Livingston Post Acute Care

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that licensed staff credentials were verified upon hire for 56 newly hired licensed staff reviewed. During the entrance conference, the survey team requested a list of employees hired since the last recertification survey, along with their titles and dates of hire, and asked for all new employee files and medical records. The Licensed Nursing Home Administrator stated that the Human Resource Manager was on leave and that the employee files were disorganized, which was why there were loose files and missing documents. The administrator also confirmed that other documents could not be accounted for, and the facility reported 228 total new hires since the last recertification survey. Review of the employee files by multiple surveyors showed that numerous newly hired staff did not have documented reference checks prior to the date of hire. Staff #43, 44, 45, 48, 50, 51, 53, 54, 55, 56, 58, 59, 60, 121, 122, and 124 lacked evidence of previous employment reference checks before hire. Additional files reviewed showed no reference checks for Staff #62, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 78, 79, and 80, as well as Staff #83, 88, 89, 90, 92, 95, 96, 98, 99, 102, 103, 104, 105, 106, 107, 108, 109, 110, 115, 116, 117, 118, 119, and 120. When asked about the missing reference checks, the LNHA stated that when she completed a reference check, she filled out the form or noted that the reference was called, and if the form was not filled out, she did not complete the reference check and did not know what happened.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to evaluate the need for continued indwelling catheter use for two residents who were admitted with Foley catheters, failed to include catheter care in the comprehensive care plan for one resident, and failed to provide appropriate catheter care when catheter tubing was observed touching the floor. One resident was admitted with diagnoses including metabolic encephalopathy due to UTI and dementia, and the MDS showed severe cognitive impairment with a Foley catheter and no corresponding diagnosis. The resident’s record did not show a physician order for the Foley catheter until 39 days after admission, and the physician note reviewed did not identify the diagnosis for catheter use or indicate that the UTI was resolved. For the second resident, the record showed diagnoses including cerebral infarction, hypertension, and generalized muscle weakness, with severe cognitive impairment and an indwelling urinary catheter on the MDS. The comprehensive care plan did not include any focus, goal, or interventions for the indwelling urinary catheter, although it did include an IV catheter. During observation, the resident’s catheter tubing was hung low and the catheter bag, inside a privacy bag, was touching the floor. The DON stated that catheter bags and tubing should be kept off the floor and below bladder level for drainage, and the facility policy stated that drainage bag or tubing should never touch the floor. Interviews with the Charge Nurse, MDS staff, DON, ADON, and LNHA showed that staff did not identify documentation supporting the Foley catheter diagnosis for one resident, and the MDS staff could not explain why the catheter diagnosis was not coded or whether the physician should have been queried. The ADON stated that a urinary catheter should be included in the care plan if a resident was admitted with one, and the DON stated that catheter bags and tubing should not be on the floor and should be checked regularly. The facility policy also stated that when a patient is admitted with a urinary catheter, the catheter is to be removed within 24 hours per physician order unless otherwise directed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services in accordance with professional standards for controlled medications. During medication cart inspections, surveyors found that a resident’s Pregabalin (Lyrica) bingo card count did not match the declining sheet, and the nurse acknowledged she had administered the medication but forgot to sign the record. A similar mismatch was later observed for another resident’s Clonazepam (Klonopin), where the declining sheet and bingo card count did not match and the RN stated she had given the medication but had not signed because she was responding to a resident’s call. Surveyors also reviewed the backup controlled medication system and found that cycle counts were not being performed routinely. Facility staff stated the cycle count was supposed to be done daily, yet the printed records provided showed only 8 of 29 days in the month had cycle counts documented. Several dates with discrepancies had no cycle count completed at all. Staff gave inconsistent explanations about the process, including whether cycle counts were done once a day or every shift, who was responsible, and whether discrepancies required reporting or investigation. The backup system also showed multiple unresolved controlled medication discrepancies involving several residents, including Lorazepam, Clonazepam, Oxycodone IR, Lyrica, and Xanax. Facility leadership stated that some discrepancies were not addressed timely because of the holiday and described them as miscounts rather than missing medications. The policy provided stated that discrepancies should be reported to the charge nurse or supervisor when created, investigated before the end of the shift, and resolved immediately upon discovery, but staff interviews showed that nurses were not aware of how to resolve discrepancies and that only certain leaders had access to do so.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to inform the resident’s representative in advance of the risks, benefits, purpose, and alternatives related to antipsychotic medication use for one resident. Resident #8 had diagnoses including metabolic encephalopathy due to UTI, moderate dementia without behavioral disturbance, psychotic, mood, and anxiety disturbances, and psychosis. The resident’s MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, and noted no behaviors but use of an antipsychotic medication. The resident had an order for quetiapine fumarate (Seroquel) 12.5 mg at bedtime for psychosis for 5 days, and the medication was administered from 11/20/25 through 11/24/25. During record review and staff interview, the LPN/charge nurse stated she was not aware of the regulation for antipsychotic medications, and the MDS coordinator stated that because the resident was a readmission and had been on the medication before, there was no need to get consent again. The facility provided an interdisciplinary team note from 8/20/24 stating meds were reviewed with the resident representative, but no documentation was provided showing the representative was informed in advance of the November 2025 Seroquel use. The LNHA later confirmed there were no notes showing the representative was informed of the antipsychotic use, and that psychiatry did not see the resident for the November 2025 admission.