severe cognitive impairment, was admitted to the facility on [DATE] with active diagnoses which included traumatic subdural hemorrhage (a bleed in the area between the brain and skull) without loss of consciousness, syncope and collapse, and a seizure as recent as 1/21/22 in the hospital. The resident had a physician's order (PO) for an anti-seizure medication and controlled drug (Vimpat) to be given twice a day since admission. The medication was not administered for ten days from 2/7/21 until 2/17/22 at the 9:00 AM dose.
Further, the hospital discharge instructions indicated to continue on another anti-seizure medication (Keppra) but the resident was never started on the medication at the facility. There was no documented evidence as to why the Keppra was not re-ordered from admission to the facility on 2/7/21 through 3/1/22 when the resident was subsequently re-hospitalized , and there were no labs drawn to determine therapeutic levels. Interviews with the Director of Nursing (DON) who reconciled the resident's admission orders, indicated that she could not speak to why the Keppra was not re-ordered. The resident was not seen by the Attending Physician or a Nurse Practitioner until 2/24/22.
Resident #163 was never monitored for seizure activity while the medications were omitted, an alternate anti-seizure medication or other intervention was never discussed with the Physician or implemented while Vimpat was not available and while Keppra was not being given to prevent rebound seizure activity. A second resident, Resident #27, who had severe cognitive impairment had a physician's order dated 9/21/21 for the anti-seizure medication and controlled drug, Vimpat, twice a day for seizures. The Vimpat was neither available nor administered from 1/31/22 at 9:00 PM until 2/8/22 at 9:00 AM and again from 2/10/22 at 9:00 PM until 2/12/22 at 9:00 AM. There was no documented evidence that the physician was made aware that the medication was unavailable. Interviews and review of records revealed that some nurses were falsely documenting for the administration of the medication when it was not available, never sent from the pharmacy and it was not kept in a back-up supply of medications. There was no documented evidence of seizure monitoring, monitoring of side effects for omitted dosage, or an alternate anti-seizure medication or other intervention discussed with the Physician as a means to prevent rebound seizures.
The facility's failure to ensure all residents who had physician orders for anti-seizure medications were administered the doses as ordered or otherwise received the necessary follow-up and communication with the Physician, and the failure to implement ongoing monitoring for those residents for rebound seizures while therapeutic doses of those medications over periods of time were being omitted, posed a serious and immediate threat for adverse effects, including various seizure types which is likely to result in serious harm, impairment, or even death.
This resulted in an Immediate Jeopardy (IJ) situation that began on 1/31/22. The facility Administration was notified of the IJ on 3/4/22 at 2:44 PM. The facility submitted an acceptable written Removal Plan (RP) on 3/4/22 at 5:25 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 3/7/22.
The non-compliance remained on 3/6/22 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The evidence was as follows:
A review of the Manufacturer specifications for the anti-seizure medication and controlled drug VIMPAT included, Highlights of Prescribing Information: WARNINGS AND PRECAUTIONS . VIMPAT should be gradually withdrawn to minimize the potential of increased seizure frequency. 5.5 Withdrawal of Antiepileptic Drugs (AEDs) As with all AEDs, VIMPAT should be withdrawn gradually (over a minimum of 1 week) to minimize the potential of increased seizure frequency in patients with seizure disorders.
A review of the Manufacturer specifications for the anti-seizure medication, Keppra included, Antiepileptic drugs, including KEPPRA, should be withdrawn gradually to minimize the potential of increased seizure frequency.
1. On 2/23/22 at 10:59 AM, the surveyor observed Resident #163 with his/her eyes closed in bed, appearing to be asleep. The surveyor observed that the bed was positioned low, floor mats were on both sides of the bed, and the resident was wearing a helmet on their head.
The next day on 2/24/22 at 9:56 AM, the surveyor observed the resident with their eyes closed in a bed positioned low with floor mats on either side on the bed. The surveyor observed that the resident was not wearing the helmet but it was placed on a nightstand next to the bed. The surveyor observed that the resident had a bandage applied to the right side of the forehead.
On 2/25/22 at 11:43 AM, the surveyor observed the resident with his/her eyes closed in bed appearing to be asleep. The bed was in the low position with floor mats on either side of the bed. The surveyor observed that the resident was not wearing the helmet and there was still bandage to the right side of the forehead.
The surveyor reviewed the medical record for Resident #163.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility on [DATE] following a hospitalization. Diagnoses included traumatic subdural hemorrhage without loss of consciousness (hematoma), seizures, syncope and collapse, encounter for surgical aftercare following surgery on the nervous system, and a gastrostomy tube (a flexible feeding tube that is surgically placed through the abdominal wall into the stomach used as an alternate oral route).
The surveyor reviewed the hospital records for Resident #163 prior to the resident's admission to the facility which revealed the following:
A review of the Neurosurgery Health and Physical Noted dated 1/17/22 included that the [resident] has a past history of seizures and convulsions with a fall/syncope (temporary loss of consciousness caused by a fall in blood pressure) on 1/14/22 and was sent to the emergency room. The [resident] had a right forehead hematoma (pool of blood outside of blood vessels) from a previous fall and had a computed tomography scan (CT scan; multiple x-rays to create pictures of the head) which revealed an enlargement of the hematoma; the Neurosurgeon was consulted for possible intervention.
A review of a Nursing Note dated 1/17/22 at 5:49 AM, reflected that the [resident] was found sitting on the floor in the room with a big hematoma to the right side of the face and blood on the floor. The [resident] could not recall what happened, and a CT and x-ray were ordered.
A review of a Nursing Note dated 1/17/22 at 1:50 PM, reflected that the [resident] had neurosurgery at the bedside.
A review of a Nursing Note dated 1/21/22 at 8:15 AM reflected that at 6:21 AM, the [resident] started twitching, not responding to verbal commands. Blood sugar was rechecked, and vital signs were taken. At 6:45 AM, laboratory tests were drawn, and the physician ordered Keppra (anti-seizure medication) 2000 milligrams (mg); the first bag was hung [via the intravenous route].
A review of a Nursing Note dated 1/22/22 at 10:00 PM reflected that the resident had electroencephalography (EEG; method to record an electrogram of electrical activity on the scalp) and neurological checks (an assessment of an individual's neurological functions and level of consciousness to determine if a person is functioning correctly and reacting appropriately to tests) every two hours.
A review of a Nursing Note dated 1/25/22 at 8:05 AM, reflected that the resident had video EEG monitoring in progress with no observed seizure activity during the shift.
A review of the hospital discharge medications included the following anti-seizure medications:
1. Lacosamide (Vimpat) 10 milligram/milliliter (mg/mL) solution; give 10 mL (100 mg total) by feeding tube (FT) two times a day. Maximum daily dose 200 mg.
2. Keppra 500 mg tablet; give 2.5 tablets (1,250 mg total) by FT two times a day.
3. Valproate sodium (Depakene) 250 mg/5 mL oral liquid; give 15 mL (750 mg total) by nasogastric route (a tube that delivers food and medicine to the stomach from the nose) two times a day.
The surveyor continued to review the facility's medical record for Resident #163 upon admission to the facility on 2/7/22.
A review of the Progress Notes reflected an admission Progress Note dated 2/7/22 at 7:37 PM, which included that the resident was newly admitted to the facility from the hospital with slurred speech and severe cognitive impairment with an admission diagnosis of right temporal lobe subdural hematoma evacuation and history of seizures. The resident was admitted for sub-acute rehabilitation with sutures to [his/her] right temporal lobe and helmet to be worn out of bed.
A review of the admission Minimum Data Set (MDS), an assessment tool dated 2/14/22, reflected a Brief Interview for Mental Status (BIMS) score could not be determined, so staff conducted a cognitive assessment for the resident which determined that the resident had a short and long-term memory problem with a severely impaired decision-making capacity.
A review of the resident's individualized comprehensive Care Plan reflected a focus area initiated on 2/8/22 that the resident was at the facility for a short term stay with a goal to discharge to the community upon completion of sub-acute rehabilitation. A further review reflected a focus area for seizures initiated on 2/10/22 due to a history of subdural hematoma, which was evacuated status post craniectomy (surgery to remove a portion of the skull). The goal was to remain free of injuries related to seizure activity during the facility stay. Interventions included to give medications as ordered, and monitor/document for effectiveness and side effects; nurse will obtain and monitor laboratory/diagnostic work as ordered; and seizure precautions: do not leave alone during seizure, protect from injury if out of bed help to the floor to prevent injury, remove or loosen tight clothing, don't attempt to restrain during a seizure as this could make the convulsions more severe, protect from onlookers, draw curtain, etc. (etcetera; and the rest).
A review of the current physician Order Summary Report reflected the following physician's order (PO) for anti-seizure medications:
1. A PO dated 2/8/22 for Lacosamide (Vimpat) solution 10 mg/mL; give 10 mL via FT two times a day related to traumatic subdural hemorrhage.
2. A PO dated 2/7/22 for Valproate sodium (Depakene) solution 250 mg/5 mL; give 15 mL via FT two times a day related to traumatic subdural hemorrhage.
The Order Summary Report did not include a PO for the Keppra tablets in accordance with the hospital discharge medication list.
A review of the Medication Administration Record (MAR) for February 2022 reflected the following for order for the Vimpat: A PO dated 2/7/22 and discontinued 2/8/22 at 2:28 PM, for Vimpat 10 mg/mL; give 100 mg via FT two times a day. The nurses signed that the resident allegedly received the Vimpat on 2/7/22 at 9:00 PM and 2/8/22 at 9:00 AM. A review of the corresponding MAR for PO dated 2/8/22 reflected that from 2/8/22 at 9:00 PM through the 2/15/22 at 9:00 PM dose, the nurses signed a code 9, which indicated the medication was not given and other/see Nurse Notes. The same MAR reflected that the resident allegedly received the next doses of Vimpat beginning on 2/16/22 at 9:00 AM.
