Every finding on record at Careone at Wayne

Based on observation, interview, and record review, it was determined that the facility failed to follow a physician's order for 1 of 5 residents (Resident #125) observed during medication administration, according to the standards of clinical practice and the facility's policy.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 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.On 12/18/2025 at 8:24 AM, the surveyor observed a Licensed Practical Nurse (LPN) administer medications to Resident #125. The resident was alert, verbally responsive, and able to swallow their medications whole. The surveyor observed the LPN prepare and administer to the resident Aspirin (ASA) 81 milligram (mg) enteric coated (EC; delayed release) to Resident #125. The surveyor reviewed Resident #125's electronic medical record. The admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to, multiple sclerosis. A Brief Interview/Assessment for Mental Status evaluation dated 12/17/2025 was completed by the facility to assess the resident's cognition. Resident #125 scored a 15 out of 15 which indicated the resident was cognitively intact.A review of the physician's orders and the December 2025 Medication Administration Record (MAR) revealed the resident had an order dated 12/18/25 for ASA 81 mg chewable tablet by mouth one time a day at 8 AM. The 12/18/25 ASA 81 mg chewable order entry was signed as administered by the LPN on the MAR. The LPN did not administer an ASA 81 mg chewable tablet as ordered by the physician during the medication administration. On 12/18/2025 at 10:00 AM, the surveyor with the LPN checked the medication cart for ASA 81 mg tablets available. The LPN showed the surveyor a house stock ASA 81 mg EC tablet bottle and a house stock ASA 81 mg chewable bottle. The LPN stated the physician's order would determine which form of ASA would be administered to the resident. The surveyor discussed with the LPN regarding the observation that ASA 81 mg EC was administered to Resident #125 and not ASA 81 mg chewable as ordered by the physician. The LPN acknowledged ASA 81 mg EC should not be administered for a resident with an order for ASA 81 mg chewable.On 12/18/2025 at 10:16 AM, the surveyor informed the Director of Nursing (DON) of the concern that the LPN administered ASA 81 mg EC and not ASA 81 mg chewable as ordered by the physician. The DON acknowledged the concern and stated he would follow up with the LPN. On 12/18/2025 at 12:17 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the DON about the above concerns. On 12/19/2025 10:11 AM, the DON and the LNHA met with the survey team. The LNHA stated the nurse was provided in-service education, the physician was made aware, and the resident was okay. The surveyor reviewed the facility provided policy titled, Administering Medications with a last revised date of April 2019 revealed under Policy Statement: Medications are administered in a safe and timely manner, and as prescribed.NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to follow a physician's order for the application of a resting hand splint to the left hand of one resident. The deficient practice was identified for 1 of 3 residents (Resident #11) reviewed for positioning and mobility.This deficient practice was evidenced by the following: On 12/16/2025 at 11:00 AM, the surveyor observed that Resident #11's left hand did not have any resting splint. The resident stated they did not know where it was, and the staff must have forgotten to put it on. The resident acknowledged the importance of using the splint. When asked if they refused to use it, the resident denied refusing the splint. On 12/17/2025 at 10:15 AM, the surveyor observed Resident #11 again, not wearing the splint. Resident #11 stated that they were waiting for their family member to help put the splint on. Resident #11 added that the staff usually put the splint on, but the sgtaff probably forgot. On 12/17/25 at 1:26 PM, the surveyor reviewed the hybrid medical record, which included the electronic medical record and the paper medical record of Resident #11, which revealed the following: A review of the admission Record (AR) (an admission summary) reflected that Resident #11 was admitted to the facility with diagnoses that included but were not limited to hemiplegia (complete loss of strength on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (blood vessel in the brain becomes blocked) affecting right dominant side. A review of the admission Minimum Data Set, an assessment tool dated 11/23/25, reflected that Resident #11 had a Brief Interview for Mental Status score of 14 out of 15, which indicated an intact cognition. A further review is reflected in Section GG, Functional Limitation in Range of Motion A. Upper extremity (shoulder, elbow, wrist, hand) 1. Impairment on one side. A review of the resident's Order Summary Report reflected an active order of applying a resting hand splint to the left hand every shift to be worn when in bed. Remove for hygiene and skin checks, with the start date of 11/24/25. A review of the electronic Medication Administration Record revealed that the nurses were signing the order for a resting hand splint on the left hand every shift and this included the dates of 12/16/25 and 12/17/25. A review of the Care Plan (CP) report with an initiated date of 11/17/25, which focused on ADL self-care deficit related to physical limitations, right-sided hemiparesis due to cerebrovascular accident (stroke). The CP interventions included, but were not limited to, a resting hand splint on the left hand while in bed, removed for hygiene and skin checks with date initiated on 11/24/25. On 12/17/2025 at 10:45 AM, the surveyor interviewed the Certified Nurse Assistant, who stated that sometimes she puts the splint, but she will usually refer to the nurse. On 12/17/2025 at 10:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that she was supposed to put the splint on the resident, but she got busy. The LPN stated that during care, the resting hand splint should be removed, and the nurse should check the skin integrity, and then she would put the splint back as soon as she checks the resident's skin for any redness. On 12/17/2025 11:25 AM, the surveyor interviewed the Occupational Therapy (OT), who stated that he knew the resident well because he was the OT who took care of the resident. He stated that OT recommended using a rolled-up small towel, then the resting splint. The OT stated that the resident verbalized that they want to use the resting hand splint. The OT added that they have given in-service training to the family, aids, and nurses on how to put on the resting splint. The OT said that he did put the resting hand splint on Resident #11 yesterday after lunch. The OT was not sure if the resident did or did not have a splint on yesterday. On 12/18/2025 at 10:33 AM, the team of surveyors met with the Licensed Nursing Home Administrator and the Director of Nursing, but did not provide further information. The surveyor reviewed the facility policy titled Orthotic/Splint with the revised date of 6/14/2007, which revealed under Purpose: an orthosis/splint is a device that can be added to a person's body to support, position, or immobilize a part; to correct deformities; to assist weak muscles and restore function; or to modify tone. NJAC 8:39-27.1(a)

Based on observation, interview, and record review it was determined the registered dietitian failed to provide a timely initial comprehensive nutritional evaluation for 1 resident (#94) of 3 residents reviewed for nutrition. The deficient practice was evidenced by the following: The surveyor observed the resident asleep in bed on 12/17/2025 at 9:40 AM. One container of a nutritional supplement and 2 bottles of water were observed on the over bed table. The surveyor interviewed the unit licensed practical nurse (LPN) on 12/17/2025 at 12:13 PM. The LPN stated the resident eats poorly at times and has lost weight since admission. She further stated the resident's spouse brings in food from home daily and the resident is on appetite stimulating medication. The LPN stated the nurse practitioner sees the resident frequently and would be in later that day to adjust the appetite stimulating medication. She stated the resident was able to feed themself. She stated the resident was depressed and that would be re-addressed by the nurse practitioner. During the conversation with the LPN, the resident's spouse was observed assisting the resident with their lunch. The surveyor reviewed the electronic medical record which revealed the following information. The resident had been admitted recently with diagnosis including but not limited to type 2 diabetes mellitus with hypoglycemia, anorexia, anxiety, depression, and urinary tract infection. Upon Resident # 94's admission, the Registered Dietitian (RD) put a comprehensive nutritional care plan in place, yet there was no documented comprehensive nutritional evaluation in place upon admission. The resident's record revealed that one week after the resident's admission to the facility, the Registered Dietitian (RD) documented a 'Mini Nutritional Assessment.(MNA).' The screening tool included information that the resident had a moderate decrease in food intake and weight loss within the last 3 months, mobility needs, psychological problems, and height and weight. The screen did not include calculations for the resident's nutritional needs. The resident scored a '7' on the assessment indicating malnutrition. There was no comprehensive nutritional evaluation or diet type documented within MNA as well. At that time the primary physician ordered a medication to stimulate the appetite. The interdisciplinary team updated the resident's food preferences. The resident's spouse continued to bring in food from home daily. The surveyor interviewed the RD on 12/22/25 at 9:40 AM regarding the omission of an initial comprehensive nutritional evaluation for this resident. The RD stated the week the resident was admitted there were many admissions and 2 of her assistants were not in. She stated while she handwrote the comprehensive evaluation in a timely manner in a notebook, she failed to document the evaluation in the medical record. The RD provided a photocopy of a comprehensive nutritional evaluation created on 12/19/25 which reflected the status of the resident at the time of the initial comprehensive assessment. The RD stated (and the surveyor confirmed) she initiated a comprehensive nutritional care plan at the time of admission along with the resident's food preferences. She stated the primary physician and the nurse practitioner were also closely following the resident for nutrition. The surveyor reviewed physician orders for weight monitoring, nutritional supplementation, appetite stimulating medication and mood enhancing medication beginning within a week of admission and continuing to present. The licensed nursing home administrator (LNHA) and director of nursing (DON) spoke to the surveyor on 12/22/25 at 11:26 AM stating they had noticed the evaluation was late. The LNHA stated the RD had comprehensively assessed the resident at the time of their admission, however, neglected to enter the assessment into the medical record. The LNHA provided the surveyor with the facility policy titled 'Nutritional Assessment,' revised October 2017. Step #1 indicated the RD in conjunction with the nursing staff and healthcare practitioners will conduct a nutritional assessment within current baseline assessment timeframes. NJAC 8:39-17.2(d); 27.1(a)

Based on observation, interview, record review of medical records, and pertinent facility documentation, it was determined that the facility failed to ensure that the physician's orders were followed according to the standard of clinical practice. This deficient practice was identified for 2 of 3 of the residents (Resident #18 and #29) who were reviewed for respiratory care.This deficient practice was evidenced by the following: 1. On 12/16/2025 at 11:21 AM, the surveyor observed Resident #18, who was sitting in bed, with oxygen (O2) at 2.5 lpm (liters per minute) via nasal cannula (NC, a plastic prong attached to a tube, inserted into the nostrils through which oxygen flows) attached to the oxygen concentrator (a device that supplies oxygen). Resident #18 stated that they have been using the O2 continuously. On 12/19/25 at 9:34 AM, the surveyor reviewed the electronic medical record and the paper medical record of Resident #18, which revealed the following: A review of the admission record (AR) reflected that Resident #18 was admitted with diagnoses that included, but were not limited to, acute and chronic respiratory failure with hypoxia (low level of O2). A review of the admission MDS (A/MDS), (an assessment tool used to facilitate the management of care), which was dated 12/12/25, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident had intact cognition. Further review of the A/MDS in Section O -Special Treatments, Procedures and Programs revealed that Resident #29 used oxygen while in the facility. A review of the Order Summary Report (OSR) showed an active order for oxygen at 2 lpm via NC every shift for SOB (shortness of breath), with the start date of 12/5/25. A review of the electronic Medication Administration Record revealed that the nurses were signing the order for oxygen at 2 lpm via nasal cannula every shift, with the start date of 12/5/25. A review of the Care Plan (CP) report with an initiated date of 12/7/25, which focused on at-risk for respiratory impairment. The CP interventions included, but were not limited to, administering O2 per physician order. 2. On 12/16/2025 at 11:11 AM, the surveyor observed Resident #29 lying in bed asleep, with O2 at 1.5 lpm via NC attached to the oxygen concentrator. On 12/17/2025 at 10:38 AM, the surveyor observed Resident #29 in bed, asleep. The surveyor observed that the oxygen was at 1.5 lpm via NC attached to the concentrator. On 12/19/25 at 11:02 AM, the surveyor reviewed the electronic medical record and paper medical record of Resident #29, which revealed the following: A review of the AR reflected that Resident #29 was admitted with diagnoses that included, but were not limited to, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (too much carbon dioxide in the blood). A review of the A/MDS dated [DATE] indicated that the facility assessed the residents' cognitive status using a BIMS score of 9 out of 15, which indicated that the resident had moderately impaired cognition. Further review of the A/MDS in Section O -Special Treatments, Procedures and Programs revealed that Resident #29 used oxygen while in the facility. A review of the OSR showed an active order for oxygen at 2 lpm via NC every shift for SOB, with the start date of 12/2/25. A review of the eMAR revealed that the nurses were signing the order for oxygen at 2 lpm via nasal cannula every shift. A review of the CP report with an initiated date of 10/29/25, which focused on at-risk for respiratory impairment. The CP interventions included, but were not limited to, administering O2 per physician order. On 12/17/2025 at 10:49 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that it was at 2 lpm. The Registered Nurse/MDS Coordinator (RN/MDSC) revealed that Resident #29 O2 is at 1.5 lpm in the presence of the LPN. The RN/MDS adjusted the oxygen to 2 lpm. She added that now it was at 2 lpm. On 12/18/2025 at 10:33 AM, the team of surveyors met with the Licensed Nursing Home Administrator and the Director of Nursing, but did not provide further information. On 12/19/2025 at 10:05 AM, the surveyor reviewed the facility policy titled Oxygen Administration with the revision date of October 2010, stated under Steps in the Procedure: 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. NJAC 8:39-25.2(c)3, 27.1(a)