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that call bells were within reach and usable for 3 of 26 residents, including residents with significant mobility and cognitive impairments. During the initial tour, a surveyor observed Resident #2 sleeping in bed with the call bell hung off the side of the bed and the cord wrapped around the side rail, leaving it out of reach. Resident #2’s record showed diagnoses including generalized muscle weakness, cerebral infarction, and aphasia, along with severe cognitive impairment and a care plan noting limited physical mobility and need for bed mobility assistance from one person. A similar concern was observed for Resident #171, who was found sleeping in a low bed with the call bell hanging off the side of the bed and the cord wrapped around the side rail, also out of reach. Resident #171’s record showed diagnoses including cerebral infarction, essential hypertension, and generalized muscle weakness, and assessments reflected severe cognitive impairment and the need for partial or moderate assistance to roll left and right. The care plan identified limited physical mobility, bed mobility assistance from two staff, and a fall-risk intervention directing staff to keep the call light within reach and encourage use for assistance. Resident #15 was observed lying in bed with the call bell dangling from the bedside rail behind the resident and not within reach, and the resident could not locate it when asked. On a later observation, the resident was seated in a wheelchair with the call bell lying on the floor next to the bed, still out of reach, and then observed on a reclining chair after a CNA had made the bed, again not within reach. Resident #15’s record showed diagnoses including senile degeneration of the brain, dementia with psychotic disturbance, schizoaffective disorder, rheumatoid arthritis, spinal stenosis, essential hypertension, macular degeneration, and multiple chronic conditions, with moderate cognitive impairment and a care plan that included keeping the call bell within reach for a resident at risk for falls.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately monitor target behaviors for psychotropic medication use for two residents receiving antipsychotic-related medications. One resident was admitted with diagnoses including right femur fracture, unspecified dementia with behavioral disturbance, and anemia, and had a BIMS score of 8 indicating moderately impaired cognition. The resident was receiving Seroquel 12.5 mg at bedtime for schizoaffective disorder, and the care plan directed staff to monitor and record target behaviors such as hitting, kicking, yelling, hallucinations, restlessness, delusions, interference with care, throwing objects, paranoia, and similar behaviors. For this resident, the electronic behavior monitoring order required staff to document whether behaviors were observed by marking yes or no and, if yes, to enter progress note findings each shift. The nurses’ documentation contained check marks for each shift rather than a yes or no response, and the record did not show whether behaviors were present or absent. The psych follow-up note stated the resident had been paranoid and psychotic and that Seroquel had been started with good effect, with a recommendation to reduce the dose and observe for reemergence of psychosis. A second resident was admitted with diagnoses including unspecified dementia, schizoaffective disorder, and unspecified visual loss, and had severely impaired cognitive skills for daily decision making. This resident was receiving Depakote Sprinkles for mood disturbance and had a care plan noting potential physical and verbal aggression related to psychosis and use of antipsychotic medication related to mood disorder and psychotic disturbances with visual hallucinations at times. The behavior monitoring order also required yes or no documentation and progress note findings each shift, but on several dates the nurse documented yes without describing what behavior occurred. The progress notes did not identify the specific behaviors observed, and the psych follow-up note described the resident as having been very paranoid, needing Seroquel, and later having Seroquel discontinued while continuing Depakote and monitoring for reemergence of paranoia and psychosis.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain professional standards of nursing practice by not following physician orders for two residents. One resident had diagnoses including dysphagia, esophageal obstruction, and dependence on tube feeding, with a care plan reflecting the need for TF related to dysphagia. The physician orders included oral Gabapentin and oral Acetaminophen, as well as a full liquid diet and GT tube feeding. During interview, the RN stated that she crushed the Gabapentin and Tylenol, mixed them with water, and administered them via GT because the resident was unable to swallow, and confirmed there was no order to crush the medications and give them through the GT. The second resident had diagnoses including a right femur neck fracture, dementia with behavioral disturbance, and anemia, and had a BIMS score indicating moderately impaired cognition. The December records showed an order to place an abduction pillow between the legs when in bed and in chair every shift for the hip fracture, but surveyors observed the resident seated without any device between the legs on two occasions. The nurses documented the abduction pillow as given each shift throughout the month despite the surveyor observations and staff statements that the resident was no longer using it on that unit. The same resident also had multiple medication side effect monitoring orders, including for an anticoagulant, antidepressant, and antipsychotic medications, with instructions to document yes or no each shift. The eMAR/eTAR showed nurses signing with check marks rather than documenting the required yes or no responses. Staff interviews confirmed that the monitoring entries should have been documented as yes or no, and that the abduction pillow order should have been discontinued when it was no longer being used.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that treatment and care were provided in accordance with orders and the provider’s assessment and plan for one resident. Resident #166 was admitted with diagnoses including altered mental status, hypertension, type 2 diabetes mellitus, protein-calorie malnutrition, and dysphagia. The resident’s most recent MDS reflected intact cognition with a BIMS score of 13 and indicated an unplanned transfer to the hospital. Review of the resident’s record showed late-entry NP progress notes with assessment and plan entries stating that post-treatment labs were scheduled for 11/24 but were not drawn and were still pending. The record did not show documented nursing follow-through explaining why the plan was not carried out. A nursing note later documented that the resident was transferred to the hospital for a change in status and unstable vital signs, with the NP indicating the resident needed to be sent out and the resident representative notified. The order summary also showed a Glucerna supplement order for twice daily nutrition, with instructions to record the amount taken in percentage form, but there were no percentage entries documented for November 2025. In addition, the record did not contain a physician’s order for acute transfer to the hospital transcribed in the order summary. Facility leadership confirmed that transfer orders should be present, that supplement intake should be documented according to the order, and that communication and follow-through on NP assessments should be documented in the progress notes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Safe and appropriate respiratory care was not provided for a resident receiving oxygen by nasal cannula. During the initial tour, the surveyor observed the resident sitting in a wheelchair on oxygen from a wall mount, with no labels on the tubing to show when it was applied or last changed. A second