A review of the corresponding electronic Progress Notes (PN) for the above dates reflected the following Nurse Notes (NN):
For the 2/8/22 at 9:00 PM - NN at 9:07 PM that Pharmacy call, awaiting prescription delivery and Physician #1 made aware.
For the 2/9/22 at 9:00 AM - NN at 3:06 PM that needs a prescription.
For the 2/9/22 at 9:00 PM - NN at 10:29 PM awaiting delivery.
For the 2/10/22 at 9:00 AM - NN at 11:44 AM called Physician #1's office for a prescription.
For the 2/10/22 at 9:00 PM - NN at 10:47 PM with no additional information.
For the 2/11/22 at 9:00 AM - NN at 1:57 PM with no additional information.
For the 2/11/22 at 9:00 PM - NN at 10:56 PM, that medication ordered will administer upon delivery.
For the 2/12/22 at 9:00 AM - NN at 1:49 PM that medication not administered, and Pharmacy called.
For the 2/12/22 at 9:00 PM - NN at 11:05 PM awaiting a prescription.
For the 2/13/22 at 9:00 AM - no NN or additional information.
For the 2/13/22 at 9:00 PM - NN at 9:35 PM awaiting a prescription.
For the 2/14/22 at 9:00 AM - NN at 7:24 PM, no additional information.
For the 2/14/22 at 9:00 PM - NN at 10:13 PM, no additional information
For the 2/15/22 at 9:00 AM - NN at 12:01 PM that Physician #1 needs to send a prescription. An additional NN at 2:50 PM that Physician #1 was called due to needing a prescription and awaiting a callback. The NN further indicated that helmet must be worn at all times.
For the 2/15/22 at 9:00 PM - NN at 10:58 PM for awaiting delivery.
There was no documentation that the resident was being monitored for seizure activity or monitored for side effects of missing dosages of anti-seizure medications or that the Medical Director was notified in an effort to promptly communicate with a physician, when Physician #1 was not available.
A review of the Individual Patient Controlled Substance Administration Record (a declining inventory record used for the accountability of controlled drugs) reflected that 300 mL of Vimpat 10 mg/mL solution was filled on 2/16/22 and received by the facility on 2/17/22. The sheet reflected the first documented dose was on 2/17/22 (not on 2/16/22 at 9 AM as the MAR was allegedly signed). The time was not recorded when the 10 mL was administered on 2/17/22 and there was no balance remaining documented. The declining inventory record revealed there was only one dose removed from inventory on 2/17/22 and not two doses in accordance with the physician's order, but the MAR for February 2022 was signed to reflect the resident received two doses on 2/16/22, one at 9 AM and the second at 9 PM and again on 2/17/22 at 9 AM and 9 PM. The Individual Patient Controlled Substance Administration Record further reflected that the next dose that was signed out was on 2/18/22 for 10 mL. The space to record the time of removal was left blank, and the balance remaining was also left blank. The third time the medication was removed from inventory was 2/19/22 at 9:00 AM for 10 mL for a remaining balance of 270 mL. (This revealed that even when the facility had the medication available for the resident on 2/17/22, the resident only received one dose on 2/18/22, instead of the two doses daily as ordered).
On 3/3/22 at 12:09 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), DON, Assistant Director of Nursing (ADON), and Corporate Nurse and requested for additional information regarding the blanks on the Individual Patient Controlled Substance Administration Record for the Vimpat delivered on 2/17/22.
On 3/4/22 at 10:12 AM, the LNHA stated in the presence of the DON, ADON, Corporate Nurse, and the survey team, that the facility completed an audit upon surveyor inquiry of the Individual Patient Controlled Substance Administration Record for the Vimpat received on 2/17/22, which revealed that the dose signed out on 2/17/22 with no recorded time and the 2/18/22 dose removed with the no recorded time were both signed by the evening nurses who gave the 9:00 PM doses. The LNHA stated that the nurses allegedly administered the 2/17/22 at 9:00 AM and 2/18/22 at 9:00 AM, but they forgot to document it on the Controlled Substance Administration Record. (There was no explanation as to why the remaining balance would indicate 270 mL total on 2/19/22 at 9 AM, which reflected only 30 mL was removed, instead if the resident received those doses then it should have have reflected 50 mL total was removed with a balance of 250 mL remaining as of 2/19/22 at 9 AM).
On 3/4/22 at 11:22 PM, the surveyor reviewed with the LNHA and the DON the Progress Notes written from 2/8/22 through 2/15/22 regarding the Vimpat and the conflicting documentation of waiting for the Pharmacy to deliver the medication and waiting on the prescription. The LNHA responded that he thought poor verbiage by the nurse was waiting for a prescription and not delivery.
At this time, the surveyor reviewed the February 2022 MAR for Vimpat with the LNHA and DON, which reflected that the nurses signed that the resident allegedly received Vimpat on 2/7/22 at 9:00 PM, 2/8/22 at 9:00 AM, 2/16/22 at 9:00 AM and 9:00 PM (which did not correspond with any declining inventory logs and the availability of the medication from the Pharmacy Provider). The DON stated that the resident did not receive those doses because the facility did not have the Vimpat until 2/17/22 at 4:30 AM. The DON also confirmed that the facility did not have Vimpat in their emergency back-up supply of controlled medications. The LNHA stated that the Vimpat was included in the resident's admission PO, and the facility was unable to reach Physician #1 to obtain a prescription for the Vimpat. When asked what the nurse should do in a situation where they cannot contact the physician, the LNHA stated that they should try to contact another Physician, including the Medical Director. When asked if any adverse reactions could occur from not receiving the Vimpat, the DON responded that it was an anti-seizure medication that was being administered to the resident for a hematoma and craniectomy. The DON confirmed that a person could have a seizure without observed physical activity or if staff were not present but stated that the resident had no observed seizure activity. When asked if the resident was placed on one-to-one supervision during this time, the DON responded no and acknowledged that the resident could have had an unobserved seizure, and delaying treatment or suddenly stopping an anti-seizure medication could trigger an adverse reaction or rebound seizures.
On 3/4/22 at 12:48 PM, the surveyor interviewed the resident's Registered Nurse (RN #1), who stated that the process for residents with seizures was to make sure side rails were padded, the head of the bed was elevated for safety, and make sure they have their seizure medications as prescribed. RN #1 stated that residents who did not receive their seizure medications could relapse and have a rebound seizure, and a resident could have a seizure without anyone knowing. RN #1 stated that there was no specific monitoring for residents with seizures, such as monitoring/checks at a certain time. RN #1 stated that Resident #163 was never observed out of bed or by the Nurse's Station that the resident always remained in bed. RN #1 stated that if you could not get in touch with the physician for a prescription, she would have to let the Supervisor know, and she confirmed that there were times she could not get in touch with the physician and told the Supervisor.
On 3/4/22 at 12:50 PM, the surveyor attempted to call Physician #1 via telephone with no response and a voice message system that indicated that the call was missed or do not want to speak with you.
On 3/4/22 at 12:55 PM, the surveyor confirmed Physician #1's phone number as dialed with the DON. The DON stated that since she had been at the facility, she had yet to meet Physician #1. The surveyor asked who transcribed and reconciled the resident's admission physician's orders, and the DON responded that she did.
On 3/4/22 at 12:57 PM, the surveyor team reviewed the resident's discharge PO from the hospital with the DON. The DON stated that the check next to the medication indicated that the physician wanted to continue with the medication and that she verified that the medication was in the computer. The surveyor showed the DON the checkmark next to the Keppra order, and the DON confirmed that the Keppra was ordered based on her documentation. At this time, the surveyor showed the DON the February 2022 MAR and asked her to find where the Keppra was transcribed for nurses to know it needed to be administered. The DON confirmed that the Keppra was not appearing on the MAR nor was it administered, and she would need to look into why. When asked if she would document if a Physician would not want to continue on a specific medication for the hospital discharge medication list such as Keppra or other therapeutic drug, the DON stated no. When asked if she entered an order for the medication directly into the electronic medical record at the time when reviewing the medication with the physician, the DON stated no.
The surveyor continued to review the resident's medical record.
A review of the Physician's Progress Notes revealed that the Nurse Practitioner saw the resident for the first time on 2/24/22 (7 days after the Vimpat had been delivered on 2/17/22) and there was no documentation regarding the omitted doses of Vimpat or why Keppra was not reordered. The Nurse Practitioner also saw the resident on 3/1/22 and she again did not address the omitted doses of the anti-seizure medications or the plan regarding monitoring the resident's seizure activity including obtaining therapeutic labs if doses were omitted. There was no documentation that the resident was seen by Physician #1 or their Nurse Practitioner within the forty-eight hours of admission.
A review of the resident's Admitting Evaluation History which was completed on 2/25/22 and signed (illegibly) where indicated Signature of Physician, which reflected that the resident was admitted post status right craniectomy post fall with a history of seizure disorder.
A review of the PN reflected a NN dated 3/1/22 at 8:09 PM, that the resident was noted with diaphoretic (sweating heavily), coughing and congested, noted with difficulty breathing. Upon auscultation (listening to sounds of heart, lungs, or other organs with a stethoscope), wheezing was noted to left lower lungs. The physician was made aware and ordered to be transferred to the emergency room for evaluation.
A NN dated 3/1/22 at 3:32 AM reflected that the resident was admitted to the hospital with the diagnoses of acute urinary tract infection (UTI) and sepsis (presence of harmful microorganisms in the blood or other tissues).