Complaint #400262 Based on observation, interview, record review of medical records, and pertinent facility documentation, it was determined that the facility failed to ensure that the physician's orders were followed according to the standard of clinical practice. This deficient practice was identified for one of the residents (Resident #3), who was reviewed for respiratory care.This deficient practice was evidenced by the following: On 10/29/25 at 9:46 AM, the surveyor observed Resident #3 in bed awake, alert, wearing a nasal cannula (NC) connected to the oxygen (O2) from a wall outlet (a device that supplies oxygen) at 3 (three) lpm (liters per minute). On 10/29/25 at 11:02 AM, the surveyor observed the resident in bed awake on O2 via NC at 3 lpm connected to the wall outlet. On the same day, the surveyor showed up at the Licensed Practical Nurse (LPN) Resident #2 O2 at 3 lpm. The LPN stated that the oxygen order was 2 lpm, but the actual oxygen liters the resident is getting is above 2 lpm. The LPN added that it is not supposed to be above 2 lpm, then the LPN adjusted the resident's liters of oxygen to 2 lpm. On 10/29/25 at 12:10 PM, the surveyor reviewed the electronic Health Record (eHR)/ hybrid medical record (paper and electronic) of Resident #3, which revealed the following: A review of the admission Record (an admission summary) (AR) reflected that Resident #3 was admitted with diagnoses that included but were not limited to shortness of breath (SOB) and congestive heart failure (CHF - the heart cannot pump blood well enough to give the body a regular supply). There was no Minimum Data Set (MDS) (an assessment tool used to facilitate the management of care) in the hybrid medical records for Resident #3 A review of the Order Summary Report (OSR) showed an active order for oxygen at 2 (two) lpm via nasal cannula continuously, every shift, with the start date of 10/29/25. A review of Resident #3's Care Plan (CP) report initiated on 10/28/25, focused on at-risk for respiratory impairment related to CHF. Interventions included, but were not limited to, administering oxygen per physician order. On 10/29/25 at 1:16 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss the above concern; however, no further information was provided. A review of the facility policy titled Oxygen Administration, revision date on October 2010, revealed the following under Steps in the Procedure 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. NJAC 8:39-25.2(c)3

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) follow appropriate infection control practices for personal protective equipment (PPE) use when exiting an enhanced barrier precaution (EBP) room to decrease the possibility of spreading infection for 1 of 4 nurses observed during medication administration and, b.) follow appropriate infection control practices and perform appropriate hand hygiene as indicated during meal service observation in 1 of 4 units (South Unit) for 1 of 2 staff observed during meal service. This deficient practice was evidenced by the following: A review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. 1. On 8/28/24 at 9:28 AM, the surveyor observed the Licensed Practical Nurse (LPN) #1 administer medication to Resident #60. The door to the resident's room had an EBP sign. EBP indicated that PPE such as gloves and gown should be worn while providing high-contact care activating with a resident to reduce the spread of multidrug resistant organisms (MDROs). The surveyor observed the LPN #1 don gloves and gown prior to entering the resident's room to administer medication. the LPN #1 administered a nasal spray to the resident. The surveyor observed the LPN #1 put her gloved hands under her gown into her scrub top pockets and retrieve the plastic top for the nasal spray. The LPN #1 then applied a pain relief medication patch to the resident's back while the resident was lying in their bed. The LPN #1 gave Resident #60 the oral (by mouth) medications to be given. While the LPN #1 observed the resident take their medications, the LPN #1 with her gloved hands, searched through her scrub pockets without removing any items. Upon exiting the room, the LPN #1 at the doorway removed her gown and gloves disposing the items outside the resident's room in the medication cart garbage bin. At 8/28/24 at 10:00 AM, the surveyor observed the LPN #1 administer medications to Resident #338. The door to the room of Resident #338 had an EBP sign. The surveyor observed the LPN #1 don gloves and gown prior to entering the resident's room to administer medication. The LPN #1 administered medications to the resident and exited the room. The LPN #1 removed her gown and gloves outside doorway of the room and disposed of the PPE in the medication cart's garbage bin. On 8/28/24 at 12:45 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1 about PPE use. The LPN #1 stated when removing used PPE gown and gloves, they should be disposed of inside the room. The LPN #1 further stated gloved hands shouldn't be put inside scrub pockets under PPE gown. The surveyor discussed observations during medication administration pass. The LPN #1 acknowledged she did not dispose of removed PPE prior to exiting the room and should not have disposed the used PPE in the medication cart garbage bin outside of the room. Additionally, the LPN #1 stated she should not have put gloved hands under her gown and into her scrub pockets. On 8/28/24 at 12:51 PM, the surveyor interviewed the Infection Preventionist (IP) about PPE use and removal. The IP stated PPE should be disposed of in the resident's room, prior to exit and not outside the room in the hallway. The IP stated it was not ok to go into pockets with gloved hands while using PPE and in the resident's room. The surveyor discussed the above concerns observed during medication administration by the LPN #1. The IP acknowledged it was not appropriate protocol. On 8/28/24 at 1:44 PM, the surveyor, in the presence of the survey team, informed the Licensed Nursing Home Administrator and the Director of Nursing (DON) of the above concerns observed during medication administration. There was no verbal response by the facility at this time. On 8/29/24 at 8:30 AM, the facility provided competency of PPE use for LPN #1. There was no additional response provided by the facility. The surveyor reviewed the facility's policy titled Enhance Barrier Precautions with a last revised date of August 2022. The policy did not address removal and disposal of PPE. The surveyor reviewed the facility's policy titled Personal Protective Equipment with a last revised date of October 2018. Under Policy Interpretation and Implementation, it read, .5. Training on the proper donning, use, and disposal of PPE is provided upon orientation and at regular intervals . The policy did not further address removal and disposal of PPE. 36419 2. On 8/28/24 at 12:05 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the facility had a communal dining area, but most of the residents preferred meals in their rooms. On 8/28/24 at 12:15 PM, the surveyor observed meal service in the South Unit. The surveyor observed the Certified Nursing Assistant (CNA) approached the food cart, removed a tray and entered room # 134. The CNA placed the food tray on the bedside table (BST) of the resident who resided in the right side bed and moved the BST closer to the resident. The resident requested a cup of ice. The CNA exited the room, went to the ice machine, used the scoop, removed the ice, reentered room [ROOM NUMBER] delivered the cup of ice, exited the room and returned to the food cart with no observed hand hygiene. The surveyor observed signage outside of Room # 132 which indicated the resident was on Enhanced Barrier Precautions (EBP) which included: everyone must clean their hands, including before entering and when leaving the room; wear gloves and a gown for the following High-Contact Resident Care Activities which included .dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tube (Gastrostomy tube), tracheostomy; wound care including any skin opening requiring a dressing. On 8/28/24 at that same time, the surveyor observed the CNA removed a tray from the food cart, and with no observed hand hygiene, entered resident room # 132, placed the food tray on the BST of the resident who resided in the right side bed , removed the plastic coverings from the food items, and poured the thickened water into a cup. The CNA exited the room and went directly to the linen cart with no observed hand hygiene. The surveyor observed the CNA removed a pillowcase from the linen cart and reentered room # 132 right side. The CNA placed the pillowcase on top of the residents clothing which the CNA explained she used to protect the residents clothing. The surveyor observed the CNA then went directly to the resident in room # 132 and put a towel on the resident which she again stated was used as a clothing protector. There was no observed hand hygiene when the CNA entered the room, exited the room or between visiting the residents. On that same date, at 12:45 PM, the surveyor discussed the breaks in infection control with the CNA who acknowledged she should have performed hand hygiene between residents. The surveyor showed the CNA the EBP signage. The CNA stated that she was not aware that she should have performed hand hygiene when entering and exiting a resident's room who was on EBPs. A review of the facility's policy entitled, Handwashing/ Hand Hygiene, dated as revised and edited on 3/18/2024 revealed .the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .all personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .all personnel are expected to adhere to hand hygiene policies and procedures. A review of the facility's policy entitled; Enhanced Barrier Precautions dated as revised 8/2022 revealed .the EBPs are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .staff are trained prior to caring for residents on EBPs. A review of the facility's policy entitled; Assisting the Resident with In-room Meals revised 12/2013 revealed .the purpose of this procedure is to provide appropriate assistance for residents who choose to receive meals in their rooms .place the tray on the overbed table .open cartons as necessary .assist resident as necessary .wash your hands. On 8/28/24 at 1:44 PM, the surveyor discussed the above observations and concerns with the LNHA and Director of Nursing (DON) who acknowledged that hand hygiene should be performed according to CDC regulations including before entering and exiting a resident's room who is on EBP and between residents during meal service assistance. No further information was provided. NJAC 8:39 - 19.4(a); (n)

Based on observation, interview, and record review it was determined the facility failed to consistently follow standards of clinical practice with regards to ensuring a medication was administered to a resident and not left at the bedside for 1 of 8 residents, Resident # 338, observed during medication administration. 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 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. 1. On 8/28/24 at 10:00 AM, the surveyor observed the Licensed Practical Nurse (LPN) #1 administer medication to Resident #338. The LPN #1 accompanied by the surveyor entered the resident's room and approached the resident's bedside. Resident #338 handed the LPN #1 a clear medicine cup with one red and white colored capsule taken from the bedside table. The resident stated they were handing it to the LPN #1 because they forgot to take the colace[docusate sodium]. The LPN #1 took the medicine cup from the resident and then administered the routine medications that the resident was scheduled to take. The LPN #1 threw out the medicine cup in the garbage bin. The surveyor interviewed the LPN #1 outside of the room about the medicine cup with the capsule. The LPN #1 stated she did not know about the medication, and she did not give to the resident. The LPN #1 stated it could have been from last night's nurse, but she was not sure. The LPN #1 acknowledged medication should not be left at the resident's bedside. The surveyor asked the LPN #1 about where the medicine cup with the capsule was. The LPN #1 accompanied by the surveyor returned to the resident's room. The LPN #1 retrieved the plastic garbage bag that contained the medicine cup with the capsule from the garbage bin. The surveyor observed the capsule in the medicine cup in the plastic bag. The LPN #1 removed the plastic bag from the resident's room and disposed of the medication. On 8/28/24 at 11:00 AM, the surveyor interviewed the Director of Nursing (DON) who stated medications to be administered should not be left at the resident's bedside by the nurses. The surveyor informed the DON of the above concerns. The DON stated she would follow up and provide additional information. The Surveyor reviewed the electronic health record (EHR) of Resident #338. The Admission Record (a summary of important resident information), Resident #338 had diagnoses that included hypertension (high blood pressure), generalized muscle weakness, and chronic idiopathic (disease of unknown cause) constipation. A Comprehensive Minimum Data Set (MDS) assessment, a tool used to facilitate management of care, dated 8/24/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #338 scored a 14 out of 15, which indicated the resident was cognitively intact. A physician's order dated 8/24/24 read: Docusate Sodium Capsule 100 MG Give 1 capsule by mouth in the evening for constipation A review of the August 2024 Medication Administration Record (MAR) revealed for the entry of docusate sodium capsule it was signed by the nurse as administered on 8/27/24 at 1700 [5 PM]. On 8/28/24 at 1:44 PM, the surveyor, in the presence of the survey team, informed the Licensed Nursing Home Administrator (LNHA) and the DON of the above concern. There was no verbal response by the facility at this time. On 8/29/24 at 8:30 AM the facility provided a follow up investigation related to the Colace medication that was found at Resident #338's bedside. The investigation included a written statement by the LPN #2 who was the assigned nurse for Resident #338 on 8/27/24 in the evening. The written statement revealed that LPN #2 gave Resident #338 the colace capsule and did not observe the resident take the medication. The LPN #2 further revealed she did not know Resident #338 did not take the colace medication. The surveyor reviewed the facility's provided policy titled, Administering Oral Medications with a last revised date of October 2010. Under Steps in the Procedure it read, .21. Remain with the resident until all medications have been taken . Additionally it read Under Reporting, 1. Notify the supervisor if the resident refuses the procedure . NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to maintain the necessary respiratory care and services for residents who were receiving nebulizer (neb) treatments according to standards of practice. This deficient practice was identified for one (1) of three (3) residents (Resident #35) reviewed for respiratory care. This deficient practice was evidenced by: On 08/25/24 at 09:27 AM, the surveyor observed Resident #35 lying in bed with the oxygen Nebulizer treatment mask (NTM) was not dated. The surveyor asked Resident #35 if the NTM had been changed weekly. Resident #35 did not know if the NTM was being changed weekly. The surveyor reviewed the medical records of Resident #35 The resident's Admission Record (AR; or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to Congestive Heart Failure (CHF) and Pneumonia, unspecified organism. A review of the Comprehensive Minimum Data Set (CMDS), an assessment tool used to facilitate the management of care, revealed a Brief Interview for Mental Status (BIMS) score was 14, which indicated that the resident's cognition was intact. The August 2024 Order Summary Report (OSR) revealed an order date of 08/25/24 for Ipratropium Bromide Solution 0.02%, 1 vial, inhale orally via nebulizer every 6 hours shortness of breath (SOB). Document any abnormal lung sounds. A review of the Patient Center Care Plan (CP) revealed there was not a care plan in place for the nebulizer treatment, incentive spirometer, or any respiratory care plans. On 8/29/24 at 11:57 AM, surveyor interviewed the Infection Preventionist (IP), he stated, that all tubing is changed every Wednesday on night shift and that it should be labeled and dated to ensure all staff are aware of when it was done. My expectation of staff is to follow facility policy. The nurse should administer medication as ordered and then wash, dry and place treatment mask and equipment in a labeled and dated bag. Doing these tasks ensures that the resident is not overmedicated and keeps the equipment clean to prevent infection. During the interview the IP and surveyor observed the respiratory equipment not labeled and with medication sediment in the chamber. The IP acknowledge these findings. A review of a treatment administration record (TAR) dated 07/01/24 through and including 8/31/2024 revealed the resident had an Incentive Spirometry ordered 5 sets times 3 times daily for SOB and CHF. On 8/29/24 at 12:22 PM, surveyor interviewed the Director of Nursing, who stated, that the respiratory equipment should be labeled and dated, washed in between uses and stored in a patient care bag that is dated as per policy. Furthermore, she stated that a resident on a respiratory treatment should be care planned for that treatment or oxygen use. On 8/29/24 at 12:34 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated, I expect the facility policies to be followed by all staff. During the interview the LNHA and the DON reviewed Resident #35's CP and acknowledged that there was not a respiratory treatment care plan in place. A review of the policy Administering Medication through a Small Volume Nebulizer with a revision date of October 2010, provided by the LNHA read as follows: Purpose: the purpose of this procedure is to administer aerosolized particles of medication safely and aseptically into the resident's airway. #27) Steps in the procedure: Rinse and disinfect the nebulizer equipment according to facility protocol, or: a) wash pieces with warm, soapy water. b) rinse with hot water. c) place all pieces in a bowl and cover with isopropyl (rubbing) alcohol, soak for 5 minutes. d) rinse all pieces with sterile water (NOT tap, bottled, or distilled); and e) allow to air dry. #29) When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. N.J.A.C. 8:39-27.1(a)