set of oxygen tubing was also observed lying on the resident's bed and attached to an oxygen tank on the back of the wheelchair, again with no labels showing when it was applied or last changed. The tubing and nasal cannula that were not in use were left open on the resident's bed sheets rather than being contained in a bag or other container. Record review showed the resident's order summary did not include a physician's order for oxygen, and the care plan did not include information that the resident was receiving continuous oxygen. The comprehensive MDS indicated that the resident was receiving continuous oxygen. Facility staff, including the ADON and DON, stated that oxygen should have a physician's order, that tubing is usually changed on Wednesdays, that the order should include the date and frequency for changing it, and that oxygen should be included in the care plan. The facility's oxygen administration policy required verification of a physician's order and review of the resident's care plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by allowing an excessive dose of lidocaine patch therapy. Resident #7 was admitted with diagnoses including essential hypertension, pain due to internal orthopedic implants, and muscle weakness. The resident’s cMDS showed a BIMS score of 13 out of 15, indicating no cognitive impairment. The physician orders included two lidocaine-related orders: one for Lidocan External Patch applied at bedtime and another for Lidocaine Pain Relief 4% Patch applied to the right shoulder once daily for pain management. Review of the eMAR showed the Lidocan External Patch was administered from 12/1/25 through 12/28/25, with administration times indicating the patch was removed at 8:59 PM and applied again at 9:00 PM. The eMAR did not reflect administration of the separate Lidocaine Pain Relief 4% Patch order. The resident’s progress note referenced a lidocaine patch to the lower back without dose or timing details. The ADON and consultant pharmacist both stated that lidocaine patches should be applied for no more than 8 to 12 hours depending on the product and then removed, and that they should not be applied continuously for 24 hours.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medications were administered without error at a rate of 5% or greater. During observation of medication administration for 3 residents, surveyors identified 6 errors out of 25 opportunities, resulting in a 24% medication administration error rate. The deficient practice involved 2 of 3 residents and 2 of 3 nurses observed during the med pass. For one resident, an LPN prepared and administered aspirin 81 mg chewable even though the active order on the eMAR was for aspirin 81 mg delayed release. After the medication was given, the surveyor asked the LPN to compare the bottle label with the eMAR, and the LPN acknowledged that the delayed-release formulation should have been administered. The surveyor also observed that the correct delayed-release aspirin bottle was present in the med cart. For another resident, an RN could not locate folic acid, duloxetine, or insulin glargine during the med pass. The RN documented the medications as not in the cart, did not prepare the folic acid or duloxetine, and placed medications on the resident’s tray table before leaving the room, while the resident took the medications left unattended. The RN later returned with insulin glargine and administered it with insulin aspart. The surveyor also noted that oxycodone was late and that the RN stated insulin aspart was being delayed until after the resident ate. Facility leadership and the consultant pharmacist confirmed that medications should be administered per physician orders and not left unattended at the bedside.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services by ensuring accurate administration of Midodrine for a resident with diagnoses including hypotension, orthopedic aftercare, and bilateral femur fractures. The resident had intact cognition with a BIMS score of 14 out of 15. The physician’s order directed Midodrine 5 mg via G-tube three times daily for low blood pressure, with instructions to hold the medication if systolic blood pressure was greater than 120 mm/Hg. Review of the December 2025 eMAR showed that Midodrine was administered on multiple occasions when the recorded blood pressure was above the ordered parameter, including readings of 128/88, 128/66, 124/70, 125/68, 143/83, 129/74, and 130/70. The eMAR also showed numerous instances where the medication was withheld, but the blood pressure field contained an X instead of an actual blood pressure reading. During interview, an RN confirmed she signed the medication as given even though she did not administer it, stated that Midodrine should be withheld when systolic blood pressure was over 120, and could not explain how the blood pressure was determined when only an X was documented. The facility also failed to ensure a resident was free from a significant medication error during a med pass observation. An RN prepared and administered insulin aspart to a resident with diabetes based on a blood sugar reading of 159 that had been taken about two hours earlier. The order required insulin aspart to be given at scheduled times, including 7:30 AM, with dosing based on the current blood sugar result. The RN delayed administration until after the resident ate and gave the insulin at 9:33 AM using the earlier blood sugar value. The DON confirmed that medications should be given as ordered, that insulin should not be administered two hours later and after the meal when ordered for a specific time before meals, and that the blood sugar reading used for dosing should be current.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Medication was found left in active inventory for a resident who had already been discharged from the facility. During inspection of medication cart #2, the surveyor and an LPN observed Cosopt Ophthalmic Solution still inside the cart for a resident who the LPN confirmed had been discharged to home approximately two days earlier. The LPN stated the medication should have been disposed of when the resident was discharged and removed it from the cart during the inspection. The third floor emergency cart was also found to contain expired supplies. In the presence of the LPN/Unit Manager, the surveyor observed expired suction catheter kits, suction tubing, non-rebreather masks, and IV needles in the ecart. The LPN/Unit Manager stated that expired supplies should not be in the ecart and identified the 11-7 shift supervisor as responsible for checking it. The DON later confirmed that discharged residents’ medications should be removed from the medication cart and that there should be no expired supplies in the ecart.