There was no documentation of seizure monitoring or increased seizure monitoring specifically during the time in which there were omitted doses of anti-seizure medications, and there was no documentation as to why Keppra was not ordered and no evidence that therapeutic laboratory tests were ordered for the resident's Keppra levels.
On 3/4/22 at 1:15 PM, the surveyor attempted to interview the Nurse Practitioner via telephone but there was no response. The surveyor left a message to call back.
On 3/4/22 at 1:16 PM, the surveyor attempted to interview the facility's Provider Pharmacy Representative (PPR) via telephone with no response. The surveyor was unable to leave a message because the mailbox was full.
On 3/4/22 at 1:19 PM, the surveyor attempted to interview the Medical Director via telephone with no response. The surveyor left a message to call back.
On 3/4/22 at 1:25 PM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone, who confirmed that the manufacturer recommended that Vimpat was weaned off and not abruptly stopped. The CP acknowledged that there are various seizure types that may not be visible to another person.
The facility's failure to ensure all residents who had physician orders for anti-seizure medications were administered the doses as ordered or otherwise received the necessary follow-up and communication with the Physician, and the failure to implement ongoing monitoring for those residents for rebound seizures while therapeutic doses of those medications over periods of time were being omitted, posed a serious and immediate threat for adverse effects, including various seizure types which is likely to result in serious harm, impairment, or even death.
This resulted in an Immediate Jeopardy situation. The IJ was identified on 3/4/22, and the LNHA, DON, ADON, and Regional Administrator were notified of the IJ at 2:44 PM. An acceptable written Removal Plan was accepted on 3/5/22 which included identifying all residents with seizure diagnoses; audit of charts for residents with seizure diagnosis to ensure accuracy of medication reconciliation, availability of seizure medications, omitted doses, and timeliness of administration; staff in-serviced on anti-seizure medications; monitoring for seizure activity; and reconciling of hospital discharged medications.
On 3/7/22 at 9:15 AM, the surveyor interviewed Resident #163's Representative (RR) via telephone, who confirmed that the resident was still in the hospital. The RR stated that the resident had seizures for the past three years and has been on two to three seizure medications for the past few years. The RR could not recall which anti-seizure medications the resident had been taking. The RR stated that he/she visited the resident while at the facility, and the resident was always in their room in bed during those visits.
On 3/7/22 at 2:48 PM, the surveyor interviewed the Provider Pharmacy Representative (PPR) via telephone, who stated that the facility received medication deliveries twice a day with a delivery that leaves the Pharmacy at noon and midnight. The PPR stated that if the facility ordered new medications, the cutoff time was 10:00 AM for noon deliveries, and all refill medication was delivered at midnight. The facility could also order a STAT or emergency order that the facility paid an additional fee for but received the medication within four hours. The PPR stated that the prescription was entered into the facility's [electronic medical system] for controlled medications. The prescription was faxed to the Pharmacy; the physician could send an electronic prescription directly to the Pharmacy; or the physician can call a three-day supply directly into the Pharmacy. The PPR stated that medications were generally not delayed from the Pharmacy unless the facility missed the order cutoff time or the order needed to be clarified.
At this time, the surveyor requested a timeline regarding Resident #163's Vimpat for February 2022.
On 3/7/22 at 4:49 PM, the PPR emailed the surveyor the following timeline regarding Resident #163's Vimpat: The resident was admitted to the facility on [DATE], and the facility did not fax the order from the [electronic medical system] the day the [resident] was admitted . All C2-5 medications (class of controlled medications) must be printed out from [electronic medical system] and faxed to the Pharmacy. Customer Service received a phone call from the facility on 2/10/22. Please see attachment. (*nurse will follow-up with physician for prescription)
On 2/10/22, physician wrote the wrong strength; instead of 10 mL wrote 10 mg on D-letter.
On 2/11/22, Pharmacy sent clarification to the physician and the facility.
On 2/11/22, Pharmacy sent blank D-letter to Physician's office.
On 2/14/22, Pharmacy paged the physician and left a voice message.
On 2/15/22 and 2/16/22, Pharmacy reached out to the physician's office and faxed D-letter.
On 2/16/22, the physician corrected D-letter to read 10 mL and was faxed to Pharmacy.
On 2/16/22, medication was sent to the facility on Midnight delivery.
On 3/8/22 at 9:56 AM, the surveyor interviewed the Medical Director via telephone, who stated that his role was to ensure compliance was met and attended quarterly meetings. The Medical Director stated that he was at the facility almost daily and was available 24-hours a day for any issues. The Medical Director stated that he did not involve himself with other physician's residents and does not like to interfere with other Physicians. The Medical Director stated if the physician was not returning their calls to the facility, he would expect to be notified. The Medical Director stated that for a prescription for a controlled substance, he preferred that the resident's physician wrote their own prescription. The Medical Director stated that if the facility was trying to contact the physician for several days with no response, he would then write a prescription for the resident for a few days. When asked how many days were acceptable for the resident to wait for their medications, the Medical Director stated that there is no answer.
The surveyor reviewed the resident's hospital records from their staying beginning on 3/1/22.
A review of the physician's orders revealed on 3/2/22 at 10:00 AM, Keppra 750 mg liquid two times a day was ordered.
A review of a Neurology Consultation Final Report dated 3/5/22 included that at the present time, neurological evaluation is limited; I would suggest having a CT scan of the head to evaluate for any acute or chronic intracranial processes [existing or occurring within the cranium]; I would suggest having routine EEG .[he/she] has a history of seizure disorder, treated with Keppra; I would suggest having blood work for Keppra level .further management will be determined on above-mentioned test results.
A review of a Video Electroenchalography (Video-EEG) Report included on date of study dated 3/7/22 from 7:00 AM to 3/8/22 7:00 AM, that abnormal VEEG. The above findings are c/w [consistent with] nonconvulsive focal status with epileptogenic zone Rt F-T-C region [a prolonged seizure that manifests primarily as altered mental status as opposed to dramatic convulsions]. Further adjustment of AEDs [antiepileptic drugs] is recommended.
During the sample expansion of reviewing residents receiving anti-seizure medications on 3/7/22, the survey team identified a second resident (Resident #27) who did not receive their anti-seizure medication (Vimpat) for a prolonged period of time because it was not available. The findings were as follows:
2. On 3/7/22 at 10:32 AM, the surveyor observed Resident #27 in bed with Jevity 1.5 (nutrition formula) being administered via a feeding tube. The resident was unable to be interviewed.
The surveyor reviewed the medical record for Resident #27.
A review of the admission Record reflected that the resident was admitted to the facility in September of 2021 with diagnoses which included other sequelae following unspecified cerebrovascular disease (stroke), dysphagia following cerebral infarction (difficulty swallowing food or liquids following a stroke), nontraumatic intracranial hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery), cerebral amyloid angiopathy (a condition in which proteins called amyloid build up on the walls of the arteries in the brain increasing risk for stroke), gastrostomy status (FT), and seizures.
A review of the most recent quarterly MDS dated [DATE] reflected a BIMS score was unable to be determined. The resident had short and long-term memory problems with a severely impaired decision-making capacity.
A review of the individualized person-centered Care Plan
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that a Registered Nurse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that a Registered Nurse completed full body assessments after a fall prior to being moved in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 resident (Resident #50) reviewed for falls.
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
The evidence was as follows:
On 2/23/22 at 11:36 AM, the surveyor observed Resident #50 lying in a low positioned bed with floor mats on either side of the bed. The resident was unable to be interviewed.
On 3/1/22 at 12:41 PM, the surveyor interviewed Resident #50's Representative (RR) via telephone who stated that the resident had multiple falls since admission at the facility.
The surveyor reviewed the medical record for Resident #50.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility in April of 2021 with diagnoses which included brain damage (caused by complete lack of oxygen to the brain), epilepsy (a disorder that causes seizures), muscle weakness, and type II diabetes mellitus.
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/18/22, reflected a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated severely impaired cognition.
A review of the individualized person-centered Care Plan included a focus area initiated 4/13/21, for at risk for further falls due to a history of falls, impaired balance and mobility, deconditioning, seizure disorder and confusion. Actual falls on: 12/23/21 with minor injury; 1/20/22 without injury; and 2/6/22 without injuries. Interventions included to anticipate and meet needs; air pressure mattress/scoop mattress check proper function every shift; keep bed in lowest position at all times except when giving care; padded side rails are to be maintained at all times; and provide bilateral safety floor mats to reduce risk of injury should a fall occur.
A review of the fall Incident Report dated 12/23/21, reflected that the resident was found by wound care nurse on the floor. The incident report included a statement from Registered Nurse (RN #1) that the resident was assessed and found to express back and leg pain, so the resident was transferred to the hospital for evaluation.
A review of the fall Incident Report dated 1/20/22, reflected that the resident was found at 9:30 PM by the writer [Licensed Practical Nurse (LPN #1)] on the floor with no noted injury. The resident with assistance of two Certified Nursing Aides (CNA) was transferred back to bed. The report also included that LPN #1 documented in a Nurse Note dated 1/20/22 at 11:02 PM, that a full body assessment was done with no injury noted. The report also included a Fall Risk assessment dated effective date 1/20/22 at 10:08 PM, was completed by LPN #1. There was no documentation that the resident was assessed by a RN prior to being moved.
A review of the fall Incident Report dated 2/6/22, reflected that the writer [LPN #1] found the resident at 8:40 AM in their room lying on the floor mat. There was no injury noted and the resident was transferred with the assistance of two CNAs. The report included a Nurse Note from LPN #1 dated 2/6/22 at 11:01 AM, that she was called to the room at 8:40 AM and found the resident lying on the left side of bed on the floor mat; a quick assessment was done with no injury noted and the resident was transferred by two CNAs back to bed. A full body assessment was done with no injury noted. The report also included a Fall Risk assessment dated [DATE] at 3:43 PM, that was completed by LPN #1. There was no documentation that the resident was assessed by a RN prior to being moved.