2. On [DATE] at 11:31 AM the surveyor inspected medication cart # 3 on the South Unit with LPN #2. The surveyor observed a [MEDICATION(S)] pen stored in the cart. There was an open date of [DATE] written on the pen. There was also an expiration date of [DATE] written on the pen. The insulin was labeled for Resident # 136. The surveyor confirmed the open date and the expiration date with LPN # 2. The surveyor asked LPN #2 if Resident #136 received that insulin that day. LPN # 2 said yes, she had given it to the resident that morning and didn't notice that it was expired. LPN # 2 further stated there was a new [MEDICATION(S)] pen in the refrigerator she would take out and start using. According to manufacturer specifications, once opened, [MEDICATION(S)] pens should be discarded after 28 days. On [DATE] at 12:00 PM the surveyor reviewed the medical record for resident # 136 which revealed the following: An admission sheet that listed a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Once opened may store at room temperature. Date when opened and discard after 28 days. Do not mix with other insulin. The order date was [DATE] and there was a start date of [DATE]. A current Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Refrigerate before opening. Once opened may store at room temperature. Date when opened and discard after 28 days. Do not mix with other insulin. There was a start date of [DATE]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The previous order read [MEDICATION(S)] [MEDICATION(S)] Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 5 units subcutaneously in the morning for Diabetes Mellitus. Refrigerate before opening. Once opened may store at room temperature. Date when opened and discard after 28 days. Do not mix with other insulin. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:00 PM the survey team spoke to the Director of Nursing and the Administrator about the concern with LPN #2 administering insulin after the expiration date written on the insulin pen. They agreed that the insulin should not have been administered past the expiration date written on the insulin pen. On [DATE] at 10:00 AM the surveyor reviewed the facility's policy and procedure titled Insulin Administration. Under Steps in the Procedure number 4. read; Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial. (follow manufacturer recommendations for expiration after opening). There was no policy provided that was specific to insulin pens. NJAC 8:,d+[DATE].1 (a)

Based on observation, interview and review of facility documentation, it was determined that the facility failed to follow hand hygiene practices and to consistently offer residents hand hygiene during meals. This deficient practice was identified on three consecutive days in the main dining room (MDR) and was evidenced by the following: On 7/9/19 at 12:18 PM, the surveyor observed the staff serve lunch to the residents seated in the MDR with no hand hygiene offered to the residents. On 7/10/19 at 12:16 PM, another surveyor observed the staff serve a table of three residents with no hand hygiene offered to the residents. At 12:26 PM, the surveyor observed a basket of moist towelettes on the counter but the staff had not offered them to the residents. On 7/11/19 at 11:49 AM, another surveyor observed 11 residents seated in the MDR who were offered hand wipes. At 12:15 PM, five more residents entered the MDR but were not offered hand wipes. At 12:15 PM, one of the residents left the MDR and returned at 12:18 PM. This resident had been touching the wheels of his/her wheelchair and had not been provided with hand wipes prior to eating. On 7/11/19 at 12:45 PM, the surveyor observed a Certified Nurses Aide (CNA) leave a resident they were assisting with feeding and go to another resident to assist. While with the other resident, the CNA touched the resident's back and bare arm, table and wheelchair. The CNA next retied her scrub pants and then returned to the original resident she had been assisting, sat down and proceeded to feed the resident without performing hand hygiene. On 7/11/19 at 12:49 PM, the same CNA scratched her nose and then touched her hair before placing a lid on a coffee cup. The CNA then handed the coffee cup to a resident that was leaving the dining room. The CNA did not perform hand hygiene after touching her hair and nose. During an interview with the surveyor on 7/15/19 at 10:56 AM, the Director of Nursing (DON), who is also the facility's infection control nurse, stated that handwashing should be done before and after serving food, and that the staff is to clean residents hands before and after eating. The DON stated that staff should also perform hand hygiene after touching their own hair, clothes and in between residents. During an interview with the surveyor on 7/15/19 at 11:22 AM, the Facility Educator stated that staff are to perform hand hygiene prior to and after feeding, serving, touching their uniforms, and between residents. Review of the undated Dining Room Program Protocol revealed to use hand wipes before and after meals for each resident. The protocol indicated to practice appropriate hand hygiene and use hand sanitizer three times before hand washing if hands are not visibly soiled. Review of a policy titled, Handwashing/Hand Hygiene, dated 8/15, revealed all personnel shall follow the handwashing/hand hygiene procedures and use an alcohol-based hand rub for the following situations: before and after direct contact with residents, before and after handling food and before and after assisting a resident with meals. The policy also indicated that residents will be encouraged to practice hand hygiene NJAC 8:39-19.4(a)(1)

Based on observation, interview and review of facility documentation, it was determined that the facility failed to ensure that dining experience was provided in a manner to promote the dignity and respect of the residents. This deficient practice was identified on three consecutive days in the main dining room (MDR) and was evidenced by the following: On 7/9/19 at 9:30 AM, the surveyor observed that 3 of 3 residents seated in the MDR were served breakfast on plastic trays. On 7/9/19 at 12:00 PM, the surveyor observed that 5 of 5 residents seated in the MDR were served lunch on plastic trays. On 7/10/19 at 12:10 PM, the surveyor observed that 8 of 8 residents seated in the MDR were served lunch on plastic trays. On 7/11/19 at 12:19 PM, another surveyor observed the tables in the dining room which had been set up with drinking glasses and ceramic mugs. The surveyor observed that the staff had unloaded the trays off the carts, but only some of the 16 residents had their plates taken off the plate warmers and five residents had been served their drinks in gray plastic mugs and not the ceramic mugs placed at the tables. On 7/11/19 at 12:45 PM, a Certified Nursing Assistant (CNA) who had been feeding a resident lunch, removed the plastic wrap from the resident's dessert and placed the dessert plate on top of the residents plate with the partially eaten lunch food. The CNA proceeded to feed the resident his/her dessert while it was on top of the lunch. During an interview with the surveyor on 7/15/19 at 11:17 AM, the Director of Nursing (DON) stated the Facility Educator oversees the MDR as well as the Dietician. During an interview with the surveyor on 7/15/19 at 11:22 AM, the Facility Educator stated that the dining room process was for the staff to serve the residents at the table at the same time; to take the meals off the trays and put them in front of the resident. She stated that staff should serve the residents at the same time for dignity, and should be just like when you go out for dinner. The Facility Educator stated that there had been staff education since she started in (MONTH) 2019 and that the staff know that's the process. Review of the undated facility, Dining Room Program Protocol, document provided by the Facility Educator, revealed to always take all the food off the trays and place it in front of the patient and residents. NJAC 8:39-4.1(a)12; 17.2(e)(g)

Based on observation, interviews and record review, it was determined that the facility failed to ensure a fall intervention was in place after a resident had a room change. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #44) and was evidenced by the following: According to the Admission Record, Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Admission Minimum Date Set (MDS), an assessment tool dated 6/21/19, revealed that the resident had short and long term memory problems and required extensive assistance with activities of daily living. Additionally, the MDS revealed that the resident had a fall in the last month and 6 months prior to admission. On 7/9/19 at 12:00 PM, Resident #44 was observed in his/her room seated in a wheelchair. Review of the resident's care plan reflected that the resident was at risk for falls related to right [MEDICAL CONDITION] and had a fall on 6/25/19 while attempting to transfer self. The goal was to minimize the risk for falls and interventions included but were not limited to; stop sign reminder placed in room to call for assistance able to demonstrate proper use which was dated 6/28/19. Review of the Certified Nurses Aide (CNA) Kardex (a plan of care for the resident) revealed, under safety, stop sign reminder placed in room to call for assistance able to demonstrate proper use. Review of the Progress Notes (PN), dated 6/26/19 at 1:07 AM, reflected that a CNA found the resident sitting on the floor in his/her room. There were no injuries and the physician was notified. Review of an Incident Report (IR), dated 6/25/19 at 11:50 PM, revealed that the resident was found sitting on the floor in the resident's room and had no injuries. The IR reflected a section titled, Notes, dated 6/28/19 and revealed there was no injury after the fall and that a stop sign reminder was in place to call for assistance. The note also included that the resident was participating in therapy, focusing on strength, endurance and fall safety. On 7/11/19 at 9:45 AM, there was no stop sign observed in Resident #44's room. During an interview with the surveyor on 7/12/19 at 9:51 AM and 10:06 AM, the Licensed Practical Nurse (LPN), assigned to Resident #44, stated that the resident was a fall risk and was not aware that a stop sign should have been in the resident's room. During an interview with the surveyor on 7/12/19 at 9:57 AM, the Registered Nurse Unit Manager (RN/UM) stated that after a resident falls, rehab and nursing would meet by the following day to discuss the fall and interventions. The interventions would be placed on the care plan and the CNA plan of care. The RN/UM stated that after Resident #44 had fallen, a stop sign was placed in the resident's room as an intervention to remind the resident to call for assistance. On 7/12/19 at 10:06 AM, the surveyor and the RN/UM went into Resident #44's room and the RN/UM confirmed that the stop sign was not in the room. The RN/UM stated while in the room that the resident had a prior room change. At that time, the surveyor and the RN/UM went to the previous room where the resident resided and observed the stop sign on the wall in front of a bed. The RN/UM stated that the stop sign should have been moved when the resident's room was changed. The RN/UM placed the stop sign in the resident's current room. During an interview with the surveyor on 7/12/19 at 10:12 AM, the CNA who was assigned to Resident #44 stated that she was not aware that the resident was a fall risk or had any interventions in place. During an interview with the surveyor on 7/12/19 at 11:17 AM, the Director of Nursing (DON) stated that after a fall, IRs are reviewed by herself and the interdisciplinary team, the CP is updated, and interventions are put into place. The DON stated report is given to the nurses, the CNAs and that nursing supervisors and the nurses ensure the interventions are put into place by checking during daily rounds. The DON stated that when the resident's room was changed, the stop sign intervention should have moved to the new room. During an interview with the surveyor on 7/15/19 at 9:40 AM, the RN/UM stated the resident's room was changed on 7/5/19. Review of the facility's Falls-Clinical Protocol document, revised (MONTH) (YEAR), included that the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to ensure that medication was administered in accordance with physician orders. This deficient practice was identified for Resident #59, 1 of 22 residents reviewed for medication administration and 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 indicated, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or 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 regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. On 8/15/18 at 10:53 AM, the surveyor reviewed Resident #59's medical record which revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #59 had two physician's orders [REDACTED]. position) give if SBP is less than 130. On 8/15/18 at 11:03 AM, the surveyor reviewed Resident #59's (MONTH) (YEAR) Electronic Medication Administration Record [REDACTED]. The EMAR documentation also revealed that Resident #59 was administered [MEDICATION NAME] when the SBP was documented as greater than 130 on 7/19/18-SBP 138. The surveyor reviewed Resident #59's (MONTH) (YEAR) EMAR which revealed documentation that on the following dates, Resident #59 was administered [MEDICATION NAME] when the SBP was documented as less than 150: 6/18/18-SBP 122; 6/27/18-SBP 146: 6/28/18-SBP 148; and 6/30/18-SBP 145. On 8/15/18 at 11:27 AM, the Director of Nursing stated that the check mark on the EMAR indicated that the above [MEDICATION NAME] and [MEDICATION NAME] medications were administered and indicated that the physician's orders [REDACTED]. NJAC 8:39 - 27.1(a), 29.2(d)