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to perform testing of close contacts after residents tested positive for COVID-19. The report identified three residents who tested positive in sequence, with the first two residents sharing the same room and the third resident later becoming positive as well. Facility staff documented that the first resident was placed in isolation and the roommate was moved but kept as a PUI, yet there was no documentation that staff or resident close contacts were tested after the first positive case or after the second positive case. The Assistant Director of Nursing/Infection Preventionist stated that contact tracing was done for the initial resident, but the resident representative was not tested even though they were not feeling well. She also stated that staff were not tested after the first positive case and that the facility was waiting for guidance from the Local Health Department. The second resident was initially asymptomatic, later developed a slight cough, and then tested positive. The contact tracing sheets for the first two residents did not identify any close contacts or show that any staff or residents were tested. The Local Health Department emailed the facility that the two residents in the same room constituted an outbreak and provided guidance that asymptomatic close contacts should receive a series of three viral tests. A later email from the Local Health Department again directed the facility to conduct contact tracing on all resident and staff cases and to test close contacts on days 1, 3, and 5. Despite this, the facility’s documentation showed no testing of close contacts for the first two residents, and for the third resident the facility identified staff encounters and therapists but did not test those asymptomatic contacts. The DON stated he did not do anything with the Local Health Department emails and was not aware if testing had been done, while the ADON/IP stated that the facility did not test any residents and did not believe asymptomatic close contacts had been tested.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident admitted with end stage renal disease, Parkinson's Disease, type 2 diabetes, and osteomyelitis did not receive ordered intravenous (IV) antibiotic therapy as prescribed. The resident was admitted for the primary purpose of receiving IV Cefazolin to treat a bone infection. Despite physician orders for daily administration of Cefazolin, the resident did not receive four consecutive doses following admission, with the first dose not administered until several days later. The facility's policy required nursing staff to contact the pharmacy, attempt to obtain the medication from available sources, and notify the physician if a medication was unavailable. Documentation in the resident's medical record indicated that the antibiotic was not on hand and that there were difficulties establishing IV access, including unsuccessful attempts to start a line and delays in obtaining a midline due to the need for renal clearance. However, there was no documentation that the resident's physician was notified of the missed doses or the unavailability of the medication during this period, nor was there evidence of alternative orders or instructions from the physician regarding the missed therapy. Interviews with facility leadership confirmed that the expectation was for the physician to be informed of missed medication doses and for this communication to be documented in the resident's record. The record review and staff interviews revealed that the physician was not made aware of the missed doses until several days after the initial missed administrations, and the medical record did not reflect timely notification or a plan to address the missed antibiotic therapy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically N.J.S.A. 30:13-18, which mandates minimum staffing levels in nursing homes. During the investigation of complaints NJ00179449, NJ00179546, and NJ00181407, it was found that the facility did not have the required number of Certified Nurse Aides (CNAs) on several day shifts. For the period from August 11, 2024, to August 24, 2024, the facility was deficient in staffing on five out of fourteen day shifts. For instance, on August 11, 2024, there were only 15 CNAs for 130 residents, whereas at least 16 were required. Similar deficiencies were noted on August 21, 22, 23, and 24, 2024, where the number of CNAs was consistently below the required ratio. Additionally, a review of staffing levels for the two weeks prior to the complaint survey, from December 22, 2024, to January 4, 2025, revealed a deficiency on one day shift. On December 22, 2024, the facility had 14 CNAs for 120 residents, falling short of the required 15 CNAs. These staffing deficiencies had the potential to affect all residents in the facility, as adequate staffing is crucial for ensuring proper care and safety for residents.

Plan Of Correction

No residents were identified as having been affected. All residents have the potential to be affected. Will add a certified nursing aide to all shifts that did not meet the requirement to be in compliance with staffing ratio of 1:8 during daytime hours, 1:10 for afternoon, and 1:14 for overnight. When an employee calls out coverage to be obtained by nursing supervisor and Director of Nursing. Director of Nursing, Staffing Coordinator and Administrator will meet daily during the week to review recruitment efforts, staffing for next day, and staffing for upcoming week. Trends identified from these meetings will be presented during monthly QAPI meeting. The facility has implemented a multifaceted approach for recruitment and retention of employees, which includes increased utilization of PRN/Per diem staff (Staff hired without any set hours, usually staff who have another job and pickup extra shifts when the need arises), Multimedia advertisements, Partnership with schools, Pick-up shift bonuses, Text message campaigns. Flyers placed around the buildings and on social media. The facility continues to utilize a recruitment company to do paid campaigns with Indeed, and other social media platforms to recruit nursing staff. Daily update emails and weekly meetings help to identify trends in hiring and review all new hires and where candidates stand in the hiring process. Targeted advertising in place to attract licensed nurses and aides. Employee engagement is led by management team/department heads to facilitate staff engagement and reduce employee turnover. Exit interviews being held to determine why staff are leaving. Referral bonus in place for any staff who refer a friend who gets hired, new hire bonus in place and paid out over a year of hire to ensure that employees stay in the position.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to handle potentially hazardous foods and maintain kitchen sanitation in accordance with professional standards, as observed by the surveyor. During a tour of the kitchen, the surveyor noted several deficiencies, including unlabeled and undated food items in a refrigerator and on wheeled carts. The refrigerator contained packages of waffles, a bowl of salad, and a pan of pasta, all without labels or dates, and debris was found at the bottom of the refrigerator. Additionally, food items on the carts were mostly unlabeled and undated, with only two items properly marked. The surveyor also observed issues with the facility's sanitation practices. DA#2 was seen washing pans in a 3-compartment sink, but the sanitizing solution in the third compartment was not present, as indicated by a test strip showing a result of zero. The test strips used did not have an expiration date, and DA#2 was not aware of the proper use of the sanitizing solution. Furthermore, a box fan with dust accumulation was blowing air on utensils, and there was an accumulation of dust on the utensil rack, as well as discolored air vents and ceiling tiles. The facility's documentation and staff training were also found lacking. The log book for the 3-compartment sink was initially missing and later found, showing entries with DA#2's initials for days he did not work. The LNHA confirmed that no other staff shared the same initials, indicating falsification of records. The facility's policies on food storage and sanitization were not adhered to, contributing to the