A review of the Progress Notes that corresponded with the falls on 1/20/22 and 2/6/22, did not include documentation that an RN assessed the resident after the fall prior to being transferred back to bed.
On 3/2/22 at 9:55 AM, the surveyor observed resident in bed asleep. The surveyor observed that the bed was positioned low, side rails were padded and in the up position, and fall mats were on either side of the bed.
On 3/2/22 at 11:02 AM, the surveyor interviewed RN #1 who stated that the resident had multiple falls since admission at the facility with interventions put in place which included bed in lowest position, floor mats to both sides of the bed, and padded side rail in the up position while in bed. RN #1 stated that the resident had only fell once during her shift and she completed the assessment for that fall. RN #1 stated that a RN had to complete the assessment when a resident falls.
On 3/2/22 at 11:40 AM, the surveyor interviewed the Director of Nursing (DON) who stated that when a resident fell, a head-to-toe assessment was completed to ensure the resident had no injuries which included vital signs, cognition, range of motion, and skin checks. The DON confirmed that in accordance with standards of practice for nursing, only a RN and not a LPN could assess the resident and the assessment was completed prior to be moved from the floor. The DON stated that the RN should also document their assessment in the Progress Notes or in the Incident Repot. The surveyor reviewed the fall Incident Reports for Resident #50 dated 1/20/22 and 2/6/22. The DON acknowledged that even though she documented Interdisciplinary Care Plan Summary notes on 1/24/22 and 2/7/22, there was no documented RN assessments completed after the fall prior to moving the resident.
On 3/4/22 at 10:12 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, Assistant Director of Nursing (ADON), Corporate Nurse, and survey team, acknowledged that no RN assessment was completed for the falls on 1/20/22 and 2/6/22.
A review of the facility's Incident/Accident Reporting Policy and Procedure dated updated 11/2021, included that it was the responsibility of the Licensed Nurse who first witnessed the incident/accident to initiate and complete the Incident/Accident Report in its entirety utilizing input from the staff present at the time of the incident/accident. The Nurse evaluates the resident's condition, renders appropriate treatment, i.e. [id est; that is] first aid or calls the Physician who orders specific treatment or decides if the resident is to be transferred to the emergency room . the policy did not include/specify that the RN completed the assessment.
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
2. On 2/23/22 at 11:28 AM, the surveyor in the presence of LPN #3 inspected the Northwest medication cart. During the reconciliation of controlled medications with the LPN caring for Resident #163, th...
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2. On 2/23/22 at 11:28 AM, the surveyor in the presence of LPN #3 inspected the Northwest medication cart. During the reconciliation of controlled medications with the LPN caring for Resident #163, the surveyor observed that the Vimpat (a medication used for seizures) 10 milligrams/milliliter (mg/mL) liquid bottle contained approximately 175 mL. A review of the corresponding Individual Patient Controlled Substance Administration Record (declining inventory sheet) reflected the last time the Vimpat was signed as administered was on 2/22/22 at 9:00 PM, with a remaining balance documented as 200 mL.
On 2/23/22 at approximately 11:40 AM, the surveyor interviewed LPN #3 regarding the discrepancy with the Vimpat declining inventory sheet which indicated there was 200 mL remaining in the bottle, while the actual bottle contained 175 mL. LPN #3 was unable to speak to this. At this time, LPN #3 had the ADON and an additional surveyor (Surveyor #2) joined them at the medication cart. Surveyor #2 verified the volume remaining was approximately 175 mL and asked LPN #3 how much Vimpat was remaining in the bottle. LPN #3 responded that we were told here that we cannot guess with the amount of medication, and it should be measured to determine how much medication was left on the bottle. LPN #3 also stated that she administered 10 mL of Vimpat at 9:00 AM to the resident and she forgot to sign it on the declining inventory sheet. The LPN confirmed that she should have signed the declining inventory sheet immediately upon administering the medication at 9:00 AM, and it's my fault.
At this time, the ADON read the measurement of the liquid remaining in the medication bottle and stated, approximately there were 175-180 mL remaining in the bottle. The ADON further stated that in order to verify the exact amount remaining, it would need to be measured, and she would be right back with the Registered Nurse/Unit Manager (RN/UM) to measure the actual amount left.
On 2/23/22 at 11:57 AM, the RN/UM in the presence of LPN #3, ADON, and the surveyors measured the Vimpat and confirmed the amount remaining in the bottle was 175 mL.
A further review of the declining inventory sheet revealed in addition to the omission of the 2/23/22 9:00 AM dose, on 2/17/22 and 2/18/22 the balance remaining and the administered time were both blank.
On 3/3/22 at 10:49 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that she checked the narcotics and the corresponding declining inventory sheets and always checked the liquid medications because there was generally a higher incidence of errors. The CP acknowledged the declining inventory sheet should match the volume remaining in the bottle. The CP further stated the nurse should sign the declining inventory as she administered the medication and if there was an issue that someone forget to sign, it should be found at change of shift, when the nurses double checked the counts and signed the change of shift log. The CP concluded there should be no discrepancies between the documented declining inventory sheet remaining volume and the actual volume remaining in the bottle.
On 3/4/22 at 10:13 AM, the LNHA in the presence of the DON, ADON, and the survey team, acknowledged the discrepancies in the documentation of the Vimpat and stated that those errors accounted for the differences in the Vimpat volume. The DON further acknowledged that one dose on 2/17/22 and one dose on 2/18/22 was not documented but was administered which was in addition to the 2/23/22 9:00 AM, dose that was also not accounted for.
A review of the facility's Controlled Drug Storage and Administration Policy dated updated 5/2021 included that . controlled medication dose should be prepared based on the order in the Medication Administration Record; declining inventory sheet [Individual Patient Controlled Substance Administration Record] should be signed as dose is prepared and reconciled with quantity on hand; immediately after administration, Medication Administration Record should be signed.
Refer F760
NJAC 8:39-27.1(a); 29.7(c)
Based on observation, interview, and record review, it was determined that the facility failed to a.) ensure medications were administered to a resident in accordance with professional standards of practice and b.) a controlled anti-seizure medication, Vimpat, was accurately accounted for in accordance with professional standards of practice. This deficient practice was identified for 2 of 24 residents (Resident #51 and Resident #163) reviewed for medication management and the evidence was as follows:
1. On 2/23/22 at 11:02 AM, the surveyor observed Resident #51 alone, lying in bed awake with their tray table directly over the bed. The surveyor observed on top of the tray table, a disposable medication cup that contained five medication pills and an additional medication cup that contained 30 milliliters (mL) of an orange/brownish colored liquid. The surveyor interviewed the resident who stated that he/she still had their morning medications in front of them because the nurse left their morning medications with them, but the nurse did not give them all their medications. The resident stated that he/she was waiting for the nurse to return to their room to inform them they were missing medications.
On 2/23/22 at 11:07 AM, the surveyor observed the Registered Nurse (RN) in the hallway outside the resident's room. The surveyor asked the RN to come into Resident #51's room. At this time, the RN noticed the medications and asked the resident why he/she had not taken their medications. The resident responded that he/she was missing medications. The RN proceeded to remove the medications from the tray table and proceeded into the hallway to the medication cart with the surveyor.
At this time, the RN identified the five medication pills as (1) amlodipine, (1) gabapentin, (1) Renvela, (1) vitamin D, and (1) Zoloft. The RN identified the liquid cup to be 30 mL of Prostat (a protein supplement). The RN stated that she was training Licensed Practical Nurse (LPN #1) this morning who administered the resident their medications. The RN reviewed the Medication Administration Record (MAR) and stated that LPN #1 signed for the administration of the above medications at 8:19 AM. The RN identified that the LPN only administered one Renvela tablet instead of two and one Zoloft tablet instead of three. The RN stated that medications should never have been left bedside, and the nurse was expected to sign the MAR after they witnessed the resident swallow the medications. The RN stated that Resident #51 was alert and oriented to person, place, and time and knew what medications they were supposed to receive. The RN stated that the resident had a roommate who was confused, but they could not ambulate or self-propel in a wheelchair and were dependent on staff for all activities of daily living. The RN disposed of the medication at this time and informed the surveyor that she was going to follow-up with the Assistant Director of Nursing (ADON).
On 2/23/22 at 11:20 AM, the surveyor interviewed LPN #1 who stated that she was a new nurse and was shadowing LPN #2 today. She stated that she had dispensed medications today for one resident who she could not recall that resident's name, but she did not administer the medications to the resident. LPN #1 stated that she had dispensed the medication with LPN #2 today and denied touching any of the RN's residents' medications today. LPN #1 confirmed that medications should not be left bedside with the resident.
On 2/23/22 at 11:30 AM, the surveyor re-interviewed Resident #51 who stated that LPN #1 had administered the medications to him/her today and did not dispense all his/her anxiety medications (Zoloft).
On 2/23/22 at 12:34 PM, the surveyor re-interviewed the RN who stated that she spoke with the resident's Nurse Practitioner (NP) who gave a one time order for all the missed medications except the Renvela which needed to be administered with meals since it was a phosphate binder. The RN stated that the resident would receive the Renvela with lunch.
The surveyor reviewed the medical record for Resident #51.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility in October of 2019 with diagnoses which included heart failure, acute kidney failure, generalized anxiety disorder, major depressive disorder, chronic kidney disease, and essential hypertension (high blood pressure).
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/19/22, reflected a Brief Interview for Mental Status (BIMS) score of a 15 out of 15, which indicated a fully intact cognition.