Based on interview and record review, it was determined that the facility failed to consistently communicate information with the [MEDICAL TREATMENT] center according to the facility's created Hemo-[MEDICAL TREATMENT] Progress Note communication sheets. This deficient practice was identified for Resident #59, 1 of 1 resident reviewed for [MEDICAL TREATMENT] and was evidenced by the following: On 8/15/18 at 10:53 AM, the surveyor reviewed Resident #59's medical record which indicated that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #59 had a physician's orders [REDACTED]. On 8/15/18 at 9:48 AM, the surveyor reviewed the Hemo-[MEDICAL TREATMENT] Progress Notes located in Resident #59's medical record. The Hemo-[MEDICAL TREATMENT] Progress Notes were dated from 4/6/18 through 8/14/18 and consisted of 49 forms in the medical record. Of the 49 forms, 16 forms were missing information from either the facility and/or the [MEDICAL TREATMENT] center as followed: 1. 4/6/18: [MEDICAL TREATMENT] Ended and Post [MEDICAL TREATMENT] Weight 2. 4/9/18: Attention [MEDICAL TREATMENT] Nurse, Signature of Facility RN/LPN, and Treatment Problem 3. 4/11/18: Attention [MEDICAL TREATMENT] Nurse, Graft Site, and Signature of Facility RN/LPN 4. 4/23/18: Attention [MEDICAL TREATMENT] Nurse and Graft Site 5. 4/26/18: [MEDICAL TREATMENT] Started, [MEDICAL TREATMENT] Ended, Pre-[MEDICAL TREATMENT] Weight, Post [MEDICAL TREATMENT] Weight, Graft Site, Treatment Problem, and Signature of [MEDICAL TREATMENT] Nurse 6. 4/27/18: Signature of Facility RN/LPN and Treatment Problem 7. 4/30/18: [MEDICAL TREATMENT] Center, Time, Graft Site, and Post [MEDICAL TREATMENT] Weight 8. 5/4/18: [MEDICAL TREATMENT] Started, [MEDICAL TREATMENT] Ended, Post [MEDICAL TREATMENT] Weight, Treatment Problem, and Signature of [MEDICAL TREATMENT] Nurse 9. 5/11/18: Attention [MEDICAL TREATMENT] Nurse, Graft Site, and Signature of Facility RN/LPN 10. 5/14/18: Graft Site, [MEDICAL TREATMENT] Ended, and Post [MEDICAL TREATMENT] Weight 11. 5/16/18: Attention [MEDICAL TREATMENT] Nurse, Graft Site, [MEDICAL TREATMENT] Started, Pre-[MEDICAL TREATMENT] Weight, and Post [MEDICAL TREATMENT] Weight 12. 6/9/18: [MEDICAL TREATMENT] Center, [MEDICAL TREATMENT] Started, [MEDICAL TREATMENT] Ended, Pre-[MEDICAL TREATMENT] Weight, Post [MEDICAL TREATMENT] Weight, Graft Site, Treatment Problem, and Signature of [MEDICAL TREATMENT] Nurse 13. 6/23/18: Attention [MEDICAL TREATMENT] Nurse, Graft Site, and Treatment Problem 14. 6/30/18: Post [MEDICAL TREATMENT] Weight and Graft Site 15. 7/2/18: [MEDICAL TREATMENT] Center, Attention [MEDICAL TREATMENT] Nurse, [MEDICAL TREATMENT] Started, [MEDICAL TREATMENT] Ended, Graft Site, and Treatment Problem 16. 7/28/18: [MEDICAL TREATMENT] Center, Post [MEDICAL TREATMENT] Weight, Graft Site, and Treatment Problem On 8/15/18 at 9:53 AM, the Registered Nurse (RN) stationed on Resident #59's unit stated that the nurses on the unit should have filled out the Hemo-[MEDICAL TREATMENT] Progress Notes with any special notes, documented vital signs, and signed the Hemo-[MEDICAL TREATMENT] Progress Notes form prior to the resident's transport to [MEDICAL TREATMENT]. The RN also stated that if the [MEDICAL TREATMENT] center returned the form with missing information, the nurses should have called the [MEDICAL TREATMENT] center for the information and then documented the information on the Hemo-[MEDICAL TREATMENT] Progress Notes form along with who they spoke to from the [MEDICAL TREATMENT] center. On 8/15/18 at 10:39 AM, the surveyor reviewed the electronic medical record for the above dates which had no further documentation that addressed the missing information on the Hemo-[MEDICAL TREATMENT] Progress Notes. On 8/15/18 at 11:20 AM, the Director of Nursing (DON) provided the surveyor with the facility, [MEDICAL TREATMENT] Pre and Post Care policy dated 3/2010 that specified the facility staff was to document all communications in the [MEDICAL TREATMENT] communication progress note or [MEDICAL TREATMENT] center communication book and ensure ongoing communication with [MEDICAL TREATMENT] center staff. Pre-[MEDICAL TREATMENT] care indicated that staff should assess residents blood pressure prior to being transported to the [MEDICAL TREATMENT] unit and check the shunt ([MEDICAL TREATMENT]) for function prior to being transported to [MEDICAL TREATMENT]. On 8/16/18 at 9:39 AM, the DON stated that the [MEDICAL TREATMENT] communication forms were reviewed and confirmed that the staff did not obtain the missing information when Resident #59 returned from [MEDICAL TREATMENT]. The DON acknowledged that the missing information was pertinent to identify any concerns that might have developed after the resident's [MEDICAL TREATMENT] treatment. The DON further stated that the facility nurses should have at least signed the top area of the Hemo-[MEDICAL TREATMENT] Progress Notes form that indicated they assessed the resident prior to transportation to [MEDICAL TREATMENT]. NJAC 8:39 - 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to revise a comprehensive care plan to address the development of a DTI (deep tissue injury)from a multi-podus boot and to revise interventions. This deficient practice occurred for 1 of 3 residents, Resident #3, reviewed for interventions to prevent pressure ulcer developement and was evidenced by the following: On 6/5/17 at 10:35 a.m., during the initial tour with the unit manager (UM), the UM stated that Resident #3 was recently re-admitted on [DATE] after a revision of right hip surgery and developed an in house right heel DTI (Deep Tissue Injury) from a boot. The UM also stated that Resident #3 required assistance with activities of daily living (ADL). On 6/6/17 at 9:35 a.m., the surveyor observed the resident in bed with a hip abductor in between their legs. The right leg had a blue soft boot on to help protect the heel area. Resident #3 had denied any discomfort. On 6/6/17 at 1:13 p.m., the surveyor reviewed the resident's medical records. The resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/8/17 at 10:15 a.m., the surveyor requested from the UM the Physical Therapy Notes which were not available in the electronic record or in the resident's chart. On 6/8/17 at 12:28 p.m., the Director of Nursing provided the Physical Therapy Notes to the surveyor. On 5/24/17, a PT (Physical Therapy) Daily Treatment Note indicated that: Checked R (right) PRAFO/Multi-podus boot and checked skin today. Found redness on his R heel. Reported this to nursing. Took off (the resident's) PRAFO after that. On 5/25/17, the PT Daily Treatment Note showed that the resident was found to be wearing the multi-podus boot again and that the therapist talked to nursing to discontinue multi-podus boot and to use heel relief boot (blue soft boot) instead. The surveyor reviewed the April 2017 and May 2017 Physician order [REDACTED]. A review of the Progress Notes revealed that on 5/26/17 at 11:17 a.m., the nurse documented that the resident was noted with 4x3 DTI on right heel, skin remains intact. R(right) heel boot (blue soft boot) placed. Skin prep ordered. Further review of the Progress notes revealed that on 6/2/17 at 9:46 a.m., the Occupational Therapist documented a Care Conference note which indicated that the resident presents with a DTI on the right heel, with treatment in progress. Followed by wound team. Area acquired from multi-podus boot. Boot discharged and patient provided with a prevalon boot (blue soft boot). On 6/8/17 at 12:28 p.m., the surveyor reviewed the physician order [REDACTED]. Clean r heel DTI with NSS, pat dry and apply skin prep daily. On 6/8/17, the surveyor reviewed the resident's care plan for a focus area of skin integrity. The care plan was not revised to include the occurrence of the DTI or revised interventions to address the new area on the right heel. NJAC 8:39-11.2 (i)

Based on observation, interview, and record review, it was determined that the facility failed to consistently monitor the application of a multi-podus boot to prevent the development of a pressure area. This deficient practice was identified for Resident #3, 1 of 3 residents reviewed for pressure ulcers, and was evidenced by the following: On 6/5/17 at 10:35 a.m., during the initial tour with the unit manager (UM), the UM told the surveyor Resident #3 was recently re-admitted on [DATE] after a surgical revision of right hip surgery and developed an in house right heel DTI (Deep Tissue Injury) from a boot. The UM also stated that Resident #3 required assistance with activities of daily living (ADL). On 6/6/17 at 9:35 a.m., the surveyor observed the resident in bed with a hip abductor in between their legs. The right leg had a blue soft boot on. Resident #3 had denied any discomfort. On 6/6/17 at 1:13 p.m., the surveyor reviewed the resident's medical records. The resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of medical records on 6/6/17 at 1:13 p.m., revealed that on 4/27/17, Resident #3's score on the Braden scale (an assessment tool for predicting pressure sore risk) was 14. This indicated resident #3 was at moderate risk to develop a pressure ulcer. On 6/8/17 at 10:15 a.m., the surveyor requested from the UM the Physical Therapy Notes which were not available in the electronic record or in the resident's chart. On 6/8/17 at 12:28 p.m., the Director of Nursing provided the Physical Therapy Notes to the surveyor. On 5/24/17, a Physical Therapy Daily Treatment Note indicated that: Checked R (right) PRAFO/Multi-podus boot and checked skin today. Found redness on his R heel. Reported this to nursing. Took off (the resident's) PRAFO after that. The next day, 5/25/17, the Physical Therapy Daily Treatment Note showed that the resident was found to be wearing the multi-podus boot again and that the therapist talked to nursing to discontinue multi-podus boot and to use a heel relief boot (blue soft boot) instead. The surveyor reviewed the April 2017 and May 2017 Physician Order Sheet . There was no order written for a PRAFO/Multi-podus boot or an order to document accountability for application of a PRAFO/right Multi-podus boot. A review of the Progress Notes revealed that on 5/26/17 at 11:17 a.m., the nurse documented that the resident was noted with 4x3 DTI on right heel, skin remains intact. R(right) heel boot (blue soft boot) placed. Skin prep ordered. Further review of the Progress notes revealed that on 6/2/17 at 9:46 a.m., the Occupational Therapist documented a Care Conference note which indicated that the resident presents with a DTI on the right heel, with treatment in progress. Followed by wound team. Area acquired from multi-podus boot. Boot discharged and patient provided with a prevalon boot (blue soft boot). On 6/8/17 at 12:28 p.m., the surveyor reviewed the physician order dated 5/26/17 for r (right) heel boot (blue soft boot) in place at all times every shift monitor placement and skin prep apply to r heel topically every day shift for wound care. Clean r heel DTI with NSS, pat dry and apply skin prep daily. On 6/8/17 at 12:28 p.m., the surveyor reviewed Hospital Discharge Instructions from the Orthopedic which indicated that the resident should be No weight bearing (NWB) to the right leg, maintain on hip precautions and PRAFO (multi-podus boot) to right foot and ankle while in bed. On 6/8/17, the surveyor reviewed the resident's care plan for a focus area of skin integrity. The care plan was not revised to include the occurrence of the DTI or revised interventions to address the new area on the right heel. Refer to F280. On 6/9/17 at 9:23 a.m., the surveyor interviewed the DON who stated that there were no physician order and accountability sheet that would reflect that the right multi-podus boot application was done on re-admission of 4/27/17. She added that no care plan was initiated to reflect interventions for the right multi-podus boot. On 6/9/17 at 9:58 a.m., the surveyor observed the Licensed Practical Nurse (LPN) assisted by the UM perform a treatment to the resident's right foot. The surveyor observed an intact nickel sized dark-red in color area to the bottom of the resident's right posterior foot. The surveyor observed the LPN cleanse the bottom of the resident's right posterior foot, applied skin prep, dried the area and applied clean sock. On 6/9/17 at 11:54 a.m., the DON provided a copy of facility's Skin Integrity Management, a Clinical Practice Guidelines for the Prevention and Management of Pressure Ulcers and other wounds. It indicated in the Prevention Strategies that: Areas of risk should be identified upon admission and associated interventions initiated and care planned. The effectiveness of the interventions will be evaluated and the plan of care will be reviewed and revised as needed. NJAC 8:39-27.1 (a)

C# NJ , C# NJ Cross Reference F-281 Based on observation, interviews, medical record (MR) review, and review of other facility documentation on 1/20/17, it was determined that the facility failed to follow the facility's policy on controlled substances by borrowing Schedule II controlled medications ([MEDICATION NAME]) and Schedule IV medications ([MEDICATION NAME]) for 3 of 9 sampled residents (Resident #1, #2 and #3) and administering these controlled medications to 4 of 9 sampled residents (Resident #5, #6, #7 and #8). This deficient practice was evidenced by the following. See example #1, #2, #3, #4, #5, #6, #7 NJ 8:39-29.2(a) NJ 8:39-29.2(d)