observed deficiencies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that its facility-wide assessment included the necessary resources to establish policies and procedures for a staffing contingency plan, as required by CMS updates. This deficiency was identified during a survey when the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were unable to provide a comprehensive Facility Assessment (FA) that included a staffing contingency plan. The FA, dated July 23, 2024, lacked details in Part 3, Section 3.2 Staffing Plan, and Section 3.5 Policies and Procedures, which are essential for managing staffing during both regular operations and emergencies. Despite the LNHA's awareness of the CMS updates effective from August 8, 2024, the FA did not reflect these requirements. Additionally, the facility did not meet its own staffing plan as outlined in the FA. The FA indicated a need for 16-18 nurse aides to meet resident needs at any given time. However, staffing reports for the weeks of September 1-7 and September 8-14, 2024, showed that the facility consistently fell short of this requirement. Specifically, nurse aide staffing was below the minimum of 16 on multiple occasions across day, evening, and night shifts. The surveyor, upon reviewing these discrepancies with the LNHA, DON, Regional Nurse Consultant (RNC), and Infection Preventionist (IP), noted the absence of a staffing contingency plan as per the CMS update and the Quality Safety Oversight memo. The facility did not provide any additional documentation to address these concerns.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a designated dining room for residents, as required by federal regulations, the approved floor plan, and facility policy. This deficiency was identified during a survey conducted by surveyors who met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA admitted that since her tenure began, there had been no physical dining area, resulting in the absence of communal dining services for the 126 residents. Instead, the facility offered room tray services. The surveyors noted that the facility was approved for communal dining on the first floor, according to the submitted floor plan, but this service was not being provided. Further investigation revealed that during a resident council meeting, four residents expressed a desire for communal dining, which was not being offered. The facility's Accommodation of Needs Policy, updated in April 2024, stated that residents' individual needs and preferences should be accommodated, including their dining preferences. However, the facility failed to adhere to this policy by not providing a communal dining option. The survey team communicated these concerns to the facility management, but no additional information was provided during the exit conference.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in the management of care. For Resident #148, the MDS did not reflect the administration of antibiotics, despite documentation in the electronic Medication Administration Record (eMAR) indicating that Cephalexin was given. Additionally, there was a discrepancy in the recorded minutes and days of respiratory therapy, as the MDS showed different values than those documented in the resident's records. The Registered Nurse/MDS Coordinator (RN/MDSC) acknowledged the discrepancies but did not provide a satisfactory explanation. Resident #62's MDS was inaccurately coded as a Significant Change in Status Assessment (SCSA) without proper documentation to support a significant change in the resident's condition. The resident's cognitive status was assessed as moderately impaired, but there was no evidence of a significant change that warranted the SCSA. Furthermore, the MDS inaccurately indicated that the resident had declined a pneumococcal vaccine, with no supporting documentation in the medical record. For Resident #209, the Quarterly MDS was completed with an incorrect timeline for the pain assessment interview, which was conducted outside the required look-back period. The RN/MDSC was unable to provide a clear response regarding the timing of the assessment. These inaccuracies in MDS coding reflect a failure to adhere to federal guidelines, impacting the accuracy of resident assessments and care planning.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure sufficient nursing staff and timely response to call bells, affecting seven residents. Observations revealed that the Certified Nursing Aide (CNA) to resident ratio exceeded the mandated New Jersey staffing law requirement of 1:8, with ratios of 1:8.6 and 1:9 on different days. This staffing inadequacy contributed to delayed responses to residents' call bells, as reported by several residents. Resident #83, who had intact cognition and required assistance with toileting hygiene, reported long wait times for call bell responses, particularly during the night shift. The resident had to call a family member to get assistance after the call bell was not answered, and the staff only responded after the family member contacted the facility. Similar issues were reported by Resident #100, who had a sacral pressure ulcer and other medical conditions, and Resident #36, who experienced long wait times during night shifts. The facility's call bell audits showed response times ranging from 4 to 25 minutes, with some instances of staff re-education when longer wait times were noted. However, the audits were infrequent and did not cover all shifts adequately. During a resident council meeting, four residents reported average call bell response times of at least 20 minutes. The facility's policy stated that calls for assistance should be answered as soon as possible, but this was not consistently achieved, as evidenced by the surveyor's observations and resident reports.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer oxygen therapy according to the physician's order for a resident who was observed receiving 4 liters per minute (LPM) of oxygen via nasal cannula, despite the physician's order specifying 2 LPM. The discrepancy was confirmed by the Unit Manager/LPN, who was unaware of who changed the oxygen setting. This oversight was acknowledged by the Director of Nursing as a human error. Another resident was observed with a nebulizer mask improperly stored, exposing it to environmental contamination. The resident's care plan lacked documentation on the proper storage of respiratory equipment. Additionally, a pulmonary consultation's recommendations were not communicated to the primary care physician, and there was no documentation of the physician's agreement or disagreement with the recommendations. The Assistant Director of Nursing/Infection Preventionist confirmed the need for proper documentation and storage practices. Further observations revealed that several residents had oxygen tubing and nebulizer masks that were not dated or stored in bags when not in use, contrary to infection control measures. One resident was found to be on oxygen therapy without a physician's order, and the facility's policy did not provide guidance on dating or storing respiratory equipment. These deficiencies were acknowledged by the facility management during meetings with the survey team.