A review of the active Order Summary Report reflected the following physician orders (PO):
A PO dated 12/14/21 for Prostat SP (sugar free) to administer 30 mL two times a day for supplement.
A PO dated 2/22/22 for amlodipine 10 milligram (mg) tablet; give one tablet by mouth one time a day every Monday, Wednesday, and Friday for hypertension.
A PO dated 10/12/21 for gabapentin 300 mg capsule; give one capsule by mouth one time a day for neuropathy pain.
A PO dated 1/18/22 for Renvela 800 mg tablet; give two tablets by mouth three times a day every Monday, Wednesday, Friday, and Sunday for end stage renal disease. Give with meals.
A PO dated 12/14/21 for vitamin D3 1.25 mg capsule; give one capsule by mouth one time a day every Wednesday for supplement.
A PO dated 10/29/21 for Zoloft 25 mg tablet; give three tablets by mouth one time per day for depression.
A review of the corresponding February 2022 MAR, reflected that the above medications were signed as administered for the morning dose on 2/23/22.
On 3/1/22 at 9:12 AM, the surveyor interviewed the ADON who stated that all newly hired nurses shadowed other nurses during orientation and were observed completing medication pass at least two or three times before completing orientation. The ADON stated that newly hired nurses were not allowed to be left alone in a resident's room without their preceptor, and the medication administration needed to be monitored. The ADON confirmed that the nurse had to observe the resident swallow the medication prior to exiting the room, and then the nurse signed that the medications were administered in the MAR.
On 3/1/22 at 10:44 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), ADON, Corporate Nurse, and the survey team, acknowledged that medications should not be left by the nurse with the resident.
A review of the facility's Medication Administration policy dated updated 10/2021, included that .10. the nurse will stay with same resident until all medication is prepared and taken; and 11. the nurse will then document per regulation. The nurse will initial on the MAR for the scheduled time of medication administration .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that the facility failed to ensure the Consultant Pharmacist identified that a medication used to control seizures was administere...
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Based on observation, interview, and record review, it was determined that the facility failed to ensure the Consultant Pharmacist identified that a medication used to control seizures was administered in accordance with manufacturer's specifications. This deficient practice was identified for 1 of 3 resident (Resident #27) reviewed for anticonvulsant medications and was evidenced by the following:
Reference: VIMPAT Highlights of Prescribing Information: VIMPAT tablets should be swallowed whole with liquid. Do not divide VIMPAT tablets.
On 3/7/22 at 10:32 AM, the surveyor observed Resident #27 in bed with Jevity 1.5 (nutrition formula) being administered via a feeding tube (FT; tube surgically inserted through the abdomen to the stomach to provide nutrition). The resident was unable to be interviewed.
The surveyor reviewed the medical record for Resident #27.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility in September of 2021 with diagnoses which included other sequale following unspecified cerebrovascular disease (stroke), dysphagia following cerebral infarction (difficulty swallowing food or liquids following a stroke), nontraumatic intracranial hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery), cerebral amyloid angiopathy (a condition in which proteins called amyloid build up on the walls of the arteries in the brain increasing risk for stroke), gastrostomy status (FT), and seizures.
A review of the most recent quarterly Minimum Data Set (MDS) an assessment tool dated 12/29/21, reflected a Brief Interview for Mental Status (BIMS) score to be unable to determine. The resident had short and long-term memory problems with severely impaired cognition.
A review of the active Order Summary Report reflected the following physician's orders (PO):
A PO dated 9/21/21, may administer crushed medications as bolus (administered through FT) if not contradicted by manufacturer.
A PO dated 9/21/21, for lacosamide (Vimpat) 200 milligram (mg) tablet; give one tablet via FT every twelve hours for seizures.
A review of the Consultant Pharmacist Evaluation from admission until present, did not include to not crush Vimpat.
On 3/8/22 at 9:33 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the resident received small amounts of food and liquids orally, but their main nutrition was provided by the Jevity 1.5 via the FT. The LPN stated that the resident received all their medications through their FT either in liquid form or a crushed tablet. When asked how she determined if a medication could not be crushed, the LPN responded that it was not written on the Medication Administration Record (MAR) so if she was unsure about a medication, the LPN could look the medication up on the Internet. When asked if Vimpat can be crushed, the LPN responded that the Vimpat had always been crushed at the facility.
On 3/8/22 at 10:17 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that monthly she reviewed all residents' medications to ensure that the medications ordered were appropriate, they were in the appropriate form for the resident, and no irregularities. The CP stated that medication cautionaries were written on the bingo card (blister packet which contains the medication) and if the cautionary advised against crushing a medication, the nurse would need to clarify the order with the Physician. When asked if Vimpat tablets could be crushed, the CP stated that she was unsure and would need to research that. The CP confirmed that Vimpat was available in liquid source and that liquid medications were the preferred medication form for FT.
At this time, the surveyor provided the CP with a copy of the resident's Vimpat bingo card with the displayed cautionary Swallow Whole. Do Not Chew Or Crush. The CP acknowledged the cautionary and stated that she was unsure where the Provider Pharmacy received their cautionaries from. The surveyor then provided the CP with a copy of the resident's Consultant Pharmacist Evaluation from admission until present and asked the CP if she had addressed the Vimpat tablet could not be crushed. The CP acknowledged that the Vimpat tablet not being crushed was not on the sheet. The CP stated that she would get back to the surveyor with any additional information.
On 3/8/22 at 11:31 AM, the CP in the presence of the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Corporate Nurse, and survey team, confirmed that the manufacturer did not recommend Vimpat being crushed.
A review of the facility's Title: Consultant Pharmacist during regular monthly visits policy dated updated 1/2022, include .the Consultant Pharmacist shall identify, document and report actual and potential irregularities for review and action to the Director of Nursing and/or Designee, Administrator, Medical Director and physicians (where appropriate). The physicians recommendations will be communicated to the Director of Nursing and/or Designee for distribution and action by the attending physician via email, fax (or both) .
NJAC 8:39-
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) administer oxygen therapy according to the physician's order and b.) ensure respiratory equipment was stored and dated properly. This deficient practice was identified for 5 of 7 residents (Resident #35, Resident #51, Resident #57, Resident #69, and Resident #363) reviewed for respiratory care and the evidence was as follows:
1. On 2/23/22 at 11:25 AM, the surveyor observed Resident #35 sitting in a wheelchair in their room watching television. The resident was being administered oxygen from a concentrator alongside their bed that was set to one liter per minute (1 lpm) via an undated nasal cannula (tubing used to deliver oxygen through the nose). The resident appeared to be in no distress.
The surveyor reviewed the medical record for Resident #35.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility in January of 2017 with diagnosis which included multiple sclerosis (a disease in which the immune system attacks the nerves).
A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 1/10/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated a fully intact cognition. A further review reflected the resident was not on oxygen therapy at the time of this assessment.
A review of the individualized person-centered Care Plan initiated on 10/3/19, did not include that the resident received oxygen or respiratory therapy.
A review of the Order Summary Report included a physician's orders (PO) dated 2/1/22 for oxygen at 2 lpm via nasal cannula as needed for shortness of breath or for pulse oximeter (SPO2; blood oxygen saturation level) less than 92%.
On 2/24/22 at 10:07 AM, the surveyor observed the resident in bed with the oxygen concentrator set to 1 lpm being delivered to the resident by an undated nasal cannula tube. The resident appeared to be in no distress.
On 2/24/22 at 10:34 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the resident's SPO2 was checked that morning at 8:05 AM, and it was at 91%. The LPN stated that the PO was to administer oxygen at 2 lpm when the SPO2 was less than 92%. The LPN also stated that oxygen tubing was changed once a week and should be dated when changed.
At this time, the surveyor accompanied by the LPN observed Resident #35's oxygen concentrator and tubing. The LPN confirmed the oxygen tubing was not dated, and the concentrator was not set to the ordered 2 lpm. The surveyor observed the LPN replace the oxygen tubing and dated it 2/24/22.
On 2/25/22 at 1:04 PM, the surveyor observed the resident's oxygen tubing connected to the concentrator that was not in use was dated 2/20/22 and not the 2/24/22 date observed yesterday.
On 2/25/22 at 1:46 PM, the surveyor interviewed the LPN regarding the resident's oxygen tubing who confirmed that she dated the tubing 2/24/22 yesterday, and she was unable to explain why the tubing was now dated 2/20/22. The LPN called the Assistant Director of Nursing/Infection Preventionist (ADON/IP) over to the resident's room. The ADON/IP confirmed that she was aware of the tubing being changed and dated the previous day on 2/24/22, and she confirmed the current tubing was now dated 2/20/22. The ADON was unable to speak to this discrepancy.
On 3/4/22 at 10:11 AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LHNA), ADON/IP, and the survey team, stated that oxygen tubing was changed and dated weekly on Sundays during the 11:00 PM to 7:00 AM shift by nursing staff and as needed if the tubing was on the floor. The DON also acknowledged that oxygen should be administered according to the PO. The DON was unable to speak to the discrepancies in the oxygen tubing dates.
2. On 2/23/22 at 11:14 AM, the surveyor observed Resident #69 in their room resting in bed with no distress. The resident was being administered oxygen from a concentrator alongside their bed that was set to 1 lpm via an undated nasal cannula.
The surveyor reviewed the medical record for Resident #69.
A review of the admission Record reflected that the resident was admitted to the facility in December of 2018 with diagnosis which included chronic obstructive pulmonary disease (COPD; constriction of the airways making it difficult or uncomfortable to breathe), anemia (deficiency of red blood cells), asthma, and end stage renal disease (condition in which a person's kidneys permanently stop functioning).
A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 5 out of 15, which indicated a severe cognitive impairment. A further review reflected the resident was on oxygen replacement therapy and had shortness of breath or trouble breathing when lying flat.