C# NJ , C# NJ Based on observations, interviews, medical record (MR) review, and review of other pertinent facility documentation on 1/9/17 and 1/20/17, it was determined that the facility failed to follow their policy on re-ordering medications in advance to ensure availability of Schedule II ([MEDICATION NAME]) and Schedule IV ([MEDICATION NAME]) controlled medications for 4 of 9 sampled residents (Resident #5, #6, #7 and #8) which resulted in the borrowing of these controlled medications for 3 of 9 sampled residents (Resident #1, #2 and #3). In addition, the facility administered the borrowed controlled medications for 4 of 9 sampled residents (Resident #5, #6, #7 and #8). Furthermore, the facility failed to document the administration of Schedule II controlled substance medications ([MEDICATION NAME]) on the Medication Administration Record (MAR) for 2 of 9 sampled residents (Resident #6 and #7). This deficient practice is evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter. 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 or 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 well-being, and executing a 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. 1. According to the Admission Record, Resident #1 was admitted on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was discharged on [DATE]. According to Resident #1's Minimum Data Set (MDS), an assessment tool dated 10/28/16, the resident had impaired short and long-term memory, and had impaired decision making ability. According to the physician's orders [REDACTED].#1 was prescribed [MEDICATION NAME] 0.25 milligram (mg.) 1 tablet by mouth once a day. In addition, on 10/24/16, [MEDICATION NAME] 0.25 mg 1 tablet by mouth every 6 hours as needed for anxiety was ordered. According to Resident #1's December 2016 Medication Administration Record (MAR), the [MEDICATION NAME] was documented as having been administered as ordered until 9:00 a.m. of 12/26/16, and was recorded on Resident #1's Controlled Drug Administration Record (CDAR). On 1/9/17 at 10:05 a.m., an inspection of the Narcotic box inside the South Unit's Medication Cart (MC#3) was conducted with the Unit Manager/Registered Nurse (RN #1) and RN #2. The surveyor observed three Bingo cards (pop-out medication dispensing packages) of controlled drugs with a CDAR on each Bingo card, for three discharged Residents (Resident #1, #2 and #3). The Bingo card for Resident #1 revealed that there were 13 tablets of [MEDICATION NAME] 0.25 mg. left (not administered). A review of the CDAR for Resident #1's [MEDICATION NAME] revealed four tablets were signed by RN #2 as wasted (disposed of). This same CDAR for Resident #1 revealed that there should have been 18 tablets of [MEDICATION NAME] left instead of 13 tablets. The document attached to the CDAR revealed that five of Resident #1's remaining tablets of [MEDICATION NAME] were used for two other residents (Resident #5 and #8). On 1/9/17 at 1:45 p.m., the Director of Nursing (DON) stated that RN #2 and Licensed Practical Nurse (LPN #1) were interviewed by the the Assistant Director of Nursing (ADON) on 1/9/17. The DON stated that RN #2 and LPN #1 informed the ADON that Resident #1's four tablets of [MEDICATION NAME] were not wasted but were given to Resident #8 by RN #2. The DON stated that RN #2 and LPN #1 were given verbal warnings and provided with an In-service Education on 1/9/17, which included: No borrowing of any kind of medications, the physician would need to be notified for all controlled medications that would need prescriptions, the nurse should follow the Medication Unavailable Flow Chart to determine what to do, and all controlled medications that get wasted would need a witness. An interview with RN #2 and LPN #1 was conducted on 1/9/17 at 3:20 p.m. RN #2 stated that Resident #1's [MEDICATION NAME] was not wasted, but was borrowed and administered to Resident #8. RN #2 stated that she should not have borrowed Resident #1's [MEDICATION NAME] for Resident #8 however, Resident #8 had no available medication at that time and there was none available in the Pyxis (an automated medication delivery cabinet used for emergency). RN #2 stated that she documented Resident #1's [MEDICATION NAME] as wasted because she knew that the facility would not allow borrowing of medications. During this interview, LPN #1 stated that she was present when RN #2 borrowed Resident #1's [MEDICATION NAME] for Resident #8. LPN #1 also stated that RN #2 documented the 4 doses of 0.25 mg [MEDICATION NAME] as wasted because the nurses were not supposed to borrow any medications. 2. According to the Admission Record, Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #2 was discharged on [DATE]. According to the Admission assessment dated [DATE], Resident #2 was alert and oriented to person, place, and time. According to the physician's orders [REDACTED].#2 was on [MEDICATION NAME] 2 mg. 1 tablet by mouth every 6 hours as needed for moderate pain. A review of Resident #2's November 2016 MAR revealed that the resident was on [MEDICATION NAME] 2 mg. 1 tablet by mouth every 6 hours as needed for moderate pain and documented that Resident #2 was administered this medication as ordered until 11/18/16 at 6:03 p.m., as well as recorded on Resident #2's CDAR. On 1/9/17 at 10:05 a.m., an inspection of the Narcotic box inside the South Unit's MC#3 was conducted by the surveyor in the presence of RN #1 and RN #2. The Bingo card for Resident #2 revealed that there was zero tablets left of [MEDICATION NAME] 2 mg. (for pain) for Resident #2. A review of the CDAR for Resident #2's [MEDICATION NAME] revealed that there should have been 26 tablets left instead of zero tablets. The document attached to the CDAR revealed that all of Resident #2's remaining tablets of [MEDICATION NAME] were used for three other residents (Resident #6, #7 and #8). 3. According to the Admission Record Resident #3 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #3 was discharged on [DATE]. According to Resident #3's MDS dated [DATE], the resident scored 15/15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. According to the physician's orders [REDACTED].#3 was on [MEDICATION NAME] 0.25 mg. 1 tablet by mouth every 4 hours as needed for Anxiety. A review of Resident #3's December 2016 MAR revealed documentation that Resident #3 was administered this medication as ordered until 12/23/16 at 1:19 a.m. and was recorded on Resident #'3's CDAR. On 1/9/17 at 10:05 a.m., an inspection of the Narcotic box inside the South Unit's MC#3 was conducted by the surveyor in the presence of the RN #1 and RN #2. The Bingo card for Resident #3 revealed that there were 3 tablets left of [MEDICATION NAME] 0.25 mg. for Resident #3. The CDAR for Resident #3's [MEDICATION NAME] revealed that there should have been 16 tablets left instead of 3 tablets. The document attached to the CDAR revealed that thirteen of Resident #3's remaining tablets of [MEDICATION NAME] were used for two other residents (Resident #5 and Resident #8). 4. According to the Admission Record, Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #5 was discharged on [DATE]. Resident #5's MDS dated [DATE], revealed that the resident had impaired short term and long-term memory, and had impaired decision making ability. According to the physician's orders [REDACTED].#5 was on [MEDICATION NAME] 0.25 mg. 1 tablet by mouth every 6 hours as needed. A review of Resident #5's December 2016 and January 2017 MAR documented that Resident #5 was administered the [MEDICATION NAME] as ordered until 1/15/17 at 5:17 p.m., which included documentation of the [MEDICATION NAME] that was borrowed from Resident #1 on 1/2/17 at 12:00 a.m. and from Resident #3 on 12/25/16 at 7:11 p.m. 5. According to the Admission Record dated 12/22/16, Resident #6 was admitted with [DIAGNOSES REDACTED]. Resident #6 was discharged on [DATE]. According to Resident #6's MDS dated [DATE], the resident scored 15/15 on the BIMS which indicated the resident was cognitively intact. According to the physician's orders [REDACTED].#6 was on [MEDICATION NAME] 2 mg. 1 tablet by mouth every 4 hours as needed for breakthrough pain. In addition, on 12/27/16, [MEDICATION NAME] 2 mg. 1 tablet by mouth every 3 hours as needed [MEDICAL CONDITION] pain was ordered. A review of Resident #6's December 2016 MAR revealed that the [MEDICATION NAME] was not signed as having been administered by LPN #2, which would account for the [MEDICATION NAME] borrowed from Resident #2 on 12/22/16 at 10:00 p.m., as recorded on Resident #2's CDAR. Resident #6's MAR also revealed that the [MEDICATION NAME] was not signed as having been administered by RN #2, which would account for the [MEDICATION NAME] borrowed from Resident #2 on 12/23/16 at 9:00 a.m., as recorded on Resident #2's CDAR. A review of the Nurse's Note (NN) dated 12/22/16 at 11:17 p.m., signed by LPN #2 revealed: Pain: Currently receives medication related to pain management. A review of the NN dated 12/23/16 at 10:19 a.m., signed by RN #2, revealed that Resident #6 verbalized moderate pain on the left side of his/her body and [MEDICATION NAME] was given with relief. A post survey telephone interview was conducted by the surveyor on 1/25/17 at 2:00 p.m., with the DON. The DON confirmed that the [MEDICATION NAME] borrowed from Resident #2 on 12/22/16 at 10:00 p.m., was not signed as having been administered by LPN #2 in Resident #6's MAR. The DON also verified that the [MEDICATION NAME] borrowed from Resident #2 on 12/23/16 at 9:00 a.m., was not signed as having been administered by RN #2 in Resident #6's MAR. During the same post survey telephone interview on 1/25/17 at 2:00 p.m., the DON explained that LPN #2 documented on his/her NN dated 12/22/16 at 11:17 p.m. that the [MEDICATION NAME] was administered to Resident #6. The DON stated that LPN #2 was no longer employed in the facility. The DON further explained that RN #2 documented in his/her NN dated 12/23/16 at 10:19 a.m. that the [MEDICATION NAME] was administered to Resident #6. 6. According to the Admission Record Resident #7 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #7 was discharged on [DATE]. The physician's orders [REDACTED]. 1 tablet every 4 hours as needed for moderate pain and [MEDICATION NAME] 2 mg. 2 tablets by mouth every 4 hours as needed for severe pain. A review of Resident #7's November 2016 MAR revealed that the [MEDICATION NAME] was not documented as administered by RN #3, which would account for the [MEDICATION NAME] borrowed from Resident #2 on 11/24/16 at 4:00 a.m. and 11/29/16 at 7:30 a.m. The MAR also revealed that the [MEDICATION NAME] was not documented as administered by LPN #3, which would account for the [MEDICATION NAME] borrowed from Resident #2 on 11/24/16 at 9:55 a.m. A post survey telephone interview was conducted by the surveyor on 1/25/17 at 2:00 p.m. with the DON. The DON confirmed that the [MEDICATION NAME] borrowed from Resident #2 on 11/24/16 at 4:00 a.m., and 11/29/16 at 7:30 a.m., was not signed as having been administered by RN #3 in Resident #7's MAR. The DON also verified that the [MEDICATION NAME] borrowed from Resident #2 on 11/24/16 at 9:55 a.m., was not signed as having been administered by LPN #3 in Resident #7's MAR. A review of the facility's witness statement dated 1/26/17, written by LPN #3, revealed that LPN #3 administered [MEDICATION NAME] 2 mg. to Resident #7 on 11/24/16 at 9:55 a.m., but forgot to sign the MAR. A review of the facility's witness statement dated 2/9/17, written by RN #3, revealed that RN #3 administered [MEDICATION NAME] 2 mg. to Resident #7 on 11/24/16 at 4:00 a.m. and 11/29/16 at 7:30 a.m., but forgot to sign the MAR. 7. According to the Admission Record dated 12/14/16, Resident #8 was admitted with [DIAGNOSES REDACTED]. Resident #8 was discharged on [DATE]. According to Resident #8's MDS dated [DATE], the resident scored 14/15 on BIMS, which indicated the resident was cognitively intact. According to the physician's orders [REDACTED].#8 was on [MEDICATION NAME] 2 mg. 1 tablet by mouth every 3 hours as needed for moderate pain and [MEDICATION NAME] 4 mg. 1 tablet by mouth every 3 hours for severe pain. In addition, on 12/24/16, Resident #8 had an order for [REDACTED]. Resident #8's December 2016 MAR documented that Resident #8 was administered this medication as ordered until 12/29/16 at 9:00 p.m., which included the [MEDICATION NAME] borrowed from Resident #1 on 12/28/16 at 9:00 p.m., and the [MEDICATION NAME] borrowed from Resident #3 at 9:00 a.m. on 12/24, 12/25, 12/26, and 12/27/16. Further review of the MAR revealed that the resident was on [MEDICATION NAME] 2 mg. 1 tablet by mouth every 3 hours as needed for moderate pain and [MEDICATION NAME] 4 mg. 1 tablet by mouth every 3 hours for severe pain. This MAR documented that Resident #8 was administered this medication as ordered which included the [MEDICATION NAME] that was borrowed from Resident #2 on 12/14/16 at 4:13 p.m., on 12/14/16 at 7:40 p.m., and on 12/15/16 at 4:56 a.m. When interviewed on 1/9/17 at 10:45 a.m., RN #1 stated that the medication nurses should re-order medications as soon as it reached the blue line (eight pills left) indicated on the Bingo card to ensure availability of medications. RN #1 further stated that the nurses were not allowed to borrow medications. The surveyor conducted an interview on 1/9/17 at 11:35 a.m. with the DON. The DON stated that she was not aware that there were three bingo cards of controlled drugs from three discharged residents inside the narcotic box of MC #3 until the day of the survey (1/9/17). The DON stated that she was also not aware that the nurses were borrowing these controlled drugs and had administered the controlled drugs to other residents. The DON further stated that the facility did not have a policy for borrowing medication because the Nursing staff were not allowed to borrow any medications from a resident to be given to another resident. The DON stated that in case a resident had an order for [REDACTED]. The DON stated that the Attending Medical Doctor (AMD) was responsible for issuing prescriptions for controlled drugs, and that whenever the AMD of a resident would not be able to issue the Prescription for the controlled drug in a timely manner for any reason, there was a Physiatrist available to issue the Prescription. The DON stated that the Pyxis was only used for an emergency. When interviewed by the surveyor on 1/9/17 at 1:00 p.m., the Physiatrist stated that if and when the AMD would not be able to write a prescription for a controlled drug for a resident promptly, the facility would ask him to assess the resident and he would issue the prescription if medically necessary. When interviewed by the surveyor on 1/20/17 at 12:45 p.m., the DON stated that the facility's Pharmacy Provider delivered twice a day, the first delivery was early in the morning before the end of 11:00 p.m. - 7:00 a.m. (11-7) shift and the second delivery was later in the evening before the end of the 3:00 p.m. -11:00 p.m. (3-11) shift. When further interviewed by the surveyor, the DON stated that the facility has a Pharmacy Consultant (PC) not affiliated with their Pharmacy Provider. The DON stated that the PC would come to the facility every month and was in the facility on 1/19/17. When interviewed by the surveyor on 1/20/17 at 2:00 p.m., the PC stated that they were not affiliated with the facility's Pharmacy Provider. The PC stated that they would go to the facility every month and would conduct Drug Regimen Review, would ensure that systems/processes were in place for proper storage, labeling, administration, disposition of medication amongst other things required by local, state and federal law. The PC further stated that if and when medications ordered were not available, the staff should call the facility's Pharmacy provider for a stat delivery, or call the facility's alternate Pharmacy or call the AMD for possible medication order change. A review of the Nursing News Letter dated 12/30/16, revealed a reminder for all nurses that the medication availability form should be completed every shift and the supervisor should be notified for any missing medications. This newsletter also indicated that nurses should follow the Medication Unavailable Flow Chart which guides the staff on what to do when medications where not available. The News letter also directed that all staff must observe compliance with the controlled drugs inventory count every shift. A review of the In-service Education Record revealed that on 1/9/17, the facility provided an In-service education about No borrowing of any kind of medications. This In-service education also included the following: the AMD would need to be notified on time for all controlled medications that would need prescription, the nurse should follow the medications Medication Unavailable Flow Chart to determine what to do. A review of the cautionary instruction written on the label attached to the CDAR revealed: Caution: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed. A review of the undated facility's Policy titled Documentation on Medication Administration Record revealed that the facility should maintain the medication administration record to document all medications administered. The policy explained that the Nurse should document all medications administered to each resident's Medication Administration Record (MAR). It also explained that the documentation must include, as a minimum: (f.) signature and title of the person administering the medication. A review of the undated facility's Policy titled Medication orders and Receipt Record revealed that the Director of Nursing Services would designate individuals to be responsible for completing medication order/receipt forms and medications should be ordered in advance, based on the dispensing pharmacy's required lead time. NJ 8:39-29.2(a) NJ 8:39-29.2(d)

