The Subacute At Autumn Lake Healthcare

resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when

jeopardy to resident health or comprehensive assessment and plan of care, current professional standards of practice and the safety resident's goals and preferences .NJAC 8:39-27.1(a)

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The Subacute at Autumn Lake Healthcare 113 Route 73 Voorhees, NJ 08043

should go to the Pyxis for that one time, but you do not give scheduled medications out of the backup.

jeopardy to resident health or delivery if required.

During an interview on 09/26/25 at 1:56 PM, the DON was asked if she had any safety additional information after reviewing R16's chart on 09/25/25 after our interview, as documented above.

The DON stated she did not have any additional information.

During an interview on 09/26/25 at

medications from the Pyxis, call the doctor, and call the pharmacy. LPN3 stated you could not just leave the residents in pain.

Review of the Pharmacy policy Providing Pharmacy Services dated February 2023 indicated, .When medication is needed prior to the next scheduled delivery and is not contained in the back-up box/ stat/ emergency kit drug supply, the pharmacist arranges for both the dispensing and delivery of medication to the facility within the time frame specified by contract; .

Medication may be dispensed by either [Name of Pharmacy] or a back-up pharmacy and delivered by either a [Name of Pharmacy] driver, back-up pharmacy, or a courier service . NJAC 8:39-29.2(d)

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The Subacute at Autumn Lake Healthcare 113 Route 73 Voorhees, NJ 08043

for R16. R16 was admitted to the facility with diagnoses including pancreatic adenocarcinoma and had

levels up to a 10 (on a zero to 10 scale, with 10 being the most intense pain possible).

This failure of

painful death.

During an interview on 09/24/25 at 4:30 PM, the Pharmacist stated this written script for Dilaudid, as well as one for the admission order for Dilaudid, was not received at the pharmacy until 01/05/25.

During an interview on 09/25/25 at 11:30 AM, the DON stated, I do not recall being made aware of this resident's medications not being available from the pharmacy.

But the nurses and the nursing supervisor once they noted the medications were not being delivered, they should have called the pharmacy back to ask about them.

But to the specifics of this case regarding the pain, I will have to review this further and get back to you.

Review of the Case Review Form (complete for EACH death) indicated the review for R16 indicated a review was conducted in the following areas:-.Date/Time of Death indicated 1/6/25 [sic]-Location Facility was marked-Code Status indicated DNR [Do Not Resuscitate]/DNI [Do Not Intubate]/DNH [Do Not Hospitalize]-Advance Directives on file Yes was checked-Hospice/Palliative Care involved No was checked-Immediate Notifications & [and] [sic] Actions-Provider Notified at 1/6/25 [sic] was written in by 10:55 was written in-Next of Kin/Representative notified at 11 A [sic] [AM] was written in by was left blank-Hospice notified at was marked through-Coroner/Medical Examiner notified at was marked through and written was family notification - [name of funeral home] was written in-State reportable event determination completed at was marked through-Post-mortem care provided per policy at 1/2/25 [sic] was written in by [name of LPN4]-Medication secure/Accounted for (controlled count completed) was checked-Room/Belongings secured and inventory initiated was checked-Clinical Synopsis MDS was written in-Medication and Treatment Review Reviewed w/ [with] IDT Team was written in-Systems Reviewed Attached was written in-Root Cause Analysis (RCA) Pancreatic CA [cancer], Esophageal Varicies [sic], Cirrhosis was written in-Family Communication & Support via [by] telephone + bedside was written in-IDT [Interdisciplinary] Review Meeting Summary 1/28/25 was written in-Action Plan PIP was written in.

During an interview on 09/25/25 at 4:00 PM, the DON stated, We did a mortality review, but it wasn't an in-depth review of the Dilaudid specifically being available.

During an interview on 09/26/25 at 10:19 AM, the Medical Director stated his expectations of the DON and the IDT Team in regard to the PIP for the unexpected death, was to Be able to pinpoint the breakdowns and failures that have occurred and fix these along with providing education to the staff.

Then after the education piece and failures have been fixed; go back and access how it is or is not working and consistently be aware of all of this to make sure the staff is properly implementing the changes. In other words, you have to drive the bus to make sure it doesn't happen again and to monitor that everything is being carried out by the staff properly.

Asked what his role was in the PIP process for the unexpected death and the Medical Director stated, They ran thing by me saying this is what we are doing and is there anything else you can think of that would help in this situation.During an interview on 09/26/25 at 1:00 PM, the Administrator stated, We go over the reviews that the DON and the IDT team do for the deaths that occur in the building for each month.

The PIP for this was started before I came in February, so I was told there was an unexpected death is the reason we were doing the PIP.

The DON does the initial review of each death and brings to QAPI each month where we discuss the mortality reviews and he findings for each. I expect the DON to see the weaknesses that we had with each death to see what we can do better and then initiate these changes to reflect better quality of care.

Review of the DON's job description indicated, .

Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .

Assist the Quality Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies . NJAC 8:39-33.1

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The Subacute at Autumn Lake Healthcare 113 Route 73 Voorhees, NJ 08043

and R13) observed out of a total sample of 15 residents.

This failure had the potential to introduce

electronic medical record (EMR) indicated R14 was admitted to the facility in 9/2025.Observation on 09/11/25 at 5:40 AM, revealed Licensed Practical Nurse (LPN)1 was observed with her bare index and middle finger inside of the medication cup which contained R14's medication. LPN1 administered the medications from the cup to R14. 2.Review of R13's undated Face Sheet located under the Profile tab in the EMR indicated R13 was admitted to the facility in 08/2025.During an observation on 09/11/25 at 5:49 AM LPN1 was observed with her index finger touching the inside of the medication cup. LPN1 administered the medications from the cup to R13. LPN1 did not have gloves on during this observation.

During an interview on 09/11/25 at 5:50 AM, LPN1 stated, I should not have touched the inside of the medication cup with my bare fingers.

During an interview on 09/11/25 at 9:48 AM, the Infection Preventionist (IP) stated, The nurse should never touch the inside of the medication cup with her bare hands or fingers prior to giving the medication.

During an interview on 09/12/25 at 12:10 PM, the Director of Nursing (DON) stated, She [LPN1] should not have touched her bare fingers inside of the medication cup.NJAC 8:39-19.4 (a)(1)