A review of the individualized person-centered Care Plan initiated on 5/12/21, included a focus area for shortness of breath related to COPD and asthma. Interventions included to administer bronchodilators (medication used to open airway) in a timely manner and to position resident with proper body alignment for optimal breathing.
A review of the active Order Summary Report included a PO dated 1/21/22 for oxygen to be administered at 2 lpm via nasal cannula for shortness of breath.
On 2/24/22 at 11:06 AM, the surveyor in the presence of the LPN observed the resident in bed with the oxygen concentrator set to 1.5 lpm being delivered to the resident via a nasal cannula that was dated 2/22/22. The LPN confirmed the PO was for the concentrator to be set at 2 lpm but did not make the adjustment at that time.
On 2/25/22 at 1:02 PM, the surveyor observed the resident's oxygen concentrator was set to 2 lpm and the oxygen tubing was dated 2/20/22 which contradicted the 2/22/22 date observed the day before.
On 2/25/22 at 1:52 PM, the surveyor interviewed the ADON/IP confirmed the tubing was dated 2/20/22 and stated that she will have to look into this issue.
On 3/4/22 at 10:11 AM, the DON in the presence of the LNHA, ADON/IP, and the survey team, stated that oxygen tubing was changed and dated weekly on Sundays during the 11:00 PM to 7:00 AM shift by nursing staff and as needed if the tubing was on the floor. The DON also acknowledged that oxygen should be administered according to the PO. The DON was unable to speak to the discrepancies in the oxygen tubing dates.
3. On 2/23/22 at 10:50 AM, the surveyor observed Resident #363 in their room resting in bed. The resident was being administered oxygen from a concentrator alongside their bed that was set to 2 lpm via an undated nasal cannula.
The surveyor reviewed the medical record for Resident #363.
A review of the admission Record reflected that the resident was admitted to the facility in March of 2016 with diagnosis which included acute respiratory failure with hypoxia (sudden onset of an inability to breath resulting in decreased levels of oxygen in the blood and to body tissue), heart failure, and COPD.
A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 9 out of 15, which indicated a moderate cognitive impairment. A further review reflected the resident was on oxygen replacement therapy and had shortness of breath or trouble breathing when lying flat.
A review of the individualized person-centered Care Plan initiated on 7/18/19, included a focus for oxygen therapy related to the diagnosis of COPD and congestive heart failure (CHF). Interventions included to administer oxygen by nasal prongs/mask at 2 lpm as needed for shortness of breath.
A review of the active Order Summary Report included a PO dated 3/26/21 for continuous oxygen at 2 lpm via nasal cannula for shortness of breath. An additional PO dated 1/17/22 for oxygen at 2 lpm as needed for a pulse oximeter less than 92% or shortness of breath.
On 2/25/22 at 12:44 PM, the surveyor observed the resident's oxygen tubing not in use and hanging wedged between the nightstand table and wall with most of the tubing length lying directly on the floor. At this time, the surveyor interviewed the resident who stated that he/she needed the oxygen.
On 2/25/22 at 12:49 PM, the DON came to the resident's room and informed the surveyor that the tubing should not be stored like that; it should be in a bag when not in use. The DON also stated that the tubing should not be on the floor like that because it can cause infection control issues and needed to be changed.
4. On 2/23/22 at 11:01 AM, the surveyor observed Resident #57 in bed with an oxygen concentrator at their bedside which was turned on and set to 2.5 lpm. The surveyor observed that the undated nasal cannula was connected to the concentrator and hanging from the resident's bed side rail with the nasal prongs lying directly on the floor.
The surveyor reviewed the medical record for Resident #57.
A review of the admission Record reflected that the resident was admitted to the facility in March of 2010 with diagnoses which included COPD.
A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 12 out of 15, which indicated a moderate cognitive impairment. A further review reflected the resident was not on oxygen therapy at the time of this assessment.
A review of the individualized person-centered Care Plan initiated on 4/23/2020, included a focus area for oxygen therapy related to the diagnosis of COPD. Interventions included to give oxygen therapy as ordered by the physician.
A review of the active Order Summary Report included a PO dated 11/8/21 for oxygen to be administered at 2 lpm via nasal cannula for shortness of breath as needed for SPO2 less than 90%.
On 2/24/22 at 10:34 AM, the surveyor along with the LPN observed the resident in their room not receiving oxygen. The LPN stated that the resident received oxygen as needed for an SPO2 less than 90%. The LPN stated that she checked the resident's SPO2 that morning and the level was above 90% so the resident did not need oxygen.
On 3/4/22 at 10:11 AM, the DON in the presence of the LNHA, ADON/IP, and the survey team, stated that oxygen tubing should be stored in a bag when not in use.
5. On 2/23/22 at 11:02 AM, the surveyor observed Resident #51 awake lying in bed. The surveyor observed a nebulizer machine (a device used to create a mist out of liquid respiratory medications to transport to the lungs) with connected tubing and a face mask lying directly on the floor underneath the resident's bed.
The surveyor reviewed the medical record for Resident #51.
A review of the admission Record reflected that the resident was admitted to the facility in October of 2019 with diagnoses which included cough variant asthma, other specified disorders of nose and nasal sinuses, heart failure, and kidney failure.
A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 15 out of 15, which indicated a fully intact cognition.
A review of the active Order Summary Report reflected a PO dated 2/10/22, for albuterol solution 0.5-2.5 (3) milligram/3 milliliters (mg/3 mL); 3 mL inhale orally via nebulizer every six hours every Monday, Wednesday, Friday, Sunday for respiratory treatment on non-dialysis days.
A review of the individualized person-centered Care Plan included a focus area initiated 2/12/2020, for altered respiratory status/difficulty breathing with regards to congestive heart failure (CHF; a chronic condition in which the heart does not pump blood as well as it should). Interventions included to administer medications as ordered; monitor for effectiveness and side effects.
On 2/28/22 at 11:05 AM, the surveyor observed Resident #51 awake lying in bed with the nebulizer machine with the connected tubing and mask lying directly on the floor underneath the resident's bed.
On 2/28/22 at 11:05 AM, the surveyor accompanied by the Registered Nurse (RN) entered Resident #51's room and the RN confirmed that the resident's nebulizer machine with connected tubing and mask was lying directly on the floor underneath the resident's bed. The RN stated that she needed to change the tubing and mask and proceeded to pick up the nebulizer machine with the attached tubing and mask and placed them in bed with the resident. The RN removed the tubing and mask and stated that she needed to grab new tubing and mask since it was on the floor for infection control purposes. The RN changed the tubing and mask, leaving the nebulizer machine in bed with the resident and exited the room.
At this time, the surveyor interviewed the RN in the hallway who confirmed that the tubing and mask on the floor would be an infection control concern, so she changed them. When asked about the nebulizer machine that was on the floor and now in bed with the resident was okay, the RN acknowledged that she should have changed the nebulizer machine or wiped it down with alcohol. The RN stated that she would now change the nebulizer machine, tubing, and mask.
On 2/28/22 at 11:20 AM, the surveyor interviewed the resident who stated that the Certified Nursing Aide (CNA) placed the nebulizer machine, tubing, and mask on the floor when they performed care, and the CNA had not placed the nebulizer back in bed. The resident confirmed that the nebulizer machine was usually placed in bed with them.
On 2/28/22 at 11:30 AM, the surveyor interviewed the CNA who stated that she had not performed care on the resident yet, and she had not placed the nebulizer machine on the floor.
On 2/28/22 at 11:38 AM, the surveyor re-interviewed the resident who confirmed that the CNA had not placed the nebulizer machine, tubing, and mask on the floor, and they were unable to speak to who did.
On 3/1/22 at 9:19 AM, the surveyor interviewed the ADON/IP who stated that the nebulizer machine should not be on the floor or in bed with the resident. The ADON/IP stated that the nebulizer machine should be placed on a table, and the tubing and mask should be stored in a bag when not in use to prevent contamination.
On 3/4/22 at 10:12 AM, the LNHA in the presence of the DON, ADON/IP, Corporate Nurse, and survey team acknowledge that the nebulizer, tubing, and mask should not be placed on the floor.
A review of the facility's Oxygen Administration policy dated updated 12/2021 included it is the policy and procedure of [NAME] Manor to provide oxygen to residents in compliance with their physician order as followed out by the resident's care provider .Tubing and other accessories will be changed weekly and dated.
A review of the facility's Respiratory Tubing policy dated updated 11/2021, included . respiratory tubing will be properly dated, maintained, and stored to prevent infection .when not in use, store respiratory tubing in an oxygen bag that is labeled with the date the tubing was changed.
NJAC 8:39-11.2(b); 19.4(a); 27.1(a)
Nov 2019
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, it was determined that the facility failed to implement side rail bumper pads an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, it was determined that the facility failed to implement side rail bumper pads and protective sleeves for a resident with behaviors in accordance with the individualized care plan. This deficient practice was identified for 1 of 28 residents reviewed for care plans (Resident #89), and was evidenced by the following:
On 11/17/19 at 10:25 AM, the surveyor observed Resident #89 lying in bed in their room. The surveyor observed that the resident had unpadded bilateral half side rails in the upright position. The surveyor also observed bruises on top of the resident's right hand and arm that were in multiple stages of healing. The bruise on top of the resident's right hand was red in color. The bruising observed on the resident's right arm were yellow and purple in color. The surveyor observed that the resident was not wearing protective sleeves or long sleeve clothing. The surveyor attempted to interview the resident but the resident's responses were not consistent.
The surveyor reviewed the medical records for Resident #89.