C# NJ , C# NJ Based on observation, interviews, medical record (MR) review, and review of other pertinent facility documentation on 1/9/17 and 1/20/17, it was determined that the facility failed to ensure that all nursing staff performed accurate reconciliation and accounting of Schedule II (Duragesic Patch) and Schedule IV (Xanax) Controlled medications for 2 of 9 sampled residents (Resident #1 and #9). In addition, the facility failed follow facility policy to remove controlled medications in a timely manner (Dilaudid and Xanax) for residents that were discharged from the facility for 3 of 9 sampled residents (Resident #1, #2 and #3), and failed to follow facility policy when Nursing Staff borrowed Dilaudid and Xanax for 3 of 9 sampled residents (Resident #1, #2 and #3) and administered these controlled medications to 4 of 9 sampled residents (Resident #5, #6, #7 and #8). Furthermore, the facility Nursing staff failed to document proper witnessed disposal of controlled medications for 1 of 9 sampled residents (Resident #1). This deficient practice is evidenced by the following: 1. According to the Admission Record, Resident #1 was admitted on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was discharged on [DATE]. According to Resident #1's Minimum Data Set (MDS), an assessment tool dated 10/28/16, the resident had impaired short and long-term memory and had impaired decision making ability. According to the physician's orders [REDACTED].#1 was on Xanax 0.25 milligram (mg.) 1 tablet by mouth once a day. In addition, on 10/24/16, Xanax 0.25 mg 1 tablet by mouth every 6 hours as needed for anxiety was ordered. According to Resident #1's December 2016 Medication Administration Record (MAR), the Xanax was documented as having been administered as ordered until 9:00 a.m. on 12/26/16, and was recorded on Resident #1's Controlled Drug Administration Record (CDAR). On 1/9/17 at 10:05 a.m., an inspection of the Narcotic box inside the South Unit's Medication Cart (MC#3) was conducted with the Unit Manager/Registered Nurse (RN #1) and RN #2. The surveyor observed three Bingo cards (pop-out medication dispensing packages) of controlled medications, with a CDAR for each Bingo card, for three discharged Residents (Resident #1, #2 and #3). The Bingo card for Resident #1 revealed that there were 13 tablets of Xanax 0.25 mg. left. A review of the CDAR for Resident #1's Xanax revealed four tablets were wasted (disposed of) and signed by one nurse (RN #2). This same CDAR for Resident #1 revealed that there should have been 18 tablets of Xanax instead of 13 tablets. The document attached to the CDAR revealed that five of Resident #1's remaining tablets of Xanax were used for two other residents (Resident #5 and #8). The surveyor conducted an interview with RN #2 on 1/9/17 at 10:30 a.m. RN #2 stated that Resident #1 was discharged and that the four tablets of Xanax were wasted because the resident refused the medications. RN #2 stated that the controlled drugs for discharged residents were kept in the narcotic box inside the medication cart until the supervisor destroyed it with another nurse. On 1/9/17 at 1:45 p.m., the Director of Nursing (DON) stated that RN #2 and Licensed Practical Nurse (LPN #1) were interviewed by the the Assistant Director of Nursing (ADON) on 1/9/17. The DON stated that RN #2 and LPN #1 informed the ADON that Resident #1's four tablets of Xanax were not wasted but were given to Resident #8 by RN #2. The DON stated that RN #2 and LPN #1 were given verbal warnings and provided with an In-service Education on 1/9/17, which included: No borrowing of any kind of medications, the physician would need to be notified on time for all controlled medications that would need prescriptions, the nurse should follow the Medication Unavailable Flow Chart to determine what to do, and all controlled medications that get wasted would need a witness. An interview with RN #2 and LPN #1 was conducted on 1/9/17 at 3:20 p.m. RN #2 stated that Resident #1's Xanax was not wasted but was borrowed and administered for Resident #8. RN #2 stated that she should not have borrowed Resident #1's Xanax for Resident #8 however, Resident #8 had no available medication at that time and there was none available in the Pyxis (an automated medication delivery cabinet used for emergency). RN #2 stated that she documented Resident #1's Xanax was wasted because he/she knew that the facility would not allow borrowing of medications. During this interview, LPN #1 stated that she was present when RN #2 borrowed Resident #1's Xanax for Resident #8. LPN #1 stated that RN #2 documented the 4 doses of 0.25 mg Xanax as wasted because the nurses were not supposed to borrow any medications. LPN #1 further stated that it was the facility's policy to witness and document disposal of narcotics by two licensed nurses. 2. According to the Admission Record, Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #2 was discharged on [DATE]. According to Resident #2's Admission assessment dated [DATE], the resident was alert and oriented to person, place, and time. According to the physician's orders [REDACTED]. 1 tablet by mouth every 6 hours as needed for moderate pain. A review of Resident #2's November 2016 MAR revealed that the resident was on Dilaudid 2 mg. 1 tablet by mouth every 6 hours as needed for moderate pain. This MAR revealed that Resident #2 was administered this medication as ordered until 11/18/16 at 6:03 p.m., and it was recorded on Resident #2's CDAR. On 1/9/17 at 10:05 a.m., an inspection of the Narcotic box inside the South Unit's MC#3 was conducted by the surveyor in the presence of RN #1 and RN #2. The Bingo card for Resident #2 revealed that there were zero tablets left of Dilaudid 2 mg. (for pain) for Resident #2. A review of the CDAR for Resident #2's Dilaudid revealed that there should have been 26 tablets left instead of zero. The document attached to the CDAR revealed that all of Resident #2's remaining tablets of Dilaudid were used for three other residents (Resident #6, #7 and #8). 3. According to the Admission Record, Resident #3 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #3 was discharged on [DATE]. According to Resident #3's MDS dated [DATE], the resident scored 15/15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. According to the physician's orders [REDACTED]. 1 tablet by mouth every 4 hours as needed for Anxiety. A review of Resident #3's December 2016 MAR revealed that the resident was on Xanax 0.25 mg. 1 tablet by mouth every 4 hours as needed for anxiety. This MAR revealed that Resident #3 was administered this medication as ordered until 12/23/16 at 1:19 a.m., and it was recorded on Resident #'3's CDAR. On 1/9/17 at 10:05 a.m., an inspection of the Narcotic box inside the South Unit's MC#3 was conducted by the surveyor in the presence of the RN #1 and RN #2. The Bingo card for Resident #3 revealed that there were 3 tablets left of Xanax 0.25 mg. for Resident #3. The CDAR for Resident #3's Xanax revealed that there should have been 16 tablets left instead of 3 tablets. The document attached to the CDAR revealed that thirteen of Resident #3's remaining tablets of Xanax were used for two other residents (Resident #5 & #8). 4. According to the Admission Record, Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #5 was discharged on [DATE]. Resident #5's MDS dated [DATE], revealed that the resident had impaired short term and long-term memory, and had impaired decision making ability. According to the physician's orders [REDACTED]. 1 tablet by mouth every 6 hours as needed. A review of Resident #5's December 2016 and January 2017 MAR revealed that the resident had an order for [REDACTED]. The MARs revealed that Resident #5 was administered the Xanax as ordered until 1/15/17 at 5:17 p.m., which included the Xanax that was borrowed from Resident #1 on 1/2/17 at 12:00 a.m., and from Resident #3 on 12/25/16 at 7:11 p.m. 5. According to the Admission Record, Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6 was discharged on [DATE]. According to Resident #6's MDS dated [DATE], the resident scored 15/15 on the BIMS, which indicated the resident was cognitively intact. According to the physician's orders [REDACTED]. 1 tablet by mouth every 4 hours as needed for breakthrough pain. In addition, on 12/27/16, Dilaudid 2 mg. 1 tablet by mouth every 3 hours as needed for cancer pain was ordered. A review of Resident #6's December 2016 MAR revealed that the Dilaudid was not signed as having been administered by LPN #2, which would account for the Dilaudid borrowed from Resident #2 on 12/22/16 at 10:00 p.m., as recorded on Resident #2's CDAR. Resident #6's MAR also revealed that the Dilaudid was not signed as having been administered by RN #2, which would account for the Dilaudid borrowed from Resident #2 on 12/23/16 at 9:00 a.m., as recorded on Resident #2's CDAR. A review of the Nurse's Note (NN) dated 12/22/16 at 11:17 p.m., signed by LPN #2, revealed: Pain: Currently receives medication related to pain management. A review of the NN dated 12/23/16 at 10:19 a.m., signed by RN #2, revealed that Resident #6 verbalized moderate pain on the left side of his/her body and Dilaudid was given with relief. A post survey telephone interview was conducted by the surveyor on 1/25/17 at 2:00 p.m., with the DON. The DON confirmed that the Dilaudid borrowed from Resident #2 on 12/22/16 at 10:00 p.m., was not signed as having been administered by LPN #2 in Resident #6's MAR. The DON also verified that the Dilaudid borrowed from Resident #2 on 12/23/16 at 9:00 a.m., was not signed as having been administered by RN #2 in Resident #6's MAR. During the same post survey telephone interview on 1/25/17 at 2:00 p.m., the DON explained that LPN #2 documented on his/her NN dated 12/22/16 at 11:17 p.m., that the Dilaudid was administered to Resident #6. The DON stated that LPN #2 was no longer employed in the facility. The DON further explained that RN #2 documented in his/her NN dated 12/23/16 at 10:19 a.m., that the Dilaudid was administered to Resident #6. 6. According to the Admission Record, Resident #7 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #7 was discharged on [DATE]. The physician's orders [REDACTED]. 2 tablets by mouth every 4 hours as needed for severe pain. A review of Resident #7's November 2016 MAR revealed that the Dilaudid was not documented as administered by RN #3, which would account for the Dilaudid borrowed from Resident #2 on 11/24/16 at 4:00 a.m., and 11/29/16 at 7:30 a.m. The MAR also revealed that the Dilaudid was not documented as administered by LPN #3, which would account for the Dilaudid borrowed from Resident #2 on 11/24/16 at 9:55 a.m. A post survey telephone interview was conducted by the surveyor on 1/25/17 at 2:00 p.m. with the DON. The DON confirmed that the Dilaudid borrowed from Resident #2 on 11/24/16 at 4:00 a.m. and 11/29/16 at 7:30 a.m., was not signed as having been administered by RN #3 in Resident #7's MAR. The DON also verified that the Dilaudid borrowed from Resident #2 on 11/24/16 at 9:55 a.m. was not signed as administered by LPN #3 in Resident #7's MAR. A review of the facility's witness statement dated 1/26/17, written by LPN #3, revealed that LPN #3, administered Dilaudid 2 mg. to Resident #7 on 11/24/16 at 9:55 a.m., but forgot to sign the MAR. A review of the facility's witness statement dated 2/9/17, written by RN #3, revealed that RN #3 administered Dilaudid 2 mg. to Resident #7 on 11/24/16 at 4:00 a.m., and 11/29/16 at 7:30 a.m., but forgot to sign the MAR. 7. According to the Admission Record, Resident #8 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #8 was discharged on [DATE]. According to Resident #8's MDS dated [DATE], the resident scored 14/15 on the BIMS, which indicated the resident was cognitively intact. According to the physician's orders [REDACTED]. 