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations during a survey. Several staff members, including a Certified Nursing Aide (CNA), were observed not performing hand hygiene after glove removal, which is a critical step in preventing the spread of infection. The CNA admitted to not performing hand hygiene due to the absence of alcohol-based hand rub (ABHR) in the resident's room, despite having received prior education on hand hygiene and PPE use. Additionally, improper use of personal protective equipment (PPE) was noted among staff members. A CNA was observed with a surgical mask improperly worn below the nose and mouth while assisting a resident, and another CNA failed to wear a PPE gown during high-contact care activities with a resident on Enhanced Barrier Precautions (EBP). These actions were contrary to the facility's infection control policies and CDC guidelines, which require proper PPE use to prevent the spread of multidrug-resistant organisms (MDROs). Further deficiencies were observed in the handling of clean linen and medication administration. A linen cart, considered clean, was found to contain food items, which is against the facility's policy for maintaining hygienically clean linen. During a medication pass, a nurse used the same tissue to wipe both eyes of a resident after administering eye drops, which was acknowledged as an infection risk by the nurse and the unit manager. These observations highlight lapses in maintaining infection control standards during routine care activities.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify a resident's representative and physician of a change in condition in a timely manner. The resident, who had moderate cognitive impairment, reported to the nursing staff that they had fallen the previous day and were experiencing leg pain. However, there was no documentation of the fall, and the resident's representative and physician were not immediately informed of the incident. The resident was later found crying in pain, and only then was the physician notified, and an x-ray was ordered. Attempts to contact the resident's representative were made, but no immediate notification was documented. The facility's policy on accidents and incidents requires immediate notification of the resident's physician and family, which was not adhered to in this case. The Licensed Practical Nurse involved could not recall if the resident's representative was notified and had to refer to her notes. The facility management acknowledged the lapse in following their process for notifying the resident's representative and physician. The survey team reviewed the facility's policy and found it was not followed, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe discharge for a resident by not obtaining a physician's order for discharge and not documenting the acceptance of a referral for home care services. The resident, who had severe cognitive impairment and medical conditions including a pressure ulcer, was discharged without confirmation from the home care service agency that they could provide the necessary post-discharge care. The Social Worker Director (SWD) stated that the referral was sent to Home Care Service Agency #1 (HCSA#1), but there was no documented evidence of acceptance or approval from the agency. The discharge planning process was initiated at the time of the resident's admission, involving the resident's representative and the facility's interdisciplinary team. However, the facility's documentation did not include a physician's order for discharge, and the SWD did not receive or document confirmation from HCSA#1 that they could accept the referral. The SWD later learned that HCSA#1 could not take the resident and had referred them to another agency, HCSA#2, but by that time, the resident had already been taken to the hospital by their representative. The facility's policies required that a discharge summary and post-discharge plan be developed, including arrangements for follow-up care and services. Despite these requirements, the facility did not provide evidence that the home care referral was accepted or that a physician's discharge order was obtained. The lack of documentation and communication between the facility and the home care agency contributed to the failure to ensure a safe discharge for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to document a discharge summary for a resident who was reviewed for discharge. The resident, identified as having severe cognitive impairment with a BIMS score of 03 out of 15, was admitted with medical diagnoses including a pressure ulcer of the sacral region, abnormal posture, and cognitive communication deficit. The resident had a planned discharge to home/community, but upon review, the hybrid medical record did not contain a discharge summary. During the survey, the Licensed Nursing Home Administrator, Director of Nursing, Regional Nurse Consultant, and Regional LNHA were informed of the missing discharge summary. The facility's policy requires a discharge summary to include a recapitulation of the resident's stay and a final summary of the resident's status, which was not present in this case. Despite the facility's policy and the surveyor's request for confirmation, the facility administration did not provide additional information or confirm the presence of a discharge summary in the electronic medical record.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pain management for a moderately impaired resident, identified as Resident #209, who was admitted with diagnoses including lower back pain, hypertension, and metabolic encephalopathy. The resident's Quarterly Minimum Data Set indicated moderate cognitive impairment. Despite having physician orders for pain management with Acetaminophen, there was no documented evidence of routine pain assessments from June through July 2024, and the resident's care plan did not include a plan for pain management. Interviews with the Director of Nursing (DON) and other nursing staff revealed inconsistencies in the facility's pain assessment practices. The DON stated that pain assessments were conducted upon admission and every shift, but acknowledged that documentation was not always required. The Unit Manager and Licensed Practical Nurses confirmed that pain assessments should be documented every shift, but this was not consistently done for Resident #209. The facility's policy required pain assessments to be conducted and documented regularly, but this was not adhered to in practice. The facility's Pain Assessment and Management policy outlined the need for consistent pain assessment and documentation, especially for acute or worsening chronic pain. However, the facility failed to follow these guidelines, resulting in a lack of documented pain assessments for Resident #209. The survey team highlighted these deficiencies to the facility management, who acknowledged the oversight and confirmed that the pain assessment would be reinstated in the resident's orders.