A review of the admission Record (and admission summary) reflected that the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included but were not limited to epilepsy (seizures), major depressive disorder, other non-thrombocytopenic purpura (a red or purple skin discoloration not associated with low blood clotting levels), generalized anxiety disorder, and mood disorder due to known physiological condition.
A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/10/19 reflected that the resident had Brief Interview of Mental Status (BIMS) score of 7 out of 15 which indicated the resident had a moderately impaired cognition.
A review of the resident's individualized, comprehensive care plan (ICCP) dated 12/4/13 reflected that the resident was on antidepressant medication for depression which was manifested by worrying, causing distress and tears. It included that the resident had behaviors of trying to hit his/her face on the side rails. The interventions to address these behaviors included to implement bilateral adult bumper pads to the bilateral side rails and to keep long sleeve clothing or protective sleeves on the resident.
A review of the November 2019 Order Summary Report did not reflect evidence of a physician order for bilateral adult bumper pads or protective sleeves.
On 11/18/19 at 10:05 AM, and on 11/20/19 at 9:39 AM, the surveyor made additional observations of the resident in bed with unpadded bilateral half side rails in the upright position. The surveyor further observed that the resident was not wearing protective sleeves or long sleeve clothing during these observations.
On 11/20/19 at 9:44 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident would have mental episodes and sometimes attempt to hit himself/herself. The CNA further stated that she did not know if the resident was supposed to have padding placed on the side rails of the resident's bed.
On 11/20/19 at 9:49 AM, the surveyor interviewed the resident's Registered Nurse (RN) who stated that the resident was very confused and would fabricate stories. The RN further stated that the resident would pick at his/her skin and would bang the television remote control against the side rails on the bed. The RN told the surveyor that if the resident was banging things against the side rails on the bed, the resident could have very easily banged his/her arms against the side rails. The RN stated that she didn't think that the resident had padding to the side rails, but thought that it would be a good idea if the resident was agreeable to it.
On 11/20/19 at 10:21 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated that the unit manager was responsible for updating a resident's care plan. The LPN/UM stated that the purpose of the resident's care plan was to implement interventions for the resident's care and safety, and the expectation would be that the staff would follow the interventions reflected in the resident's plan of care. The LPN/UM further stated that if the interventions in the resident's care plan were not effective then the staff would try something else and update the resident's care plan as needed.
On 11/21/19 at 10:24 AM, the surveyor interviewed the Regional Nurse in the presence of the survey team who stated that the while the resident's behaviors had improved, the care plan should have been updated to reflect the appropriate interventions for the resident's behaviors. The Regional Nurse added that the bruises were from attempts to get blood draws in the resident's extremities, and they were not from recent behaviors of hitting the side rails.
A review of the facility's Nursing Interdisciplinary Care Plan Conference Policy and Procedure dated 8/8/19 included that it was, the policy of this facility to develop and review an Interdisciplinary Care Plan to meet resident care and educational needs.
NJAC 11.2(d)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure the appropriate use and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure the appropriate use and monitoring of an as-needed psychotropic medication, Risperdal. This deficient practice was identified for 1 of 7 residents reviewed for unnecessary medications (Resident #312), and was evidenced by the following:
On 11/17/19 at 11:10 AM, the surveyor observed Resident #312 sitting in their room coloring. The resident did not respond to the surveyor's inquiry. The Licensed Practical Nurse (LPN) informed the surveyor that the resident has a physician's order from the hospital for an as-needed (PRN) psychotropic medication, Risperdal, used to treat mood disorder.
The surveyor reviewed the medical record for Resident #312.
A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility on [DATE] with diagnoses which included unspecified dementia without behavior disturbances, recurrent depressive disorders, and hypertension (high blood pressure).
A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/2/19 reflected that the resident had a brief interview for mental status (BIMS) score of 3 out of 15, which indicated severely impaired cognition. A further review of the MDS, indicated that the resident was administered psychotropic medication on 1 of the lat 7 days since admission.
A review of the resident's individualized, comprehensive care plan initiated on 10/28/19 did not reflect that the resident was on an psychotropic medication for a target behavior or that the resident had a history of behaviors.
A review of the resident's Order Summary Report dated from admission to present, included a physician's order (PO) dated 10/26/19 to administer Risperdal 0.25 milligrams (mg) every 12 hours PRN for agitation (a state of anxiety or nervous excitement). The order was discontinued on 11/9/19.
A review of the October 2019 electronic Medication Administration Record (eMAR) that corresponded with this order, indicated that the resident received Risperdal on 10/28/19.
A review of the electronic Progress Notes (ePN) that corresponded with the administration of the Risperdal, did not reflect evidence of non-pharmacological interventions attempted prior to the administration of the as needed Risperdal.
A review of the November 2019 eMAR, indicated that the resident received an as needed dose of Risperdal 0.25 mg on 11/1/19 and 11/4/19.
A review of the ePN which corresponded to the administration of the Risperdal on 11/1/19 and 11/4/19 did not indicate what behaviors the resident was exhibiting or what non-pharmacological interventions were attempted prior to the administration of the as needed Risperdal.
The surveyor reviewed the most recent Consultant Pharmacist Evaluation dated 11/5/19 (?date illegible), included the notation that Risperdal was not recommended as an as-needed medication, as needed medications had a fourteen day limit, target behaviors had to be monitored, and non-pharmacological interventions needed to be included.
A further review of the Order Summary Report included a new PO dated 11/14/19 to administer Risperdal 0.25 mg every 12 hours as needed for agitation until 11/23/19. This order included instructions for target behavior tracking every shift for socially inappropriate behaviors, combative with care, unable to re-direct.
A review of the November 2019 eMAR reflected that the resident was administered a dose of Risperdal 0.25 mg on 11/15/19 and 11/17/19. A further review of the eMAR indicated that the behavior monitoring that corresponded to the dates of administration, reflected that the resident had exhibited zero, 0 target behaviors.
A review of the ePN that corresponded to the administration dates of the Risperdal did not reflect evidence of what target behaviors the resident was exhibiting, what non-pharmacological interventions were attempted, or if the medication was effective or ineffective.
On 11/19/19 at 9:48 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident was confused at times, and could not express him/her-self fully. The CNA further stated that the resident liked to clean and had not refused care or became combative with care. The CNA stated that she had no knowledge of the resident having behavior issues as the resident exhibited no behavior problems for her.
At 9:54 AM, the surveyor interviewed the LPN who stated that the resident was alert with confusion and had not refused medications or care. The resident received Risperdal as needed for a diagnosis of psychosis, and added that sometimes the resident cried because he/she was lonely and wanted someone with him/her. The LPN stated that she gave the resident the Risperdal on 11/17/19 because he/she was crying. After the Risperdal was administered, staff stayed with him/her. The LPN stated that when a as needed psychotropic medication was administered, the target behavior was monitored and a Nurse's Note (NN) was put in the ePN. The LPN stated that she thought she had written as NN on 11/17/19. The LPN was unable to produce the NN at the time of surveyor inquiry.
At 10:08 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that as needed psychotropic medications were only prescribed for fourteen days, and that it was required that target behaviors be monitored, as well as the effectiveness of the medication. The RN/UM stated that Resident #312 was confused and oriented to self only. The RN/UM stated that a Psychiatry consult was scheduled for today, that the Psychiatrist tried to see the resident in the past, but he/she was out of the facility for a scheduled medical procedure at the time of the Psychiatrist visit. The resident's Medical Doctor (MD) was aware that the Psychiatrist had not seen him/her so the MD wanted the resident to continue on the Risperdal until seen by the Psychiatrist. The RN/UM stated that the resident had a behavior of sometimes refusing care, and would refuse care early in the morning.
At 10:17 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the Psychiatrist was scheduled to see the resident today. The DON stated that behaviors were to be monitored and documented for as needed (PRN) psychotropic medications. The DON stated that the resident had behaviors of crying and exhibiting agitation. The DON continued that prior to administering the Risperdal, the nurse needed to try non-pharmacological interventions such as offering food, drink, or toileting. If the non-pharmacological intervention had not worked, then the nurse would administer the PRN Risperdal. The DON added that the Physician Order for the Risperdal came from the hospital when the resident was admitted to the facility, and the MD wanted to continue the Risperdal until the Psychiatrist saw the resident. She confirmed that the nurses should be attempting and documenting all non-pharmacological attempts prior to administering the dose of PRN Risperdal. She confirmed the care plan should specify the resident's target behaviors, a goal, and individual interventions for the use of the psychotropic medication.
At 11:12 AM, the surveyor interviewed the Director of Social Services (DSS) who stated that the resident was very confused. The resident was on a psychotropic medication, and that he/she was fixated on going home, and would become very anxious.
At 11:18 AM, the surveyor observed the resident sitting in the dining room. The resident's eyes appeared tearful. The resident stated hello to the surveyor, but did not speak further to surveyor.
At 12:34 PM, the DON informed the surveyor that the resident was ordered PRN Risperdal on 10/17/19 from the hospital for agitation, and the hospital documented the resident was weeping and became tearful. The DON stated that she was still trying to locate any information on non-pharmacological interventions attempted.
A further review of the ePN, included in a late entry NN dated 11/19/19 at 10:06 AM as effective 10/17/19, received patient up in the bed, seems lonely and crying. Risperdal tab (tablet) given as ordered and staff stayed at his/her bedside, he/she calmed down.
At 11/21/19 at 10:18 AM, the DON, in the presence of the Licensed Nursing Home Administrator, the Regional Nurse, and the survey team, stated that there was no documentation for why the PRN Risperdal was administered or what non-pharmacological interventions were attempted prior to the administration of the Risperdal. The nurses were in-serviced on non-pharmacological interventions and charting on as needed medication prior to this encounter as the facility had been working on a quality assurance (QA) project on this topic already. The DON added that the resident was seen by the Psychiatrist on 11/20/19 who discontinued the PRN Risperdal and ordered a daily antidepressant medication and an as needed anti-anxiety medication.