1 tablet by mouth every 3 hours as needed for moderate pain and Dilaudid 4 mg. 1 tablet by mouth every 3 hours for severe pain. In addition, on 12/24/16, Resident #8 had an order for [REDACTED]. Resident #8's December 2016 MAR revealed that the resident was on Xanax 0.5 mg. tablet 2 tablets by mouth every 12 hours for Anxiety. This MAR revealed that Resident #8 was administered this medication as ordered until 12/29/16 at 9:00 p.m., which included the Xanax 1 mg. borrowed from Resident #1 on 12/28/16 at 9:00 p.m., and the Xanax borrowed from Resident #3 at 9:00 a.m. on 12/24, 12/25, 12/26, and 12/27/16. Further review of this MAR revealed that the resident was on Dilaudid 2 mg. 1 tablet by mouth every 3 hours as needed for moderate pain and Dilaudid 4 mg. 1 tablet by mouth every 3 hours for severe pain. This MAR revealed that Resident #8 was administered this medication as ordered, which included the Dilaudid that was borrowed from Resident #2 on 12/14/16 at 4:13 p.m., on 12/14/16 at 7:40 p.m., and on 12/15/16 at 4:56 a.m. A review of the Precautionary warning written on the label attached to the CDAR revealed: Caution: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed. When interviewed on 1/9/17 at 10:45 a.m., RN #1 stated that all controlled medications for discharged residents were kept locked in the narcotic box inside the medication cart until the supervisor destroyed it with another nurse. RN #1 stated that the controlled medications for discharged residents should be destroyed right away, and that two nurses were required to sign when controlled medications were wasted and/or destroyed. RN #1 stated that the medication nurses should re-order medications as soon as it reached the blue line (eight pills left) indicated on the Bingo card to ensure availability of medications. RN #1 further stated that the nurses were not allowed to borrow medications. The surveyor conducted an interview on 1/9/17 at 11:35 a.m., with the DON. The DON stated that she was not aware that there were three bingo cards of controlled medications from three discharged residents inside the narcotic box of MC #3 until the day of the survey (1/9/17). The DON stated that she was also not aware that the nurses were borrowing these controlled medications and had administered them to other residents. The DON further stated that the facility did not have a policy for borrowing medication because the Nursing staff were not allowed to borrow any medications from a resident to be given to another resident. The DON stated that in case a resident had an order for [REDACTED]. The DON stated that the Attending Medical Doctor (AMD) was responsible for issuing prescriptions for controlled drugs and that whenever the AMD of a resident would not be able to issue the Prescription for the controlled drug in a timely manner for any reason, there was a Physiatrist available to issue the Prescription. The DON stated that the Pyxis was only used for an emergency. When interviewed by the surveyor on 1/9/17 at 1:00 p.m., the Physiatrist stated that if and when the AMD would not be able to write a prescription for a controlled drug for a resident promptly, the facility would ask him to assess the resident and he would issue the prescription if medically necessary. When interviewed by the surveyor on 1/20/17 at 12:45 p.m., the DON stated that the facility had no time frame as to when to destroy controlled drugs for discharged residents. The DON stated that it should remain in the medication cart under double lock until removed by the Nursing Supervisor for destruction by two Nursing staff. The DON stated that the frequency of controlled drugs destruction depends on how many controlled drugs were needed to be destroyed. During this interview with the surveyor, the DON stated that the facility's Pharmacy Provider delivered twice a day, the first delivery would be early in the morning before the end of 11:00 p.m. - 7:00 a.m. (11-7) shift, and the second delivery would be later in the evening before the end of the 3:00 p.m. -11:00 p.m. (3-11) shift. 8. According to the Admission Record, Resident #9 was admitted on [DATE], with [DIAGNOSES REDACTED]. According to Resident #9's MDS dated [DATE], the resident scored 13/15 on the BIMS, which indicated that the resident was cognitively intact. According to the physician's orders [REDACTED]. A review of Resident #9's January 2017 MAR revealed that Resident #9 received this Duragesic patch 12 mcg/hr on 1/19/17 at 5:00 p.m. The CDAR was also reviewed and revealed that RN #4 did not sign for the medication on the CDAR. On 1/20/17 at 10:50 a.m., an inspection of the Narcotic box inside the South Unit's MC #4 was conducted by the surveyor in the presence of RN #1. The surveyor observed 2 boxes of Duragesic Patch inside a plastic bag labeled with Resident #9's name, 1 opened and 1 unopened. RN#1 verified that the Duragesic patches were ordered for Resident #9. RN #1 showed the surveyor four patches of Duragesic 12 mcg/hr. from the opened box. The CDAR for the opened box revealed that there should have been 5 patches in the box. RN #4 did not sign out on the CDAR the usage of one Duragesic Patch 12 mcg/hr. on 1/19/17 at 5:00 p.m. A review of the individual statement form written by LPN #4 dated 1/20/17, untimed, revealed that LPN #4 counted narcotics with the outgoing 11:00 p.m. - 7:00 a.m. (11-7) shift, except for the Duragesic patch. The statement revealed that this was not the LPN #4's usual practice. When interviewed by the surveyor on 1/20/17 at 10:45 a.m., LPN #4 stated that a Narcotic count was conducted the morning of 1/20/17, between the outgoing 11:00 p.m. - 7:00 a.m. (11-7) shift and the incoming 7:00 a.m. - 3:00 p.m. (7-3) shift. LPN #4 stated that he/she did not count the Duragesic patches because he/she thought the box was not opened. When interviewed by the surveyor on 1/20/17 at 11:35 a.m., RN #4 stated that he/she applied one patch of Duragesic patch 12 mcg/hr. to Resident #9's right chest wall on 1/19/17 at 5:00 p.m. RN #4 stated that he/she was about to sign the CDAR but was called to attend to an agitated resident and had forgotten to sign. RN#4 stated that a Narcotic count was conducted between 3:00 p.m. -11:00 p.m. (3-11) shift and the incoming 11:00 p.m. - 7:00 p.m. shift, but forgot to count the Duragesic patches. RN#4 stated that this was the first time she missed signing the CDAR. When interviewed by the surveyor on 1/20/17 at 12:45 p.m., the DON stated that the nurses should conduct narcotic count between the incoming and outgoing shifts and whenever there would be a turn-over between the medication nurses. The DON stated the narcotic count also included the controlled substances in the Pyxis. When further interviewed by the surveyor, the DON stated that the facility has a Pharmacy Consultant (PC) not affiliated with their Pharmacy Provider. The DON stated that the PC would come to the facility every month and was in the facility on 1/19/17. When interviewed by the surveyor on 1/20/17 at 2:00 p.m., the PC verified that they were not affiliated with the facility's Pharmacy Provider. The PC stated that they would go to the facility every month and would conduct Drug Regimen Review, would ensure that systems/processes were in place for proper storage, labeling, administration, disposition of medication amongst other things required by local, state and federal law. During this interview with the surveyor, the PC informed the surveyor that medications for discharged residents were not removed from the South Unit Medication Cart for November and December 2016. The PC stated she was not able to identify whose and what medications were not removed but it should be written in the PC's Inspection report. The PC stated that they would document their findings during their monthly visit and would give it to the DON. The PC further stated that she would also talk to the nurses and DON about their findings. The PC explained that the DON was very involved and addressed their concerns and recommendations promptly. The PC further stated that if and when medications ordered were not available, the staff should call the facility's Pharmacy provider for a stat delivery, or call the facility's alternate Pharmacy or call the AMD for possible medication order change. The PC also stated that although the facility had no time frame for disposal of controlled medications, the facility should immediately remove all medications and disposed controlled medications of discharged residents to prevent medication error and borrowing. The PC further explained that it was not a good practice to keep controlled medications more than a month after a resident was discharged . A review of the Pharmacy Consultant's Unit Inspection Report from November 2016 to January 2017 revealed the following: 1. The Inspection Report for South Unit dated 11/29/16, revealed that the discontinued medications were not removed in the medication cart, controlled drugs inventory count each shift was not done for certain days, the declining inventory for one of the residents (not in the sample) was incorrectly signed and the Pyxis shift to shift narcotic count was missing. 2. The Inspection report dated 12/28/16, revealed that discontinued medications were not removed from the North and South Unit medication carts, controlled drugs inventory count each shift was not done for certain days on both units, there were missing nurses signature on both unit's narcotic shift to shift form, a controlled drug from discharged (not in the sample) residents were not removed in the South unit and Pyxis shift to shift narcotic count was missing. 3. The report dated 1/19/17, revealed that discontinued medications were not removed from the North and South Unit medication carts. A review of Nursing News Letter dated 11/30/16, revealed a reminder for all nurses to observe compliance with controlled drugs inventory count every shift. A review of the Nursing News Letter dated 12/30/16, revealed a reminder for all nurses that the medication availability form should be completed every shift and the supervisor should be notified for any missing medications. This newsletter also indicated that nurses should follow the Medication Unavailable Flow Chart which guide the staff on what to do when medications where not available. The News letter also directed that all staff must observe compliance with controlled drugs inventory count every shift. A review of the In-service Education Record revealed that on 1/9/17, the facility provided an In-Service Education which included: No borrowing of any kind of medications, the AMD would need to be notified on time for all controlled medications that would need prescription, the nurse should follow the Medication Unavailable Flow Chart to determine what to do, and all controlled medications that get wasted would need a witness. A review of the In-Service Education Record dated 1/20/17, the day of the survey, revealed that the facility provided an In-Service Education about signing out narcotics and accounting of narcotics between incoming and outgoing shifts. A review of the Facility's Policy titled Controlled Drug Count Record (CDCR) and Controlled Drug Index (CDI) dated 8/1/10, revealed that at the change of shift and/or at any time in which the narcotic keys are surrendered to another responsible party, the outgoing responsible party should count all controlled drugs with the incoming responsible party. The Policy indicated that both responsible parties would count the number of bingo cards, packs/boxes, and bottles, and document the count on the designated spaces. It also indicated that all discontinued controlled drugs would be included in the count until surrendered to the Supervisor for destruction. The same Policy revealed that at the end of each month, a reconciliation of all drugs in the medication cart will be completed and a new CDCR and CDI form would be initiated. A review the facility's Policy titled Disposal of Non Hazardous Medications-Controlled Medications revised on 6/4/14, revealed that it is the policy of the facility to assure that discontinued medications were removed from the active medication supply in a timely fashion, were returned to the provider if allowed by law and policy, were disposed of in compliance with laws and standards, and were accounted for and documented completely and accurately. The policy revealed that the controlled medications would remain in the medication cart under double lock until removed by the DON or designee for appropriate storage or immediate destruction. This Policy indicated that destruction of controlled substances would be completed by two individuals and in accordance with state, federal, and local regulations. It also revealed that both the destroying professional and the witnessing professional should sign the completion/witnessing of the destruction on the declining inventory. A review of the undated facility's Policy titled Medication orders and Receipt Record revealed that the Director of Nursing Services would designate individuals to be responsible for completing medication order/receipt forms and medications should be ordered in advance, based on the dispensing pharmacy's required lead time. A review of the undated facility's Policy titled Documentation on Medication Administration Record revealed that the facility should maintain the medication administration record to document all medications administered. The policy explained that the Nurse should document all medications administered to each resident's Medication Administration Record (MAR). It also explained that the documentation must include, as a minimum: (f.) signature and title of the person administering the medication. NJ 8:39-29.2(a) NJ 8:39-29.2(d) NJ 8:39-29.4(g) NJ 8:39-29.4(i) NJ 8:39-29.4(k)