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper monitoring and documentation of a resident's condition following falls. Resident #148 experienced two falls, one on 8/29/24 and another on 9/04/24, with the latter resulting in skin tears and a hospital visit for a CT scan. Despite the nurse practitioner's note indicating the resident was on neurochecks, there was no documented evidence of such monitoring post-fall, except on the day of the incidents. The Director of Nursing acknowledged the expectation for nurses to document every shift for three days post-incident, which was not adhered to in this case. Another deficiency involved the failure to follow a physician's order regarding urinary catheter output documentation for Resident #358. The resident had a history of urinary tract infection and obstructive uropathy, with a physician's order to document catheter output every shift. However, the electronic Treatment Administration Record showed multiple instances of missing or low urine output documentation, with no evidence of physician notification or actions taken for low output. The Assistant Director of Nursing confirmed the expectation for nurses to document output every shift and notify physicians of low output, which was not met. The third deficiency was observed during medication administration for Resident #260, where a Registered Nurse administered a tablet form of Docusate Sodium instead of the prescribed capsule form. The nurse acknowledged the error upon questioning and stated the procedure would be to contact the physician for an order change. The facility's policy requires medications to be administered as prescribed, which was not followed in this instance. The Unit Manager and Consultant Pharmacist both confirmed that the correct dosage form should be administered or the order changed if necessary.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide care and services consistent with professional standards of practice for a resident with pressure ulcers. The deficiency was identified for a resident who developed a new wound on the right heel after being admitted to the facility. The resident, who was cognitively intact and had a history of chronic kidney disease, heart failure, hypertension, diabetes mellitus, and osteoarthritis, reported the new wound to the surveyor. The facility's records indicated that the wound was first noted on 9/09/24, and treatment with Medihoney was ordered, but there was a lack of documentation and timely initiation of treatment. The surveyor found discrepancies in the facility's documentation practices. The electronic Treatment Administration Record (eTAR) showed inconsistent entries for skin evaluations, with one entry marked as 'n' instead of the required numerical codes. The Director of Nursing (DON) was unable to explain the discrepancy initially but later clarified that 'n' indicated no wound or change. Additionally, there was no documentation in the nurse's progress notes about the new wound, and the wound treatment order was missing for the period between 9/09/24 and 9/11/24. The facility's wound care policy was reviewed and found to be lacking in specific guidance on wound assessments and documentation. The surveyor noted that the policy required documentation of any change in the resident's condition, but this was not adequately followed. Despite requests for additional policies related to wound care and skin assessments, the facility did not provide any further information. The surveyor's findings highlighted the facility's failure to maintain accurate and timely documentation and to follow established protocols for wound care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care for a resident with decreased range of motion (ROM) and mobility, leading to a deficiency in maintaining and preventing further decline in the resident's condition. The resident, who was admitted with multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction, had impairments in both upper and lower extremities. Despite these impairments, the resident's personalized care plan did not address these issues, and there was no documented evidence of services or interventions provided to address the impairments. Observations and interviews revealed that the resident had bilateral upper and lower extremities contractures, and no assistive devices or splints were provided since the resident's admission. The Director of Rehabilitation (DoR) and other staff members were unable to provide evidence of quarterly rehab screens for the resident, which were supposed to be part of the facility's process. Additionally, the therapy screen forms for other residents were incomplete, lacking necessary details such as the names of the occupational therapy staff and whether evaluations were recommended. The facility's policy on range of motion devices did not include information about passive range of motion (PROM), and there was no policy provided regarding PROM. The surveyor's inquiries revealed that the resident was not included in the therapy screen list, and the facility management could not provide evidence of quarterly rehab screens for the resident. The lack of a comprehensive care plan and failure to provide necessary interventions and documentation contributed to the deficiency identified by the surveyors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper monitoring and documentation of residents' weights, leading to a deficiency in maintaining adequate nutrition and hydration. For Resident #2, the facility did not perform or document monthly weights and re-weighs as required. Despite a significant weight loss of 32.8 pounds within a month, there was no evidence that the physician was notified. The resident's medical records showed a history of various health conditions, including diabetes, chronic kidney disease, and heart failure, which necessitated careful nutritional monitoring. The dietitian noted the weight loss but did not communicate it to the physician, and the Unit Manager failed to enter the re-weighs into the electronic medical records. For Resident #67, the facility did not clarify duplicate physician orders for gastrostomy tube flushes, which were transcribed and signed off by nurses without correction. The resident, who was dependent on tube feeding due to severe cognitive impairment and other health issues, had missing weight records for certain months, and the facility did not follow the physician's order for monthly weight checks. The dietitian documented missing weights but did not follow up on them, and the Unit Manager acknowledged that weights were not taken or documented as required. The facility's policy on weight assessment and intervention was not adhered to, as evidenced by the lack of proper weight monitoring and physician notification for significant weight changes. The surveyor's interviews with staff revealed a lack of communication and responsibility in documenting and addressing weight changes, contributing to the deficiency in providing adequate nutrition and hydration to the residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain proper dialysis communication records and provide care in accordance with professional standards for two residents requiring dialysis services. For Resident #98, the Dialysis Center Communication Record (DCCR) was inconsistently filled out, with several dates showing incomplete documentation. The facility's policy did not address the protocol for completing the communication form, and the Licensed Practical Nurse (LPN) confirmed that the expectation was for the record to be fully completed upon the resident's return from dialysis. Additionally, there was no documentation of the assessment of the dialysis access site post-treatment for several dates. Resident #458, who had severe cognitive impairment and multiple health issues including chronic kidney disease and diabetes, also experienced deficiencies in care. The facility failed to provide dialysis communication forms for this resident, and there were no progress notes for several dates when the resident was sent to or returned from dialysis. Furthermore, the Certified Nurse Aide (CNA) documentation for the resident's eating and percentage consumed was largely incomplete, with 84 out of 90 entries left blank. This lack of documentation did not reflect the resident's meal consumption or the assistance provided during meals. The facility's policies on dialysis communication and activities of daily living did not adequately address the record-keeping requirements or the provision of meals and snacks for dialysis residents. The surveyor's interviews with staff revealed inconsistencies in the understanding and implementation of these policies, contributing to the deficiencies observed in the care of Residents #98 and #458.