A review of the facility's Psychotropic Drug Usage policy updated 2/26/19 included that prior to the initiation of psychoactive drug therapy, there must be documentation that a behavior problem exists and non-pharmacological interventions have been attempted and were unsuccessful. The policy also included that behavior monitoring must be done for as needed medication orders.
NJAC 8:39-27.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure that all medications wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication passes on 11/18/19 and 11/19/19, the surveyor observed three (3) nurses administering medications to seven (7) residents. There were 31 opportunities and two (2) errors observed, which calculated to a medication administration error rate of 6.4%. The deficient practice was identified for 1 of 3 nurses and for 1 of 7 residents reviewed, (Resident #5) and was evidenced by the following:
On 11/19/19 at 10:08 AM, the surveyor observed the Licensed Practical Nurse (LPN) preparing to administer medications to Resident #5, in the presence of a second surveyor.
At that time, the LPN prepared seven (7) medications which included one (1) tablet of 8.6 milligrams (mg) of Gerikot (Senna) (a laxative medication) and one (1) tablet of 25 mg of Metoprolol Tartrate (Lopressor) (a medication used to lower blood pressure). The LPN stated that the Senna was an over the counter medication supplied by the facility and was the medication for the physician order (PO) for Senna Plus (a combination product of a laxative and a stool softener).
On 11/19/19 at 10:19 AM, the surveyor observed the LPN administer the seven (7) medications which included the Senna 8.6 mg tablet and the Lopressor 25 mg tablet.
On 11/19/19 at 10:20 AM, the surveyor at the medication cart reviewed the electronic Medication Administration Record (eMAR) with the LPN. The eMAR revealed a PO dated 7/21/19 for Senna Plus 8.6-50 mg, give two tablets orally two times a day for bowel regimen constipation. The LPN stated that she had administered one tablet and had not read that two (2) tablets were to be administered. The LPN further stated that she thought the house stock Senna was the substitute for Senna Plus. The LPN added that she was unaware that Senna Plus was a combination product containing Senna 8.6 mg and Docusate Sodium (a stool softener) 50 mg. The LPN added that her medication cart only contained the Senna 8.6 mg tablets and there was no combination house stock product. The LPN did not know whether the Senna Plus was to be supplied by the facility or the provider pharmacy (Error #1).
At that time, the surveyor, in the presence of another surveyor, further reviewed the eMAR for November 2019 with the LPN which revealed a PO dated 7/21/19 for Lopressor 25 MG which specified in the order to administer with meals. The medication was scheduled to be administered at 8:00 AM. In addition, a review of the pharmacy label for the Lopressor 25 mg tablets revealed a cautionary warning, Take with or immediately following a meal. The LPN stated that she thought the resident had breakfast around 9:00 AM, and she was running a little late because she was not familiar with passing medications on this unit. The LPN then stated that the Lopressor should have been administered with the breakfast meal (Error #2).
On 11/18/18 at 11:34 AM, the surveyor attempted to interview the resident in his/her room, but the resident's speech was garbled and inaudible.
On 11/19/19 at 11:35 AM, the surveyor interviewed the Certified Nursing Aide (CNA) who stated that the resident was confused at times and his/her speech were not always understandable. The CNA also stated that she had fed the resident breakfast in the morning, and that his/her breakfast tray was delivered on the first breakfast truck. The CNA added that she thought the resident had finished breakfast at approximately 8:00 AM.
On 11/19/19 at 12:23 PM, the surveyor reviewed the medical record for Resident #5.
A review of the admission Record (an admission summary) revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction (a stroke), hemiplegia (paralysis of one side of the body) and hypertension.
According to the significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 8/2/19 reflected that the resident had a Brief Interview for Mental Status (BIMS) attempted but was unable to complete so staff performed a cognitive assessment which reflected that the resident had a long and short term memory problem with a severely impaired decision-making capacity.
A review of the November 2019 Order Summary Report reflected a PO dated 7/21/19 for Senna Plus 8.6-50 mg, give 2 tablets orally two times a day for bowel regimen constipation and a PO dated 7/21/19 for Lopressor 25 mg, give one tablet orally two times a day for hypertension with meals.
On 11/20/19 at 10:30 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) who stated that the physician had been called regarding the Senna Plus PO for the resident. The LPN/UM added that the physician had just discontinued the Senna Plus today and ordered the Senna product that was available as house stock.
On 11/20/19 11:12 AM, the surveyor conducted a phone interview with the facility's Consultant Pharmacist (CP) in the presence of another surveyor. The CP stated that the house stock products were chosen by the facility, and that she would only observe if the wrong house stock medication was being administered if she had observed the medication pass. The CP also stated that Lopressor was to be administered with a meal and that she had instructed the nurses through in-services or a medication pass observation to follow cautionary warnings.
On 11/21/19 at 10:13 AM, the survey team met with the facility administrative team. The Licensed Nursing Home Administrator (LNHA) stated that the nurses could expand the facility over the counter house stock list when there was a PO for a house stock product that was not already purchased. The Director of Nursing (DON) added that the nurses could also contact the physician and inform the physician of the house stock products that were available and change the PO according to what the physician agreed upon. The DON acknowledged that the house stock medication must be accurate to the PO. The DON also acknowledged that the cautionary warnings and the PO should be followed.
A review of the facility policy dated as revised 9/10/19 for Medication Pass Techniques provided by the DON included, Be aware of cautionary warnings on the MAR and/or medication prescription label, e.g. Don't crush, shake well, give with food, give on an empty stomach, etc.
A review of the manufacturer specifications for Lopressor reflect that the medication should be administered with or immediately following a meal.
NJAC 8:39-11.2(b), 29.2(d), 29.4(c)
MINOR
(B)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the nurse staffing report on a daily basis. This deficient practice was ...
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Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to post the nurse staffing report on a daily basis. This deficient practice was identified on 11/17/19, and was evidenced by the following: On
On Sunday 11/17/19 at 8:58 AM, the surveyor observed a nurse staffing report on the front reception desk. There was no receptionist present. The nurse staffing report was dated for Friday 11/15/19, and reflected staffing for a resident census of 122.
On 11/17/19 at 10:07 AM, the surveyor interviewed the weekend Nursing Supervisor/Registered Nurse (RN) who said the Staffing Coordinator was responsible for posting the nurse staffing report daily. She stated that she was not involved in the process of posting the nurse staffing report.
On 11/20/19 at 9:23 AM, the surveyor interviewed the Receptionist who stated that the Nursing Supervisor/RN was responsible for posting the staffing on weekends.
On 11/20/19 at 10:53 AM, the surveyor interviewed the Staffing Coordinator who confirmed she printed out the nursing staffing reports every Friday in anticipation for the weekend. She stated that the Receptionist posted the reports on the weekends.
On 11/20/19 at 1:49 PM, the Licensed Nursing Home Administrator (LNHA) stated that the Receptionist was responsible for posting the staffing on weekends at the start of their shift at 8:30 AM.
On 11/21/19 at 10:20 AM, the LNHA stated that the Receptionist came in late at 9:17 AM on 11/17/19 according to the time card report, and had not yet posted the nurse staffing report. He could not speak to why it had not also been posted on Saturday 11/16/19.
A review of the facility's undated Procedure of Posting Staffing Ratio Sheet included, Monday to Friday staffing sheets will be posted by staffing coordinator. Staffing Coordinator will print the staffing sheet for the weekend to be posted by the receptionist. Nursing Supervisor will monitor that this procedure is being implemented.
NJAC 8:39-41.2
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
- • No fines on record. Clean compliance history, better than most New Jersey facilities.
- • 24% annual turnover. Excellent stability, 24 points below New Jersey's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 21 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade C (53/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 53/100. Visit in person and ask pointed questions.
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About This Facility
What is Stratford Manor Rehabilitation And's CMS Rating?
CMS assigns STRATFORD MANOR REHABILITATION AND CARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within New Jersey, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Stratford Manor Rehabilitation And Staffed?
CMS rates STRATFORD MANOR REHABILITATION AND CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 24%, compared to the New Jersey average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Stratford Manor Rehabilitation And?
State health inspectors documented 21 deficiencies at STRATFORD MANOR REHABILITATION AND CARE CENTER during 2019 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 19 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 Stratford Manor Rehabilitation And?
STRATFORD MANOR REHABILITATION AND CARE CENTER 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 MB HEALTHCARE, a chain that manages multiple nursing homes. With 131 certified beds and approximately 119 residents (about 91% occupancy), it is a mid-sized facility located in WEST ORANGE, New Jersey.
How Does Stratford Manor Rehabilitation And Compare to Other New Jersey Nursing Homes?
Compared to the 100 nursing homes in New Jersey, STRATFORD MANOR REHABILITATION AND CARE CENTER's overall rating (3 stars) is below the state average of 3.3, staff turnover (24%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Stratford Manor Rehabilitation And?
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 Stratford Manor Rehabilitation And Safe?
Based on CMS inspection data, STRATFORD MANOR REHABILITATION AND CARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-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 Stratford Manor Rehabilitation And Stick Around?
Staff at STRATFORD MANOR REHABILITATION AND CARE CENTER tend to stick around. With a turnover rate of 24%, the facility is 22 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. Registered Nurse turnover is also low at 17%, meaning experienced RNs are available to handle complex medical needs.
Was Stratford Manor Rehabilitation And Ever Fined?
STRATFORD MANOR REHABILITATION AND CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Stratford Manor Rehabilitation And on Any Federal Watch List?
STRATFORD MANOR REHABILITATION AND CARE CENTER 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.