Based on observation, interview and record review it was determined that the facility failed to provide necessary care and services as prescribed by the physician for 5 of 12 residents, Resident #3, #4,#8 #9 and #11 as evidenced by the following: 1. On 5/16/16 at 7:55 a.m., during the initial tour the unit manager told the surveyor that Resident #8 was alert and oriented and had a [DIAGNOSES REDACTED]. On 5/17/16 at 1 p.m., the surveyor reviewed the medical record of Resident #8. The resident was admitted on [DATE] status [REDACTED]. At 1 p.m. the surveyor reviewed the resident's current Medication Administration Record (MAR). On 5/14, 5/15 and 5/16/16, the [MEDICATION NAME] 0.4 mg daily was circled with the nurse's initials, indicating that it was not given. The nurse wrote an explanation on the back of the MAR for 5/14, timed at 9 a.m., which indicated that the physician was aware and to give dose as soon as available. On 5/15, the nurse wrote, Pharmacy will deliver tonight. On 5/16, the nurse wrote, Medication not received from pharmacy stated need clarification on dosage (clarified and will deliver.) A review of the Progress Notes revealed that on 5/16/16 at 3:13 p.m., the nurse documented, called pharmacy for delivery of [MEDICATION NAME] and [MEDICATION NAME] needed to be clarified due to the strength being higher than recommended, order clarified to remain the same, pharmacy will deliver today in the evening. On 5/16/16, a clarification order was written on the physician's orders [REDACTED]. The surveyor reviewed the clarified order on the MAR. There was an arrow through the 16th and the 17th, indicating that the first dose was to be administered on 5/18/16. On 5/17/16 at 1 p.m.,the surveyor questioned the medication nurse regarding the supply of the medication. He stated that there was no supply of [MEDICATION NAME] in the medication cart and the facility was waiting for delivery from the pharmacy. He added that the [MEDICATION NAME] was not available either, and that he forgot to circle that it was not administered at 9 a.m. as ordered. He then circled that the [MEDICATION NAME] was not administered and documented on the back of the MAR that it was not available. According to the MAR, the [MEDICATION NAME] was administered as ordered since admission except on 5/17. On 5/17/16 at 1:40 p.m., the surveyor interviewed Resident #8 and asked if the resident was receiving all their medications. The resident stated that they knew of one problem in the beginning with the [MEDICATION NAME] not being carried over but that they were getting it now. Further review of the MAR revealed that Resident #8 had an order for [REDACTED]. The surveyor noted that there were blanks on the MAR for the 7-3 shift on 5/14 and 5/16, and 3-11 shift on 5/14 and 5/16. On 5/17/16 at 2 p.m., the surveyor reviewed the Inventory Summary for the current medication supply in the back up system. There were 10 tablets of [MEDICATION NAME] 0.1 mg tabs in backup supply. At 2:15 p.m., the surveyor asked the medication nurse it he was aware that the [MEDICATION NAME] was available in the backup system. He said, No. The surveyor accompanied the medication nurse to the backup supply room. He entered the medication name and the system showed that 10 tablets of [MEDICATION NAME] 0.1 mg were available. He stated that he would speak to the unit manager for further instructions. At 2:20 p.m., the surveyor spoke to the Director of Nursing regarding medication nurses circling that the [MEDICATION NAME] 0.1 mg was unavailable, when the surveyor and the medication nurse observed that there was a back up supply. She stated that she would look into it. On 5/18/16 at 10:11 a.m., the surveyor reviewed the Activity Report for the backup system for Resident #13. From 5/13/16 to 5/18/16, there was no documentation that [MEDICATION NAME] 0.1 mg was removed from inventory. Further review of this Activity report revealed that on 5/15/16, the nurse removed eight 25 mg tablets of [MEDICATION NAME], total dose 200 mg, for Resident #13. On 5/16/16, the nurse removed two 25 mg tablets, total dose of 100 mg, of [MEDICATION NAME] for Resident #13. On 5/18/16 at 10:20 a.m., the surveyor spoke to the pharmacy provider. The pharmacist stated that on 5/14/16 the pharmacy faxed to the facility a request for clarification of the [MEDICATION NAME] 0.4 mg daily because the dosage was high and only available in 0.1 mg tablets. On 5/16/16, the pharmacist stated that the facility was called again regarding the dosage and faxed another clarification form for [MEDICATION NAME] 0.1 mg, 4 tablets daily. He added that it was processed on 5/17/16 and was to be delivered on 5/18/16 in the morning. The surveyor then spoke to the pharmacy supervisor who stated that they received the order for [MEDICATION NAME] on 5/17/16 for the first time. On 5/18/16 at 9:30 p.m., the Director of Nursing (DON) stated that the physician was made aware of the unavailability of the above medications and documented [DIAGNOSES REDACTED]. 2. On 5/16/16 at 11 a.m. the surveyor reviewed the record of Resident #4. The resident was admitted to the facility history of Renal Transplant and Hypertension. There was an order dated 4/5/16 on the POF for Daily Weights. A review of the MAR for April and May 2016 revealed the order for Daily Weights and additionally, Call MD if weight gain greater than 2 lbs (pounds) per day or greater than 5 lbs per week. The nurse initialed each day from 4/8- 5/15/16 that the weights were done. At 11:30 a.m., the surveyor questioned the DON where the weights were documented. She stated the weights were entered in the electronic medical record (EMR). The surveyor then reviewed the EMR that from 4/5 to 5/16/16 there were ten weights not recorded. On 4/20 to 4/21 the resident's weight increased five lbs. From 4/24 to 4/25 the resident's weight increased three lbs. The Progress Notes (PN) on re-admitted d 4/5/16 indicated that the resident had issues with [MEDICAL CONDITION] and or weight loss. The nurse documented that the current weight was 138 lbs. and the most recent prior weight was 137.8 lbs. On 4/6/16 at 9:47 a.m., the Dietitian documented in the PN that Unable to determine BMI and current weight status secondary to weight refusals/omissions on clinical condition/resident choice. The surveyor reviewed the MAR which did not indicate that the nurse circled the days that the weights were not done. Further review of the PN did not reveal that there were any refusals documented or that the physician was notified of the weight increases on 4/21 and 4/25. The surveyor reviewed the EMR care plan which did not indicate an intervention for daily weights with parameters to call the physician, or a rationale or a problem area for daily weights. Refer to F279 On 5/18/16 at 9:30 a.m., the DON stated that the physician and the nurse practitioner were aware of the resident's weight and that the inconsistency was due to the timing of obtaining the daily weight. The surveyor reviewed the physician's Progress Notes dated from 5/2- 5/16/16 and there was no documentation that mentioned the resident's weight status. 3. On 5/16/16 at 8:40 a.m., during the medication pass the surveyor observed with Nurse #2, that Resident #3 received six medications which included a [MEDICATION NAME] 50 mg tablet. The surveyor did not observe the nurse to take the resident's blood pressure (BP) or heart rate (HR)parameters at the time the medication was administered. The nurse then signed the current Medication Administration Record (MAR) for the six medications and circled their initials for a PO dated 5/13/16 for [MEDICATION NAME] 2 mg, 1 tablet by mouth once daily and wrote the reason the medications were not given as back order pharmacy will deliver Wednesday/Friday. At this time, the nurse said that the [MEDICATION NAME] 2 mg was not administered because it was on back order from the Provider Pharmacy and the facility was told that the medication would be delivered sometime Wednesday to Friday. At this time, the nurse referred to a piece of paper with resident's names and vital signs and documented a BP of 121/60 and HR of 79 for the PO dated 5/12/16 for [MEDICATION NAME] 50 mg, one tablet by mouth once daily, Hold for Systolic Blood Pressure(SBP) less than 100 and Heart Rate(HR) less than 60. The nurse told the surveyor that vital signs are taken when the shift starts in the morning and the BP and HR for this resident were taken at approximately 7:30 a.m. On 5/16/16 at 9:40 a.m., the surveyor reviewed the resident's records which revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. On 5/16/16 at 11:05 a.m., the surveyor interviewed the unit manager (UM) in reference to the resident's current MAR. The UM said that according to the current MAR there was no documentation that [MEDICATION NAME] 2 mg was administered on 5/14/16, 5/15/16 and 5/16/16. The UM also said that she was not aware of any availability problem with [MEDICATION NAME]. In addition, the UM said that when a medication is not in the medication cart the nurses should check the electronic back up supply (Pyxsis) in the facility first. In addition, the Provider Pharmacy should be called and clarified as to when the medication will be delivered and the physician would have to be notified that the medication can not be administered. The UM added that the physician could change the order to a medication that could be obtained. The surveyor with the UM also reviewed the current MAR for two administration times of medications that did not have nursing initials noted for administration: 1) for a PO dated 5/12/16 for Bactrim DS 800/160, 1 tablet by mouth every 12 hours at 9 p.m. on 5/13/16 and 2) for a PO dated 5/12/16 for [MEDICATION NAME] 5 mg, 1 tablet by mouth QD, Hold for SBP less than 100 at 12 p.m. on 5/15/16. The UM said that the nurses should sign their initials in the designated date and time after administration. The UM said the nurses working on those days and shifts would need to be called. At this time, the UM also said that when an order has to be held for specified BP and HR parameters then the nurse should take the BP and HR just before administration of the medication. The nurse also said that a BP and HR can change so the best time to take them would be just prior to administering the medication. On 5/18/16 9:28 a.m., the surveyor interviewed the DON who said that the [MEDICATION NAME] was not administered until it was received on 5/17/16. There was not a nursing progress note indicating the medication was unavailable. In addition, the DON said that the nurses were called in reference to the Bactrim DS and [MEDICATION NAME] 5 mg medications with no documentation of administration on the dates and times and the nurses said that medications were administered but the MAR was not signed. The surveyor reviewed the facility policy for Administering Medications which states Medications must be administered in accordance with the orders and the individual administering the medication will record in the resident's medical record the date and time the medication was administered. On 5/18/16 at 10:20 a.m., the surveyor interviewed a representative from the Provider Pharmacy via telephone who said that there was no Manufacturer back-order for [MEDICATION NAME] 2 mg and the Physician order [REDACTED]. 4. On 5/16/16 at 11:15 a.m., the surveyor observed Resident #9 in their room. The resident told the surveyor that they were concerned about their medications because there were some problems receiving all their medications since being admitted on [DATE]. On 5/17/16 at 10:36 a.m., the surveyor reviewed the records of the resident which revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The current MAR revealed a PO dated 5/14/16 for [MEDICATION NAME] 1 mg, 1 tablet by mouth once daily with circled nurses' initials for 5/15/16 and 5/17/16. The MAR also had documentation on 5/15/16 that the reason the [MEDICATION NAME] was not administered was because call pharmacy for delivery not available from back-up medication machine (Pyxsis) and on 5/17/16 not available(N/A) On 5/17/16 at 11:00 a.m., the surveyor interviewed the UM in reference to Resident #9's MAR and the UM said that the circled doses were not administered and the Provider Pharmacy was already called. In addition, the UM said the Pyxsis did not have [MEDICATION NAME] and was not sure why the Provider Pharmacy did not send the medication. On 5/18/16 at 9:28 a.m., the surveyor interviewed the DON who said that the [MEDICATION NAME] 1 mg was not administered on 5/15/16, 5/16/16 and 5/17/16. In addition, the DON said the nurse on 5/16/16 did not document properly on the MAR that the medication was not administered. The DON also said that the nurses are suppose to clarify why a medication is not available, an action must be taken and medications must be available in a timely manner. 5. On 5/16/16 at 11:02 a.m., the surveyor reviewed the records of Resident #11 which revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The MAR also had documented the reason for the circled [MEDICATION NAME] 2 mg dose for 5/14/16 was pending delivery. At this time, the surveyor reviewed Resident #11's nursing progress notes for 5/14/16 at 2:18 p.m. which stated Patient is on [MEDICATION NAME] for [MEDICAL CONDITION] with no signs and symptoms of adverse reaction noted. On 5/18/16 at 9:28 a.m., the surveyor interviewed the DON who said that the [MEDICATION NAME] was not administered on 5/14/16 because the nurse said that it was not in the medication cart or the Pyxsis. NJAC 8:39-27.1(a), 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to implement the Facility Dysphagia Management Program for identification of residents on physician-ordered thickened liquids for 2 of 12 residents, Resident #1 and 2; and failed to follow special feeding instructions for 1 of 1 resident, Resident #2. This resulted in an immediate jeopardy situation for Resident #2 who was eating without 1:1 supervision and offered thickened liquids from a cup instead of a teaspoon; and Resident #1 who was given regular consistency liquids instead of nectar thickened liquids. The immediate jeopardy situation was identified on 05/30/14 at 2:45 p.m. and the immediacy was corrected on 05/30/14 at 7:30 p.m. based on an acceptable plan of correction implemented by the facility and verified by the survey team on 6/3/14 at 11 a.m. This deficiency continued at a scope and severity of D based on the evidence in Part B. Findings were as follows: Part A: 1. On 05/29/14 at 12 p.m. the surveyor reviewed the medical record for Resident #1. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the Speech Therapy Plan of Care dated 5/21/14. The evaluation indicated that Resident #1 "required verbal cues from caregiver to swallow" and when trialed with thin liquids was observed "coughing and clearing throat." The Speech Therapy Orders based on the evaluation indicated the resident required 1:1 feeding and nectar thick liquids via teaspoon. On 05/29/14 at 10 a.m. the surveyor and dietitian witnessed that the resident did not have a green dot on his/her wristband to indicate the need for thickened liquids. There was a green dot on the nameplate of the resident's door. The dot had no letter written in the center. On 05/29/14 at 10:05 a.m. the surveyor reviewed the Resident Profile Medication Administration Guide for this resident. It was blank except for the name and room number. On 05/30/14 at 8:25 a.m. the surveyor reviewed the Resident Care Card which outlined for the CNAs the needs of each resident. It did not indicate that the resident required 1:1 feeding and was to be given nectar liquids via teaspoon. On 05/30/14 at 10:45 a.m. the surveyor spoke with the Certified Nursing Assistant (CNA) assigned to this resident. The surveyor asked the CNA how the resident drank fluids. She said she did not know because she did not normally take care of Resident #1. On 05/30/14 at 12:05 p.m. the surveyor followed the Director of Nursing (DON) into the resident's room. The resident had his/her lunch tray in front of him/her. The resident was eating unattended. The DON noted that the resident had spilled the coffee on the tray. The DON took the coffee cup and left the room. The resident continued eating. The RN and Unit Manager (UM) entered the room. The UM started to assist the resident with the meal. The surveyor asked the RN if the resident had any special feeding instructions. The RN said "no." The surveyor asked the RN if the resident had any special instructions for drinking. She said Resident #1 was able to drink the thickened liquid alone " just put it in his/her hand." The RN then placed the cup in the hand of the resident. Before the resident was able to drink anything from the glass, the surveyor alerted the RN that the Speech Therapy Order Sheet indicated the resident required 1:1 feeding and liquids via a teaspoon. The surveyor asked the RN and UM why the resident had the lunch tray in front of him/her while no staff member was available to supervise him/her. The RN said maybe the dietary aid put it there. 2. During the initial tour on 5/29/14 at 10:35 a.m., the unit manager stated that Resident #2 was confused and received thickened liquids. On 5/29/14 at 11 a.m. the surveyor reviewed the medical record for Resident #2 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/29/14 at 9:15 a.m. the surveyor observed the Registered Nurse (RN) administering medications to Resident #2. Just prior to entering the resident's room, the RN told the surveyor that the resident was on nectar thickened liquids. Upon entering the room, the surveyor noted that the resident had a breakfast tray on the over bed table. The tray included a cup of thickened orange juice, a cup of thickened water and a cup of regular consistency tea. The diet slip was present on the tray. It was not written on the diet slip that the resident required nectar thickened liquids. There was a green dot sticker on the diet slip. The surveyor asked the RN what the green dot indicated and she said it indicated a pureed diet. She agreed that there was nothing written on the diet slip to indicate that the resident required nectar thickened liquid. The surveyor asked the RN where on the Medication Administration Record [REDACTED]. The RN showed the surveyor the Resident Profile Medication Administration Guide, kept for each record just before the MAR. The Resident Profile Medication Administration Guide for this resident was blank except for the resident's name and room number. In the presence of the surveyor, the RN started to fill out this form and checked off crushed and applesauce. The RN agreed that there was nothing written on the MAR indicated [REDACTED]. The surveyor asked the RN how she knew that the resident required thickened liquids if it was not written anywhere. She said that it was told to her during change of shift report. On 05/29/14 at 9:35 a.m. the surveyor, RN and dietitian observed the breakfast tray together. The dietitian agreed that the resident received a cup of regular consistency tea and should not have. According to the dietitian, the green dot on the dietary slip indicated thickened liquid. She said the dot should have had an "N" in the center to indicate nectar consistency. The dietiian further explained that the resident should have had the same green dot on his/her wristband and on the nameplate outside the resident's door. The RN and dietitian agreed that this resident did not have a green dot on the wristband or on the door. The surveyor, RN and dietitian reviewed the resident's physician's orders [REDACTED].#2 was to receive nectar thickened liquids. A review of the Facility Dysphagia Management Program revealed: (Nursing) (1.4.1) " Place a wristband indicating the resident/patient is on the Dysphagia Management Program on the individual's wrist; " and (1.4.3) "if adopted as part of the identification process, places an identifier on the resident/patient's name plate on the door of the room." The facility implemented the following Plan of Correction: a. Resident #2 was identified to be on thickened liquids. Green dots with "N" for Nectar thickened liquid are now on the resident's door, ID band, Care Card, MAR indicated [REDACTED]. Resident #1: The Speech Therapy orders will be documented on the CNA Care Card, the Care Plan, the MAR indicated [REDACTED]. Green dots with "N" for nectar thickened are now on the resident's door, ID band, Care Card and MAR indicated [REDACTED]. b. A whole house audit will be conducted to identify residents with specific feeding instructions and thickened liquids. c. Dietitian or Food Service Director will generate a list of residents who are on any special feeding orders and thickened liquids as identified by the Speech Therapist and or ordered by the Physician on day of admission or if new order is written. Staff RN/Unit Manager/Supervisor: will update the care plan and care cards of all the identified patients and will place "green" dots with the specific letter "N" for nectar or "H" for honey on the MAR, Care Cards, ID band and by the door. The kitchen supervisor, charge nurse, dietitian or unit manager will observe patients during meals, snacks and hydration to ensure that the special feeding instruction or thickened liquid is being provided to the patient per physician's orders [REDACTED]. Nursing staff and dietary staff as well as activities staff will be in-serviced by May 31, 2014 on the "dot" system and the need to follow the tray card instructions. Staff will have available the "key" to the dot system to reinforce what the "dots" mean for provision of thickened liquids. d. Observations will be performed by the Nurse or Nurse Supervisor for those residents who have special feeding orders and or thickened liquids during meals, snacks, and hydration. Audits will be performed by Unit Manager, Dietitian, Speech Therapist, Nurse Supervisor or Manager on Duty daily for 2 weeks, then monthly for 3 months, and quarterly until deemed no longer necessary by the Quality Assurance Committee for every resident who is on any special diet, special feeding order and thickened liquids. Audits will be analyzed and further Performance Improvement plans developed as necessary. Reports will be reviewed at the Quality Assurance committee meeting quarterly. Part B: This deficiency continued at a scope and severity of D based on the following: On 06/03/14 at 9:30 a.m. the surveyor observed the breakfast tray of Resident #1. The plastic wrap that had been covering the orange juice indicated the type of juice and the date. It did not indicate the consistency. A review of the Facility Thickened Liquids Policy revealed that the lid should be labeled with the consistency of liquid (Nectar, Honey or Spoon Thick). NJAC 8:39-17.4(a)(2)