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the daily posting of licensed nurses, certified nursing aide staffing, and the resident census on two out of five days during the survey. On two separate occasions, the Nursing Home Resident Care Staffing Report (NHRCSR) was not updated for the current day shift. Specifically, on the morning of 9/16/24, the NHRCSR posted was dated for the previous day, 9/15/24, and similarly, on 9/17/24, the report was dated for 9/16/24. This oversight was observed by the surveyor upon entry into the facility on both days. The Director of Nursing (DON) acknowledged the issue when notified by the surveyor, stating that the Staffing Coordinator (SC) was responsible for posting the NHRCSR. The SC confirmed her responsibility and recognized the importance of posting the staffing information daily to inform residents and their families about the staffing levels. The facility's policy, updated in 4/2024, mandates that direct care daily staffing numbers be posted for every shift. Despite the acknowledgment of the deficiency, the facility management did not provide additional information or refute the findings during the exit conference.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner for a resident reviewed for unnecessary medications. The resident, who had diagnoses including unspecified dementia with psychotic disturbance and hypertension, was observed to be alert and verbally responsive but had moderate cognitive impairment. The resident had a physician's order for Lorazepam to be given as needed for agitation and anxiety, and a care plan involving the use of antipsychotic medication Seroquel. However, there were no psychiatry consultant notes after February 2024, and the resident's representative had requested that the primary physician manage the medication regimen. The CP reports from June, July, and August 2024 recommended specifying a duration for the PRN psychoactive medication Lorazepam unless a clinical rationale was documented by the physician. Despite these recommendations, there was no documentation of follow-up with physicians or hospice regarding the CP's suggestions. The Director of Nursing (DON) acknowledged reviewing the August 2024 CP report and the Medication Administration Record (MAR) but had not yet followed up with the physician or hospice. The facility's policy on psychotropic medication use and medication regimen reviews required timely follow-up on CP recommendations, with documentation of any actions taken. However, the surveyor found that the facility did not adhere to these policies, as there was no documentation by the primary physician or nurse practitioner about reviewing the resident's psychotropic medication regimen. The DON stated that the Assistant Directors of Nursing (ADONs) were responsible for reviewing CP recommendation reports, with an expectation of follow-up within two weeks, but this was not done in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medications were stored securely and appropriately, as observed by a surveyor during an initial tour. On the third floor, a medication cart was found with two vials of Acetylcysteine left unattended on top. The nurse responsible for the cart admitted to leaving the vials there while attending to a resident, intending to return them to the refrigerator. This action was contrary to the facility's policy, which mandates that all drugs and biologicals be stored in locked compartments and only accessible to authorized personnel. The surveyor confirmed with the Consultant Pharmacist that medications should never be left unattended or unsecured. The Director of Nursing also acknowledged that medications should not be left on top of the cart unattended. The facility's policy, last updated in April 2024, clearly states that drugs and biologicals must be stored in a safe, secure, and orderly manner, under proper conditions. Despite this policy, the facility did not provide any further pertinent information to address the observed deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain complete, accurate, and readily accessible medical records for two residents. For the first resident, there was a discrepancy in the documentation of their advance directives. Although the resident's medical records, including the POLST and care plan, indicated a DNR status, the physician's progress notes did not accurately reflect this. The facility's management acknowledged the inconsistency but did not provide additional information or policies addressing medical record accuracy. For the second resident, the facility did not properly document or follow up on a pulmonary consultation. The pulmonologist recommended a treatment plan that included duoneb and monitoring of oxygen saturation, but this plan was not communicated to or agreed upon by the primary care physician or nurse practitioner. The DON later revealed that the pulmonologist verbally advised against the plan, but this was not documented. Additionally, there were errors in the nurse practitioner's notes, which were not corrected until after the surveyor's inquiry. The facility's policy on electronic medical records did not address the issues of accuracy or documentation, contributing to the deficiencies observed. The survey team met with facility management multiple times, but no further information or corrective actions were provided to address the documentation issues identified during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to offer or document the administration or ineligibility of the pneumococcal vaccine for three residents. Resident #43, who was cognitively intact, had multiple medical conditions including metabolic encephalopathy, multiple myeloma, type 2 diabetes, hypertension, morbid obesity, anemia, and asthma. Despite these conditions, there was no documentation in the resident's medical record indicating that the pneumococcal vaccine was offered, declined, or that the resident was ineligible. The Licensed Nursing Home Administrator (LNHA) was unable to provide documentation to support the claim that the resident was not eligible for the vaccine. Resident #62, who had moderate cognitive impairment, was documented in the Minimum Data Set (MDS) as having been offered and declined the pneumococcal vaccine. However, there was no documentation in the electronic medical record (EMR) or paper chart to support this, nor were there any physician orders for the vaccine. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) acknowledged the lack of documentation and was unable to provide further information on the resident's vaccination status. Resident #148, who was cognitively intact and had conditions such as essential hypertension, anemia in chronic kidney disease, and chronic obstructive pulmonary disease (COPD), was not documented as having been offered the pneumococcal vaccine. There was no evidence in the medical records that the vaccine was offered, declined, or that education about the vaccine was provided. The ADON/IP confirmed the absence of documentation and stated that the vaccine should have been offered. The facility's policy required that all residents be assessed for vaccine eligibility and offered the vaccine unless contraindicated, but this was not followed in these cases.